Role of Helicobacter pylori infection on upper gastrointestinal bleeding in the elderly: a case-control study

Nonsteroidal antiinflammatory drug (NSAID) use is known to be associated with a high incidence of upper gastrointestinal tract bleeding in the elderly. The increased prevalence of Helicobacter pylori (HP) infection, which also occurs with age, suggests that an interaction between NSAID use and HP infection may explain the higher incidence of ulcer complications in the elderly. The aim of the present study was to determine if a relationship exists between HP infection and NSAID use in elderly patients with upper gastrointestinal bleeding. This was a case-control study on 146 elderly patients (73/group). The bleeding group consisted of 37 males and 36 females (mean age 80.4 years, range 70-96) with symptoms (hematemesis, melena, anemia with loss of more than 3 g hemoglobin), and endoscopic stigmata of bleeding. The control group consisted of 73 age- and sex-matched patients with the same endoscopic diagnosis but with no endoscopic stigmata of bleeding. NSAID use was evaluated by interview at the time of endoscopy, and HP infection was confirmed in all cases by histology and the rapid urease test. Statistical analyses were performed using the chi-square test and logistic regression. In both groups, 46.57% of patients were affected with gastric ulcer, 36.98% with duodenal ulcer, and 16.43% with erosive gastritis. The bleeding group had a significantly higher percentage of NSAID users (53.42% vs 19.17%, P < 0.0001) and a lower percentage of HP-positive patients (47.94% vs 72.60%, P = 0.004). The NSAID use pattern was as follows: occasional users (sporadic, as needed during the previous week): 53.8% of bleeding cases and 50% of controls; acute users (continuous therapy for less than one month): 17.9% of bleeding cases and 28.5% of controls; and chronic users (continuous therapy for more than one month): 28.2% of bleeding cases and 21.4% of controls. The logistic regression demonstrated that NSAID use was significantly related to an increase risk of bleeding both in gastric (odds ratio: 4.98, 95% CI: 1.83-13.6) and duodenal ulcer patients (odds ratio: 10.2, 95% CI: 2.25-46.7) while HP-positivity presented a significant inverse relationship with bleeding only in subjects with gastric lesions (odds ratio: 0.20, 95% CI: 0.07-0.55). NSAID use and HP infection were also shown to be independent, unrelated factors, with the overall risk of bleeding in HP-positive NSAID users identified to be significantly less than in HP-negative NSAID users. In conclusion, in elderly patients: (1) NSAID use increases the risk of upper gastrointestinal bleeding while HP infection was associated with a low risk for gastric bleeding; and (2) the two factors are independent variables, therefore the HP-positive NSAID user has a lower risk than the HP-negative NSAID user.