The rapidly declining prevalence of Helicobacter pylori infection and widespread use of potent anti-secretory drugs means peptic ulcer disease has become substantially less prevalent than it was two decades ago. Management has, however, become more challenging than ever because of the threat of increasing antimicrobial resistance worldwide and widespread use of complex anti-thrombotic therapy in the ageing population. Peptic ulcers not associated with H pylori infection or the use of non-steroidal anti-inflammatory drugs are now also imposing substantial diagnostic and therapeutic challenges. This Seminar aims to provide a balanced overview of the latest advances in the pathogenetic mechanisms of peptic ulcers, guidelines on therapies targeting H pylori infection, approaches to treatment of peptic ulcer complications associated with anti-inflammatory analgesics and anti-thrombotic agents, and the unmet needs in terms of our knowledge and management of this increasingly challenging condition. 

Peptic ulcer disease

Objective  To compare the predictive accuracy and clinical utility of five risk scoring systems in the assessment of patients with upper gastrointestinal bleeding. Design  International multicentre prospective study. Setting  Six large hospitals in Europe, North America, Asia, and Oceania. Participants  3012 consecutive patients presenting over 12 months with upper gastrointestinal bleeding. Main outcome measures  Comparison of pre-endoscopy scores (admission Rockall, AIMS65, and Glasgow Blatchford) and post-endoscopy scores (full Rockall and PNED) for their ability to predict predefined clinical endpoints: a composite endpoint (transfusion, endoscopic treatment, interventional radiology, surgery, or 30 day mortality), endoscopic treatment, 30 day mortality, rebleeding, and length of hospital stay. Optimum score thresholds to identify low risk and high risk patients were determined. Results  The Glasgow Blatchford score was best (area under the receiver operating characteristic curve (AUROC) 0.86) at predicting intervention or death compared with the full Rockall score (0.70), PNED score (0.69), admission Rockall score (0.66, and AIMS65 score (0.68) (all P Conclusions  The Glasgow Blatchford score has high accuracy at predicting need for hospital based intervention or death. Scores of ≤1 appear the optimum threshold for directing patients to outpatient management. AUROCs of scores for the other endpoints are less than 0.80, therefore their clinical utility for these outcomes seems to be limited. Trial registration  Current Controlled Trials ISRCTN16235737.

https://www.bmj.com/content/bmj/356/bmj.i6432.full.pdf

Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study.

Peptic ulcer disease is common with a lifetime prevalence in the general population of 5–10% and an incidence of 0.1–0.3% per year. Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10–20% of these patients. Peptic ulcer disease remains a significant healthcare problem, which can consume considerable financial resources. Management may involve various subspecialties including surgeons, gastroenterologists, and radiologists. Successful management of patients with complicated peptic ulcer (CPU) involves prompt recognition, resuscitation when required, appropriate antibiotic therapy, and timely surgical/radiological treatment. The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the board of the WSES to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the 5th WSES Congress, and for each statement, a consensus among the WSES panel of experts was reached. The population considered in these guidelines is adult patients with suspected complicated peptic ulcer disease. These guidelines present evidence-based international consensus statements on the management of complicated peptic ulcer from a collaboration of a panel of experts and are intended to improve the knowledge and the awareness of physicians around the world on this specific topic. We divided our work into the two main topics, bleeding and perforated peptic ulcer, and structured it into six main topics that cover the entire management process of patients with complicated peptic ulcer, from diagnosis at ED arrival to post-discharge antimicrobial therapy, to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

/pdf/perforated-and-bleeding-peptic-ulcer-wses-guidelines-jwg6f64ko7.pdf

Perforated and bleeding peptic ulcer: WSES guidelines

Peptic ulcer disease (PUD) is a common condition that both primary care providers and gastroenterologists encounter. Symptoms of peptic ulcer disease are variable and may include abdominal pain, nausea, vomiting, weight loss and bleeding or perforation with complicated disease. Identifying the risk factors and mechanisms that lead to the development of PUD helps to understand the approach behind diagnostic and treatment strategies.

Peptic Ulcer Disease and Helicobacter pylori infection.

Objectives Existing scores are not accurate at predicting mortality in upper (UGIB) and lower (LGIB) gastrointestinal bleeding. We aimed to develop and validate a new pre-endoscopy score for predicting mortality in both UGIB and LGIB. Design and setting International cohort study. Patients presenting to hospital with UGIB at six international centres were used to develop a risk score for predicting mortality using regression analyses. The score’s performance in UGIB and LGIB was externally validated and compared with existing scores using four international datasets. We calculated areas under receiver operating characteristics curves (AUROCs), sensitivities, specificities and outcome among patients classified as low risk and high risk. Participants and results We included 3012 UGIB patients in the development cohort, and 4019 UGIB and 2336 LGIB patients in the validation cohorts. Age, Blood tests and Comorbidities (ABC) score was closer associated with mortality in UGIB and LGIB (AUROCs: 0.81–84) than existing scores (AUROCs: 0.65–0.75; p≤0.02). In UGIB, patients with low ABC score (≤3), medium ABC score (4–7) and high ABC score (≥8) had 30-day mortality rates of 1.0%, 7.0% and 25%, respectively. Patients classified low risk using ABC score had lower mortality than those classified low risk with AIMS65 (threshold ≤1) (1.0 vs 4.5%; p Conclusions In contrast to previous scores, ABC score has good performance for predicting mortality in both UGIB and LGIB, allowing early identification and targeted management of patients at high or low risk of death.

https://gut.bmj.com/content/gutjnl/70/4/707.full.pdf

ABC score: a new risk score that accurately predicts mortality in acute upper and lower gastrointestinal bleeding: an international multicentre study.

Aliment Pharmacol Ther 2011; 34: 470–475

Summary
Background  The Glasgow Blatchford Score (GBS) is increasingly being used to predict intervention and outcome following upper gastrointestinal haemorrhage (UGIH)

Aim  To compare the GBS with both the admission and full Rockall scores in predicting specific clinical end-points following UGIH

Patients and methods  Data on consecutive patients presenting to four UK hospitals were collected Admission history, clinical and laboratory data, endoscopic findings, treatment and clinical follow-up were recorded Using ROC curves, we compared the three scores in the prediction of death, endoscopic or surgical intervention and transfusion

Results  A total of 1555 patients (mean age 567 years) presented with UGIH during the study period Seventy-four (48%) died, 223 (143%) had endoscopic or surgical intervention and 363 (233%) required transfusion The GBS was similar at predicting death compared with both the admission Rockall (area under ROC curve 0804 vs 0801) and full Rockall score (AUROC 0741 vs 0790) In predicting endo-surgical intervention, the GBS was superior to the admission Rockall (AUROC 0858 vs 0705; P < 000005) and similar to the full Rockall score (AUROC 0822 vs 0797) The GBS was superior to both admission Rockall (AUROC 0944 vs 0756; P < 000005) and full Rockall scores (AUROC 0935 vs 0792; P < 000005) in predicting need for transfusion

Conclusions  Despite not incorporating age, the GBS is as effective as the admission and full Rockall scores in predicting death after UGIH It is superior to both the admission and full Rockall scores in predicting need for transfusion, and superior to the admission Rockall score in predicting endoscopic or surgical intervention

https://hal.archives-ouvertes.fr/hal-00655064/document

Multicentre comparison of the Glasgow Blatchford and Rockall Scores in the prediction of clinical end-points after upper gastrointestinal haemorrhage.

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Multicentre comparison of the Glasgow Blatchford and Rockall Scores in the prediction of clinical end-points after upper gastrointestinal haemorrhage.