Mortality With Upper Gastrointestinal Bleeding and Perforation: Effects of Time and NSAID Use

Sebastian Straube; Martin R Tramèr; R. Andrew Moore; Sheena Derry; Henry J. McQuay

Disclosures

BMC Gastroenterol 

In This Article

Abstract and Background

Abstract

Background: Some people who suffer an upper gastrointestinal bleed or perforation die. The mortality rate was estimated at 12% in studies published before 1997, but a systematic survey of more recent data is needed. Better treatment is likely to have reduced mortality. An estimate of mortality is helpful in explaining to patients the risks of therapy, especially with NSAIDs.
Methods: A systematic review of studies published before 1997, and between 1997 and 2008. Any study architecture was acceptable if it reported on cases who died from any cause of upper gastrointestinal bleed or perforation. Analyses were conducted separately for all cases, and those prescribed NSAID or aspirin.
Results: Information was available for 61,067 cases (81% published since 1997) of whom 5,001 died. The mortality rate in all cases fell significantly, from 11.6% (95% confidence interval, 11.0 to 12.2) in pre-1997 studies to 7.4% (7.2 to 7.6) in those published since 1997. In 5,526 patients taking NSAID or aspirin, mortality increased, from 14.7% (13.6 to 15.8) before 1997 to 20.9% (18.8 to 22.9) since 1997.
Conclusion: Upper gastrointestinal bleed or perforation still carries a finite risk of death. Differences in study architecture, population characteristics, risk factors, definition of mortality, and reporting of outcomes impose limitations on interpreting effect size. Data published since 1997 suggest that mortality in patients suffering from an upper gastrointestinal bleed or perforation has fallen to 1 in 13 overall, but remains higher at about 1 in 5 in those exposed to NSAID or aspirin.

Background

Some patients who have a gastrointestinal bleed or perforation will die.[1] Risk of mortality is probably higher in older people,[2] in people with concomitant diseases, or with large ulcers in the posterior duodenal bulb or on the lesser curvature.[3]. Use of NSAIDs (non-steroidal anti-inflammatory drugs) or aspirin is likely to contribute to gastrointestinal bleeding and death.[4]

In the largest published systematic review to date, with data from 1966 to 1996, Tramèr and colleagues assessed the mortality risk of more than two months NSAID exposure as 12% in 11,000 cases of gastrointestinal bleed or perforation, though there was a large variation of between 6% and 16%.[1] Knowing the mortality of an event may be an important element in explaining risk to patients. Mortality estimates for gastrointestinal bleeding and cardiovascular events have been used in examining how the various risks of NSAIDs and coxib (cyclooxygenase-2 selective inhibitor) use can be explained to patients.[5,6]

Descriptions of the risk of dying from a gastrointestinal bleed or perforation vary significantly. For instance, an experimental study on how patients deal with risk used the following description "A small proportion of people may die from stomach bleeding" (compared to risk of dying from a heart attack which was given as 1 in 10 to 1 in 5),[5] while another described the risk as 10%.[6] These are quite different presentations, which may be interpreted very differently, by professionals and by patients.[7]

We wanted to examine the published literature since 1997, the date of the last systematic review on mortality from upper gastrointestinal bleeding or perforation.[1] We hypothesized that better treatment of patients with a bleed or perforation might have reduced the mortality rate to below 12%. Modification of standard care leading to changes in the baseline risk has been described in patients with myocardial infarction,[8] stroke,[9] and with high cholesterol.[10] We also hypothesised that mortality with NSAID use might not have fallen because guidelines concerning use of gastroprotective strategies with NSAIDs in patients with at least one gastrointestinal risk factor are not followed in 3 out of 4 patients.[11]

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