Gastroenterology

Gastroenterology

Volume 144, Issue 3, March 2013, Pages 528-535
Gastroenterology

Original Research
Full Report: Clinical—Alimentary Tract
Effects of Helicobacter pylori Infection on Long-term Risk of Peptic Ulcer Bleeding in Low-Dose Aspirin Users

https://doi.org/10.1053/j.gastro.2012.12.038Get rights and content

Background & Aims

Current guidelines recommend testing for Helicobacter pylori infection among users of low-dose aspirin (ASA) who are at high risk for developing ulcers. However, it is not clear whether this strategy affects long-term risk of ulcer bleeding. We assessed the utility of testing ASA users with a high risk of ulcer bleeding for H pylori infection.

Methods

In a prospective study, we recruited 3 cohorts of ASA users (≤160 mg/day). The first group included H pylori–positive users of ASAs with bleeding ulcers in whom the infections were eradicated (n = 249). They resumed ASA after ulcer healing and H pylori eradication. The second group included H pylori–negative (past and present) users of ASA who developed bleeding ulcers (n = 118). They received enteric-coated ASA after ulcer healing. The average-risk cohort included new users of ASA without a history of ulcers (n = 537). None of the subjects received regular treatment with anti-ulcer drugs. The primary end point was ulcer bleeding with ASA use in 5048 patient-years of follow-up evaluation.

Results

The incidence of ulcer bleeding (per 100 patient-years) in the H pylori–eradicated cohort (0.97; 95% confidence interval [CI], 0.53–1.80) did not differ significantly from that of the average-risk cohort (0.66; 95% CI, 0.38−0.99). The H pylori–negative cohort had a high incidence of recurrent bleeding (5.22; 95% CI, 3.04−8.96) (incidence rate ratio, 8.52; 95% CI, 4.29−16.95 vs the average-risk cohort).

Conclusions

The long-term incidence of recurrent ulcer bleeding with ASA use is low after H pylori infection is eradicated. ASA users without current or past H pylori infections who develop ulcer bleeding have a high risk of recurrent bleeding. Tests for H pylori infection can be used to assign high-risk ASA users to groups that require different gastroprotective strategies.

Section snippets

Screening of Study Population

Consecutive users of ASA who presented with upper gastrointestinal bleeding to the Endoscopy Centre of the Prince of Wales Hospital were screened for eligibility. The Prince of Wales Hospital serves a local population of 1.5 million people in Hong Kong.

All patients underwent endoscopy within 24 hours of hospitalization to identify the source of bleeding, to secure hemostasis, and to determine their H pylori status. The inclusion criteria were endoscopically confirmed gastroduodenal ulcer

Results

Between May 1995 and January 2000, we screened 499 aspirin users admitted for peptic ulcer bleeding and 2614 cardiovascular patients without a history of ulcer who attended outpatient clinics. Of 499 aspirin users with ulcer bleeding, 15 with indeterminate H pylori status were excluded. A total of 367 patients were enrolled (249 in the H pylori–eradicated cohort and 118 in the H pylori–negative cohort). Of 2614 cardiovascular patients without ulcer history, 537 first-time aspirin users were

Discussion

In this 10-year prospective cohort study, we set out to determine whether testing for H pylori status in ASA users with a high ulcer risk would have an impact on the long-term incidence of ulcer bleeding. All of these ASA users had a history of confirmed ulcer bleeding. They were divided into 2 cohorts, namely, ASA users with H pylori infection at the time of ulcer bleeding who subsequently received eradication therapy (H pylori–eradicated cohort) and ASA users who had no evidence of past or

Acknowledgments

The authors thank the staff of the clinical research team of the Institute of Digestive Disease and the nursing staff of the Endoscopy Center at the Prince of Wales Hospital for their invaluable support.

These results were presented at the Annual Scientific Meeting of the American Gastroenterological Association, Chicago, IL, May 2011.

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    Conflicts of interest Francis Chan has served as a consultant to Pfizer, Eisai, Takeda, and Otsuka; he received an independent research grant from Pfizer and has been paid lecture fees (including service on speakers' bureaus) by Pfizer, AstraZeneca, and Takeda; Justin Wu has received grant support from the US National Institutes of Health, and has been paid lecture fees (including service on speakers' bureaus) by AstraZeneca; and Joseph Sung has received consulting fees from the National Health Research Institutes of Taipei and also has been paid lecture fees by AstraZeneca, GSK Pharmaceuticals International, and the American Society for Gastrointestinal Endoscopy. The remaining authors disclose no conflicts.

    Funding Supported by the Focused Investments Scheme of The Chinese University of Hong Kong.

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