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Risk Factors of Peptic Ulcer

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					RISK FACTORS OF
 PEPTIC ULCER
     PROJECT REPORT




     PRESENTED BY
     ABDUL KHAYOOM
      AKHIL RAJ M.S
  ALEN ELIAS MAMMOOTTIL
                                              Risk Factors of Peptic Ulcer




     DEPARTMENT OF COMMUNITY MEDICINE
 MEDICAL COLLEGE, THIRUVANANTHAPURAM




         Certified that the project on “RISK FACTORS OF PEPTIC
ULCER” done by Abdul Khayoom, Akhil Raj M.S and Alen Elias
Mammoottil is a bonafide record of the research project
undertaken to fulfil the curriculum requirements of Graduate
Medical Education stipulated by the Medical Council of India was
done during the year 2010-2011.




GUIDED BY:

Dr. Ajith Chakravarthy
Assistant Professor,
Dept. Of community Medicine




DATE:                            PROFESSOR AND HEAD

PLACE:                           Dr. K.Vijayakumar

                                 Dept. Of Community Medicine


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                                               Risk Factors of Peptic Ulcer

                         ACKNOWLEDGEMENT


         It is with great pleasure that we place on record our
debt of gratitude to Dr. Ajith, our guide for inspiring us to this
topic and for encouraging and helping us.



         We also desire to express our sincere thanks to Dr.
Vijayakumar, Professor and Head of Department of Community
Medicine, Government Medical College, Thiruvananthapuram, for
giving us an opportunity to do a project like this.



        Also we thank Dr. Vinaykumar, Professor and Head of
Department of Medical Gastroenterology for allowing us to
conduct a study there.



        We wish to express our thanks to all members of the
staff of Department of Community Medicine and Medical
Gastroenterology.



        We also thank the people who co-operated with us for
the successful conduct of the study.




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                                                                 Risk Factors of Peptic Ulcer

                                        INDEX



   I.   INTRODUCTION...............................................................05

  II.   REVIEW OF LITERATURE................................................06

 III.   ABSTRACT.......................................................................09

 IV.    OBJECTIVES...................................................................10

  V.    MATERIALS AND METHODS...........................................10

 VI.    RESULTS AND DISCUSSION............................................12

VII.    CONCLUSION...................................................................28

VIII.   LIMITATIONS....................................................................29

 IX.    SUGGESTIONS.................................................................29

  X.    QUESTIONNAIRE.............................................................30

 XI.    BIBLIOGRAPHY................................................................32




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                                                 Risk Factors of Peptic Ulcer

                              INTRODUCTION:
     Peptic ulcer is the disruption of the mucosal integrity of the
stomach and/or duodenum leading to a local defect or excavation
due to active inflammation. Is the problem of peptic ulcer a
serious one?

     Yes, it is a serious problem which affects the quality of life
and prevents the person from carrying out daily activities.
According to WHO „‟Health is a state of complete physical, mental
and social wellbeing and not merely an absence of disease or
infirmity‟‟

     Studies conducted by International             Epidemiological
Association showed that infection rates for Helicobacter Pylori
were as high as 81% in peptic ulcer cases. Since the resources for
the study were limited we had to exclude that risk factor.
Univariate analysis suggested that male gender, age, lower
socioeconomic status, cigarette smoking, family history of peptic
ulcer and infection with H. pylori were all associated with
increased risk of peptic ulcer. Separate analyses were performed
by sex and occupational group to avoid confounding by cigarette
smoking and age. Multivariate analyses showed that for all
women and for male staff members, only family history was
significantly predictive of peptic ulcer or duodenal ulcer.

    Keralites have a high prevalence of acid peptic disease. There
are number of risk factors associated with peptic ulcer disease
like food habits, stress, smoking, alcoholism to name a few.
Kerala is known as the “land of spices ”.The people of Kerala are
known for their HOT and SPICY food consumption.

   Only very few studies have been conducted on the subject of
peptic ulcer in Kerala. The intention of our project is to widen the
knowledge about the risk factors among the general people of our
community.




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                                               Risk Factors of Peptic Ulcer

                      REVIEW OF LITERATURE

Peptic Ulcer Disease

Burning epigastric pain exacerbated by fasting and improved
with meals is a symptom complex associated with peptic ulcer
disease (PUD). An ulcer is defined as disruption of the mucosal
integrity of the stomach and/or duodenum leading to a local
defect or excavation due to active inflammation. Ulcers occur
within the stomach and/or duodenum and are often chronic in
nature. Acid peptic disorders are very common in the United
States, with 4 million individuals (new cases and recurrences)
affected per year. Lifetime prevalence of PUD in the United States
is ~12% in men and 10% in women. Moreover, an estimated
15,000 deaths per year occur as a consequence of complicated
PUD. The financial impact of these common disorders has been
substantial, with an estimated burden on direct and indirect
health care costs of ~$10 billion per year in the United States.

Gastric Physiology

Despite the constant attack on the gastroduodenal mucosa by a
host of noxious agents (acid, pepsin, bile acids, pancreatic
enzymes, drugs, and bacteria), integrity is maintained by an
intricate system that provides mucosal defense and repair.

Gastroduodenal Mucosal Defense

The gastric epithelium is under constant assault by a series of
endogenous noxious factors, including HCl, pepsinogen/pepsin,
and bile salts. In addition, a steady flow of exogenous substances
such as medications, alcohol, and bacteria encounter the gastric
mucosa. A highly intricate biologic system is in place to provide
defense from mucosal injury and to repair any injury that may
occur.

The mucosal defense system can be envisioned as a three-level
barrier, composed of preepithelial, epithelial, and subepithelial
elements. The first line of defense is a mucus-bicarbonate layer,
which serves as a physicochemical barrier to multiple molecules,
including hydrogen ions. Mucus is secreted in a regulated
fashion by gastroduodenal surface epithelial cells. It consists
primarily of water (95%) and a mixture of lipids and glycoproteins
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                                                Risk Factors of Peptic Ulcer

(mucin). The mucous gel functions as a nonstirred water layer
impeding diffusion of ions and molecules such as pepsin.
Bicarbonate, secreted in a regulated manner by surface epithelial
cells of the gastroduodenal mucosa into the mucous gel, forms a
pH gradient ranging from 1 to 2 at the gastric luminal surface
and reaching 6 to 7 along the epithelial cell surface.

Surface epithelial cells provide the next line of defense through
several factors, including mucus production, epithelial cell ionic
transporters that maintain intracellular pH and bicarbonate
production, and intracellular tight junctions. If the preepithelial
barrier were breached, gastric epithelial cells bordering a site of
injury can migrate to restore a damaged region (restitution). This
process occurs independent of cell division and requires
uninterrupted blood flow and an alkaline pH in the surrounding
environment.

Prostaglandins play a central role in gastric epithelial
defense/repair. The gastric mucosa contains abundant levels of
prostaglandins that regulate the release of mucosal bicarbonate
and mucus, inhibit parietal cell secretion, and are important in
maintaining mucosal blood flow and epithelial cell restitution.
Prostaglandins are derived from esterified arachidonic acid,
which is formed from phospholipids (cell membrane) by the
action of phospholipase A2. A key enzyme that controls the rate-
limiting step in prostaglandin synthesis is cyclooxygenase (COX),
which is present in two isoforms (COX-1, COX-2), each having
distinct characteristics regarding structure, tissue distribution,
and expression. COX-1 is expressed in a host of tissues,
including the stomach, platelets, kidneys, and endothelial cells.
This isoform is expressed in a constitutive manner and plays an
important role in maintaining the integrity of renal function,
platelet aggregation, and gastrointestinal mucosal integrity. In
contrast, the expression of COX-2 is inducible by inflammatory
stimuli, and it is expressed in macrophages, leukocytes,
fibroblasts, and synovial cells. The beneficial effects of
nonsteroidal anti-inflammatory drugs (NSAIDs) on tissue
inflammation are due to inhibition of COX-2; the toxicity of these
drugs (e.g., gastrointestinal mucosal ulceration and renal
dysfunction) is related to inhibition of the COX-1 isoform. The
highly COX-2–selective NSAIDs have the potential to provide the


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                                                Risk Factors of Peptic Ulcer

beneficial effect of decreasing tissue inflammation                 while
minimizing toxicity in the gastrointestinal tract.

Nitric oxide (NO) is important in the maintenance of gastric
mucosal integrity. The key enzyme NO synthase is constitutively
expressed in the mucosa and contributes to cytoprotection by
stimulating gastric mucus, increasing mucosal blood flow and
maintaining epithelial cell barrier function.

Pathophysiologic Basis of Peptic Ulcer Disease

PUD encompasses both gastric and duodenal ulcers. Ulcers are
defined as breaks in the mucosal surface >5 mm in size, with
depth to the submucosa. Duodenal ulcers (DUs) and gastric
ulcers (GUs); share many common features in terms of
pathogenesis, diagnosis, and treatment, but several factors
distinguish them from one another.

Epidemiology

Duodenal Ulcers

DUs are estimated to occur in 6–15% of the Western population.
The incidence of DUs declined steadily from 1960 to 1980 and
has remained stable since then. The death rates, need for
surgery, and physician visits have decreased by >50% over the
past 30 years. The reason for the reduction in the frequency of
DUs is likely related to the decreasing frequency of Helicobacter
pylori. Before the discovery of H. pylori, the natural history of
DUs was typified by frequent recurrences after initial therapy.
Eradication of H. pylori has greatly reduced these recurrence
rates.

Gastric Ulcers

GUs tend to occur later in life than duodenal lesions, with a peak
incidence reported in the sixth decade. More than half of GUs
occur in males and are less common than DUs, perhaps due to
the higher likelihood of GUs being silent and presenting only after
a complication develops. Autopsy studies suggest a similar
incidence of DUs and GUs.



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                                                  Risk Factors of Peptic Ulcer

                              ABSTRACT
As a part of SPM curriculum, we carried out a study to analyse
the association of various risk factors of peptic ulcer. Peptic ulcer
is emerging as one of the major diseases due to our changing
lifestyle. We conducted a case control study on the basis of
endoscopy done to subjects coming to Department of Medical
Gastroenterology, Medical College Hospital, Thiruvananthapuram
from 1st November to 31st December, 2010. The sample size was
60 consisting of 20 cases and 40 controls. The study was done by
direct interviewing of the subjects using a semi-structured
questionnaire. Those who were not willing to co-operate and
those critically ill were excluded from the study.

The important conclusions of the study were:

   1. Previous illness like Asthma and Arthritis are significant
      risk factors in the pathogenesis of peptic ulcer. This is
      explained by the fact that there is increased consumption of
      ulcerogenic drugs like NSAID and steroid.


   2. As per our study, fast eaters were more at risk of developing
      ulcer. Though previous studies have also considered this as
      a variable, there hasn‟t been any satisfactory explanation to
      this data. Future studies may help us further.




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                                             Risk Factors of Peptic Ulcer

OBJECTIVES:
TO FIND OUT THE RISK FACTORS OF PEPTIC ULCER AMONG
PATIENTS UNDERGOING ENDOSCOPY IN THE DEPARTMENT
OF MEDICAL GASTROENTEROLOGY, MEDICAL COLLEGE
TRIVANDRUM



MATERIALS AND METHODS:
      STUDY DESIGN-CASE CONTROL STUDY

      STUDY SETTING-DEPARTMENT OF MEDICAL GASTOENTEROLOGY,
       MEDICAL COLLEGE TRIVANDRUM



      STUDY SUBJECTS-

       CASES-SUBJECTS ENDOSCOPICALLY DIAGNOSED TO HAVE
       PEPTIC ULCER DISEASE AT DEPARTMENT OF MEDICAL
       GASTROENTEROLOGY,    MEDICAL      COLLEGE     HOSPITAL,
       TRIVANDRUM FROM NOVEMBER 1 ST TO DECEMBER 31ST 2010


       CONTROL-SUBJECTS PROVED PEPTIC ULCER NEGATIVE BY
       ENDOSCOPY AT DEPARTMENT OF MEDICAL GASTROENTEROLOGY,
       MEDICAL COLLEGE HOSPITAL, TRIVANDRUM FROM NOVEMBER
       1ST TO DECEMBER 31ST 2010

      SAMPLE SIZE-CASES:20
                   -CONTROLS: 40

      EXCLUSION CRITERIA-CRITICALLY ILL PATIENTS
                          -NON COOPERATIVE PATIENTS

      SAMPLING TECHNIQUE-NON PROBABILITY SAMPLING

      STUDY PERIOD-2 MONTHS



      STUDY TOOL- SEMI-STRUCTURED QUESTIONNAIRE




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                                              Risk Factors of Peptic Ulcer

      DATA COLLECTION-WE COLLECTED DATA FROM ENDOSCOPY
       ROOM OF THE MEDICAL GASTROENTEROLOGY. DATA WAS
       OBTAINED     BY   INTERVIEWING  THE    SUBJECTS  USING
       SEMISTRUCTURED QUESTIONNAIRE CONTAINING 20 VARIABLES,
       NAMELY AGE, SEX, OCCUPATION, EDUCATION, SOCIOECONOMIC
       STATUS, BLOODGROUP,FAMILY HISTORY,NSAIDS CONSUMPTION
       PATTERN, STEROID CONSUMPTION, HISTORY OF PREVIOUS
       ILLNESSES, HOT AND SPICY FOODS, CONSUMPTION OF FOOD
       FROM     OUTSIDE,    TEA/COFFEE   CONSUMPTION,  EATING
       HABITS(FAST OR SLOW), APPETITEE PATTERN, REGULARITY OF
       FOOD    CONSUMPTION),    SMOKING,   ALCOHOLISM, OTHER
       ADDICTIONS. THE DATA COLLECTED WERE ENTERED INTO
       MICROSOFT EXCEL AND LATER TRANSFERRED TO SPSS
       STATISTICS 17.0 FOR ANALYSIS



      DATA ANALYSIS-
        QUALITATIVE VARIABLES: FREQUENCY AND PROPORTION
                                CHI-SQUARE TEST FOR ASSOCIATION
                                ODDS RATIO WITH 95% CI FOR
                                STRENGTH
        QUANTITATIVE VARIABLES: t-TEST

      ETHICAL   ISSUES- INSTITUTIONAL  ETHICAL         CLEARANCE,
       INFORMED CONSENT FROM STUDY PARTICIPANTS




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                                                                    Risk Factors of Peptic Ulcer

                     RESULTS AND DISCUSSION
TABLE NO. 1

AGE

  VARIABLE           NUMBER              MEAN          STD. DEVIATION        STD. ERROR MEAN

    CASE                20               45.30             12.031                   2.690

  CONTROL               40               43.50             11.944                   1.889
t-VALUE-0.549    P-VALUE-0.585




TABLE NO. 2

GENDER

    VARIABLE          CASE(percentage)           CONTROL(percentage)              TOTAL

      MALE               11(31.4%)                    24(68.6%)                 35(100.0%)

     FEMALE               9(36.0%)                    16(64.0%)                 25(100.0%)

      TOTAL                   20                         40                         60
  CHI SQUARE -0.137 P-VALUE-0.711 ODDS RATIO-1.227 (0.415-3.630)



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                                                                 Risk Factors of Peptic Ulcer




  Though there is 36% percentage of females among the cases, supported
by the odds ratio, it is not statistically significant



TABLE NO. 3

OCCUPATION

        VARIABLE                 CASE(percentage)   CONTROL(percentage)            TOTAL
       UNEMPLOYED                    10(40.0%)           15(60.0%)              25(100.0%)
        UNSKILLED                    1(20.0%)            4(80.0%)                5(100.0%)
       SEMISKILLED                   4(44.4%)            5(55.6%)                9(100.0%)
         SKILLED                     1(12.5%)            7(87.5%)                8(100.0%)
CLERICAL/SHOPOWNER/FARMER            1(33.3%)            2(66.7%)                3(100.0%)
    SEMIPROFESSIONAL                  0(0.0%)            3(100.0%)               3(100.0%)
      PROFESSIONAL                   3(42.9%)            4(57.1%)                7(100.0%)
          TOTAL                         20                  40                       60
CHI-SQUARE-4.748     P-VALUE-0.576




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                                                             Risk Factors of Peptic Ulcer




 TABLE NO. 4

 EDUCATION

     VARIABLE            CASE(percentage)   CONTROL(percentage)             TOTAL

PROFESSION/HONOURS             1(100.0%)          0(0.0%)                 1(100.0%)

   GRADUATE/PG                 2(40.0%)          3(60.0%)                 5(100.0%)

 INTERMEDIATE/POST
                               4(44.4%)          5(55.6%)                 9(100.0%)
HIGH SCHOOL DIPLOMA
     HIGH SCHOOL
                               4(23.5%)          13(76.5%)                17(100.0%)
     CERTIFICATE
    MIDDLE SCHOOL
                               3(25.0%)          9(75.0%)                 12(100.0%)
     CERTIFICATE
   PRIMARY SCHOOL
                               6(40.0%)          9(60.0%)                 15(100.0%)
     CERTIFICATE

     ILLITERATE                 0(0.0%)          1(100.0%)                1(100.0%)

      TOTAL                       20                40                        60
 CHI-SQUARE-4.510     P-VALUE-0.608




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                                                                    Risk Factors of Peptic Ulcer




TABLE NO. 5

SOCIOECONOMIC STATUS

      VARIABLE           CASE(percentage)         CONTROL(percentage)               TOTAL

        APL                   14(29.2%)                 34(70.8%)                48(100.0%)

        BPL                   6(50.0%)                   6(50.0%)                12(100.0%)

       TOTAL                     20                        40                         60
CHI-SQUARE-1.875    P-VALUE-0.171         ODDS RATIO-2.429(0.668-8.835)




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                                                                     Risk Factors of Peptic Ulcer

TABLE NO. 6

BLOOD GROUP

   VARIABLE            CASE(percentage)            CONTROL(percentage)              TOTAL
       O                      9(39.1%)                  14(60.9%)                 23(100.0%)

       A                      6(28.6%)                  15(71.4%)                 21(100.0%)

       B                      4(33.3%)                   8(66.7%)                 12(100.0%)
      AB                      1(25.0%)                   3(75.0%)                 4(100.0%)

     TOTAL                       20                         40                        60
CHI-SQUARE-0.687   P-VALUE-0.876

    According to Harrison, there is a strong predilection of peptic ulcer
among subjects with O blood group, according to our study, no association
could be established. This may be due to small sample size.




TABLE NO. 7

FAMILY HISTORY

    VARIABLE            CASE(percentage)           CONTROL(percentage)             TOTAL

       NO                     12(26.7%)                 33(73.3%)                45(100.0%)

       YES                    8(53.3%)                   7(46.7%)                15(100.0%)

      TOTAL                      20                         40                       60
CHI-SQUARE-3.600   P-VALUE-0.058          ODDS RATIO-3.143(0.937-10.546)

     As per the International Epidemiological Association 1996, there was a
significant result suggestive of peptic ulcer running in the family. But our
study was unable to find a significant association. This may be due to the
sampling error.




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                                                                    Risk Factors of Peptic Ulcer

TABLE NO. 8

NSAID

      VARIABLE          CASE(percentage)         CONTROL(percentage)            TOTAL

         YES                  13(39.4%)                20(60.6%)              33(100.0%)

         NO                   7(25.9%)                 20(74.1%)              27(100.0%)

        TOTAL                    20                       40                      60
CHI-SQUARE-1.212    P-VALUE-0.271         ODDS RATIO-0.538(0.178-1.631)

     According to Harrison NSAID is considered to be the second most major
cause for acid peptic disease next to H-Pylori infection .Due to small sample
size ,we couldn‟t get a significant association between the same




TABLE NO. 9

DOCTOR OR SELF-ADMINISTERED

     VARIABLE           CASE(percentage)          CONTROL(percentage)             TOTAL
SELF-ADMINISTERED             8(36.4%)                 14(63.6%)               22(100.0%)
     DOCTOR                   5(45.5%)                  6(54.5%)               11(100.0%)
        NO                    7(25.9%)                 20(74.1%)               27(100.0%)
      TOTAL                      20                        40                       60
CHI-SQUARE-1.485    P-VALUE-0.476

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                                                            Risk Factors of Peptic Ulcer

TABLE NO. 10

FREQUENCY

     VARIABLE           CASE(percentage)   CONTROL(percentage)            TOTAL
  OCCASIONALLY                9(37.5%)          15(62.5%)              24(100.0%)
   FREQUENTLY                 4(44.4%)          5(55.6%)                9(100.0%)
       NO                     7(25.9%)          20(74.1%)              27(100.0%)
      TOTAL                      20                40                       60
CHI-SQUARE-1.354    P-VALUE-0.508

TABLE NO. 11

INTAKE OF NSAIDS

     VARIABLE           CASE(percentage)   CONTROL(percentage)            TOTAL
   AFTER FOOD                 7(25.9%)          20(74.1%)              27(100.0%)
   BEFORE FOOD                6(85. 7%)         1(14.3%)                7(100.0%)
        NO                    7(26.9%)          19(73.1%)              26(100.0%)
      TOTAL                      20                40                       60
CHI-SQUARE-9.790    P-VALUE-0.007




According to our study intake of NSAID before food has proven contributory
towards the disease. This supports the fact given in Lancet journal.



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                                                                  Risk Factors of Peptic Ulcer

TABLE NO. 12

STEROIDS

     VARIABLE           CASE(percentage)        CONTROL(percentage)            TOTAL
        NO                    14(27.5%)              37(72.5%)               51(100.0%)
        YES                   6(66.7%)                3(33.3%)               9(100.0%)
       TOTAL                     20                      40                      60
CHI-SQUARE-5.294    P-VALUE-0.021         ODDS RATIO-5.286(1.160-24.076)

     There is a significant association found in the case of steroid
consumption and occurrence of acid peptic disease. Studies conducted by
the university of Birmingham supports the above results.




TABLE NO. 13

NSAID + STEROIDS

     VARIABLE           CASE(percentage)        CONTROL(percentage)            TOTAL
        YES                   18(31.0%)              40(69.0%)               58(100.0%)
        NO                    2(100.0%)               0(0.0%)                2(100.0%)
      TOTAL                      20                      40                      60
CHI-SQUARE-4.138    P-VALUE-0.042




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                                                            Risk Factors of Peptic Ulcer




    According to our study, there is a statistically significant association
between combination of NSAID and steroids and peptic ulcer. This is in
accordance with results obtained by International Epidemiological
Association.

TABLE NO. 14

PREVIOUS ILLNESS

     VARIABLE           CASE(percentage)   CONTROL(percentage)            TOTAL
     DIABETES                  0(0.0%)          11(100%)               11(100.0%)
  HYPERTENSION                3(27.3%)          8(72.7%)               11(100.0%)
     THYROID                  2(50.0%)          2(50.0%)                4(100.0%)
     ASTHMA                   5(71.4%)          2(28.6%)                7(100.0%)
     ARTHRITIS                2(100.0%)          0(0.0%)                2(100.0%)
        NO                    8(32.0%)          17(68.0%)              25(100.0%)
      TOTAL                      20                40                       60
CHI-SQUARE-14.773   P-VALUE-0.011




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                                                                    Risk Factors of Peptic Ulcer




   According to our study, a history of previous illness like asthma and
arthritis have a significant association with peptic ulcer. In arthritis, there is
long term consumption of NSAID which has a gastric mucosa eroding
property, hence predisposing to peptic ulcer disease. In asthma, long term
usage of steroids has been proved contributive towards peptic ulcer by a
study conducted by Yale University School of Medicine.



TABLE NO. 15

HOT AND SPICY FOODS

     VARIABLE           CASE(percentage)         CONTROL(percentage)             TOTAL
        YES                   16(32.7%)                33(67.3%)              49(100.0%)
        NO                    4(36.4%)                 7(63.6%)               11(100.0%)
       TOTAL                     20                       40                       60
CHI-SQUARE-0.056    P-VALUE-0.813         ODDS RATIO-1.179(0.301-4.619)

Though consumption of hot and spicy foods is a well known risk factor for
peptic ulcer, our study failed to establish an association.




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                                                             Risk Factors of Peptic Ulcer

TABLE NO. 16

FREQUENCY OF HOT AND SPICY FOODS

      VARIABLE          CASE(percentage)   CONTROL(percentage)           TOTAL
    FREQUENTLY                14(43.8%)         18(56.3%)              32(100.0%)
    OCCASIONALLY               2(9.5%)          19(90.5%)              21(100.0%)
         NO                    4(57.1%)          3(42.9%)              7(100.0%)
       TOTAL                     20                40                      60
CHI-SQUARE-8.705    P-VALUE-0.013




As per our study, those who consume hot and spicy foods frequently have
more chance of getting acid peptic disease.

TABLE NO. 17

OUTSIDE FOOD

     VARIABLE           CASE(percentage)   CONTROL(percentage)           TOTAL
    FREQUENTLY                7(58.3%)          5(41.7%)               12(100.0%)
   OCCASIONALLY               13(27.1%)         35(72.9%)              48(100.0%)
       TOTAL                     20                40                      60
CHI-SQUARE-4.219    P-VALUE-0.040



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                                                            Risk Factors of Peptic Ulcer




Regular consumption of food from outside predisposes a person to peptic
ulcer.

TABLE NO. 18

TEA/COFFEE

     VARIABLE           CASE(percentage)   CONTROL(percentage)           TOTAL
      NO CUPS                 5(62.5%)          3(37.5%)               8(100.0%)
       1 CUP                  3(50.0%)          3(50.0%)               6(100.0%)
       2 CUPS                 7(24.1%)          22(75.9%)             29(100.0%)
       3 CUPS                 5(29.4%)          12(70.6%)             17(100.0%)
       TOTAL                     20                40                      60
CHI-SQUARE-5.304    P-VALUE-0.169

TABLE NO. 19

EATING HABITS

     VARIABLE           CASE(percentage)   CONTROL(percentage)           TOTAL
      NORMAL                  7(19.4%)          29(80.6%)              36(100.0%)
        FAST                  10(55.6%)          8(44.4%)              18(100.0%)
       SLOW                   3(50.0%)           3(50.0%)               6(100.0%)
       TOTAL                     20                40                       60
CHI-SQUARE-7.875    P-VALUE-0.019

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                                                                  Risk Factors of Peptic Ulcer




According to International Epidemiological Association, fast eating favours
the onset of peptic ulcer. This finding was also obtained by our study.

TABLE NO. 20

APPETITE

     VARIABLE           CASE(percentage)        CONTROL(percentage)            TOTAL
      NORMAL                  12(30.8%)              27(69.2%)               39(100.0%)
     INCREASED                3(23.1%)               10(76.9%)               13(100.0%)
     REDUCED                  5(62.5%)                3(37.5%)               8(100.0%)
       TOTAL                     20                      40                      60
CHI-SQUARE-3.793    P-VALUE-0.150

TABLE NO. 21

REGULAR EATING

     VARIABLE           CASE(percentage)        CONTROL(percentage)            TOTAL

        YES                   10(26.3%)              28(73.7%)               38(100.0%)
        NO                    10(45.5%)               12(5.5%)               22(100.0%)

       TOTAL                     20                      40                      60
CHI-SQUARE-2.297    P-VALUE-0.130         ODDS RATIO-2.333(0.771-7.059)


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                                                                  Risk Factors of Peptic Ulcer

TABLE NO. 22

SMOKING

     VARIABLE           CASE(percentage)       CONTROL(percentage)             TOTAL
        YES                   5(35.7%)               9(64.3%)                14(100.0%)
        NO                    15(32.6%)              31(67.4%)               46(100.0%)
       TOTAL                     20                     40                       60
CHI-SQUARE-0.047     P-VALUE-0.829         ODDS RATIO-1.148(0.327-4.028)

Harrison specifically states that cigarette smoking is implicated in the
pathogenesis of Peptic Ulcer Disease, but our research could not find any
relation.



TABLE NO. 23

NUMBER OF CIGARETTES PER DAY

     VARIABLE           CASE(percentage)       CONTROL(percentage)             TOTAL
        NO                    15(33.3%)              30(66.7%)               45(100.0%)
    LESS THAN 5               2(25.0%)               6(75.0%)                8(100.0%)
        5-10                  2(33.3%)               4(66.7%)                6(100.0%)
   MORE THAN 10               1(100.0%)               0(0.0%)                1(100.0%)
       TOTAL                    20                      40                       60
CHI-SQUARE-2.250     P-VALUE-0.522




TABLE NO. 24

NUMBER OF YEARS

     VARIABLE           CASE(percentage)       CONTROL(percentage)             TOTAL
        NO                    15(33.3%)              30(66.7%)              45(100.0%)
 LESS THAN 5 YEARS             0(0.0%)               4(100.0%)               4(100.0%)
     5-10 YEARS               1(25.0%)               3(75.0%)                4(100.0%)
   MORE THAN 10               4(57.1%)               3(42.9%)                7(100.0%)
       TOTAL                    20                      40                       60
CHI-SQUARE-3.911     P-VALUE-0.271




Dept. Of Community Medicine                                                            Page 25
                                                                    Risk Factors of Peptic Ulcer

TABLE NO. 25

FAMILY HISTORY

     VARIABLE           CASE(percentage)         CONTROL(percentage)             TOTAL
        YES                   1(50.0%)                 1(50.0%)                2(100.0%)
        NO                    19(32.8%)                39(67.2%)               58(100.0%)
       TOTAL                     20                       40                       60

CHI-SQUARE-0.259    P-VALUE-0.611          ODDS RATIO-2.053(0.122-34.628)




TABLE NO. 26

ALCOHOL

     VARIABLE           CASE(percentage)         CONTROL(percentage)             TOTAL
        YES                   1(10.0%)                 9(90.0%)                10(100.0%)
        NO                    19(38.0%)                31(62.0%)               50(100.0%)
       TOTAL                     20                       40                       60

CHI-SQUARE-2.940    P-VALUE0.086         ODDS RATIO-0.181(0.021-1.546)




TABLE NO. 27

OTHER ADDICTIONS

     VARIABLE           CASE(percentage)         CONTROL(percentage)             TOTAL
  PAAN CHEWING                1(100.0%)                 0(0.0%)                1(100.0%)
        NO                    20(33.9%)                39(66.1%)               59(100.0%)
       TOTAL                     20                       40                       60

CHI-SQUARE-0.508    P-VALUE-0.476




Dept. Of Community Medicine                                                              Page 26
                                                          Risk Factors of Peptic Ulcer

LOGISTIC REGRESSION
                                          Adjusted odds
         VARIABLE              Sig.                               95% C.I.
                                              ratio
       PREV. ILLNESS           0.027         1.469              1.045-2.064

       EATING HABITS           0.006         3.863              1.465-10.185

COX AND SNELL R SQUARE-0.176

After bivariate analysis, we obtained:

       Intake of NSAID before food
       Combination of NSAID and steroids
       Previous illness (asthma, arthritis)
       Frequent consumption of hot and spicy foods
       Fast eating habit
       Frequent consumption of food from outside

After logistic regression, we obtained:

       Previous illness
       Fast eating habit




Dept. Of Community Medicine                                                    Page 27
                                                  Risk Factors of Peptic Ulcer

                              CONCLUSION



     We have done a case control study of 60 subjects who had

attended the Department of Medical Gastroenterology in Medical

College Hospital, Trivandrum. But considering the small sample

size, the results obtained cannot be said to be 100% accurate.


The major facts obtained by our study are:


    Previous illness like Asthma and Arthritis are significant

      risk factors in the pathogenesis of peptic ulcer. This is

      explained by the fact that there is increased consumption of

      ulcerogenic drugs like NSAID and steroid.



    As per our study, fast eaters were more at risk of developing

      ulcer. Though previous studies have also considered this as

      a variable, there hasn‟t been any satisfactory explanation to

      this data. Future studies may help us further.




Dept. Of Community Medicine                                           Page 28
                                                Risk Factors of Peptic Ulcer




                              LIMITATIONS

    Sample size was small, hence results need not be accurate
    Time obtained was not sufficient collecting optimum data
    Since lab investigations for H.Pylori was not feasible for all
     the subjects, considering it as a study variable was not
     possible in our study



                              SUGGESTIONS
      LIFE STYLE MODIFICATIONS:
              1. Limited consumption of foods rich in spices and
                 having added preservatives like pickles and dried
                 fish.
              2. Maximum avoidance of food from outside,
                 especially
              3. Regular and timely consumption of food



    DRUG MODIFICATIONS:
          1. NSAID should always be taken after food
          2. Drugs should always be taken after proper
             guidance from the doctor.
          3. Doctor has a duty to properly instruct the patient
             regarding the dosage and side effects.
          4. Whenever possible, gastro-protective drugs
             should be prescribed especially for long term
             morbidities like arthritis.




Dept. Of Community Medicine                                         Page 29
                                                  Risk Factors of Peptic Ulcer

                              QUESTIONNAIRE
NAME:

AGE:

SEX: M/F

OCCUPATION:

   o   Professional
   o   Semiprofessional
   o   Clerical, shopowner, farmer
   o   Skilled worker
   o   Semiskilled worker
   o   Unskilled worker
   o   Unemployed

EDUCATION:

   o   Profession or Honours
   o   Graduate or post graduate
   o   Intermediate or post high school diploma
   o   High school certificate
   o   Middle school certificate
   o   Primary school certificate
   o   Illiterate

FAMILY INCOME (per month in Rupees):

SOCIOECONOMIC STATUS:

   o   Upper
   o   Upper Middle
   o   Lower Middle
   o   Upper Lower
   o   Lower

BLOOD GROUP:

 Age when first diagnosed:

 Is there any family history of Peptic Ulcer Disease: Y/N

Dept. Of Community Medicine                                           Page 30
                                                  Risk Factors of Peptic Ulcer

       If yes, specify:

 Are you in the habit of taking NSAIDs (Aspirin, Paracetamol etc.):
  Y/N
     If yes: Prescribed by a doctor/Self administered
     Frequency of intake of NSAIDs:
     Time of intake of drug: Before food/After food

 Do you often take steroid drugs: Y/N
     If yes, is it taken in combination with NSAID: Y/N

 Do you have a history of any previous illness: Y/N
     If yes, specify:

 Do you consume hot and spicy foods: Y/N
     If yes, how often:

 How often do you consume foods from outside:

 Do you consume tea or coffee: Y/N
     If yes, how may cups a day:

 Eating habits: Normal/Fast/Slow

 Appetite pattern: Normal/Increased/Reduced

 Do you consume food at regular intervals: Y/N

 Do you smoke: Y/N
     If yes, how many cigarettes per day: <5/5-10/>10
     No of years: <5/5-10/>10
     Does anyone else smoke in the family: Y/N

 Do you consume alcohol: Y/N
     If yes, amount of alcohol consumed at a time:

 Any other addictions: Y/N
     If yes, specify:

Dept. Of Community Medicine                                           Page 31
                                                 Risk Factors of Peptic Ulcer

                              BIBLIOGRAGHY


   1. Harrison‟s Principles of Internal Medicine, 17th edition

   2. PARK‟s textbook of Preventive and Social Medicine

   3. Davidson‟s Principles and Practices of Medicine

   4. Rose G. Sick individuals and sick population. International

      J Epidemiol.

   5. www.wikipedia.com

   6. www.medicinenet.com




Dept. Of Community Medicine                                          Page 32

				
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