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ORIGINAL ARTICLE
Year : 2023 | Volume
: 22
| Issue : 4 | Page : 420-425
Change in Prevalence and Pattern of Peptic Ulcer Disease in the Northern Savannah of Nigeria: An Endoscopic Study
Husain Yahya
Department of Internal Medicine, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna, Nigeria
Correspondence Address:
Husain Yahya
Department of Internal Medicine, Barau Dikko Teaching Hospital, P. O. Box: 9727, Kaduna
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_144_22
Abstract
Background: Peptic ulcer disease (PUD) is common worldwide. Its incidence and prevalence have been declining in recent years in developed countries, and a similar trend has been observed in many parts of Africa including Nigeria. Aim: This study aimed to provide an endoscopic update on PUD in the Northern Savannah of Nigeria and compare with past reports from the region and recent reports from Nigeria, Africa, and the rest of the world. Methods: Upper gastrointestinal endoscopy records of consecutive patients diagnosed with PUD between January 2014 and September 2022 at an endoscopy unit of a tertiary institution in North-West Nigeria were retrieved and demographic data, types of peptic ulcer, and their characteristics were extracted and analyzed. Results: Over a 9-year period, 171/1958 (8.7%) patients were diagnosed with PUD: mean age 48.8 years (range 14–85), 68.4% male, and 70% >40 years. 59.6% were gastric ulcers (GU), 31.6% duodenal ulcers (DU), and 8.8% were both. The mean age of patients with GU was slightly higher than those with DU (49.9 years vs. 46.6 years, P = 0.29); patients aged <40 years were significantly more likely to be diagnosed with DU than GU (54.7% vs. 33.9%, P = 0.016) while those >40 years significantly more GU than DU (74.6% vs. 54.7%, P = 0.016). There were no significant gender differences between GU and DU. Conclusion: The prevalence and pattern of PUD in Northern Savannah of Nigeria have changed – patients were predominantly male and older, and GU predominated.
Résumé
Fond: L'ulcère gastro-duodénal (UIP) est courant dans le monde entier. Son incidence et sa prévalence ont diminué ces dernières années dans les pays développés et une tendance similaire a été observée dans de nombreuses régions d'Afrique, y compris au Nigeria. Avoir pour but: Fournir une mise à jour endoscopique sur l'ulcère peptique dans la savane du nord du Nigéria et comparer avec les rapports antérieurs de la région et les rapports récents du Nigéria, d'Afrique et du reste du monde. Méthodes: Les dossiers d'endoscopie gastro-intestinale supérieure de patients consécutifs diagnostiqués avec PUD entre janvier 2014 et septembre 2022 dans une unité d'endoscopie d'un établissement tertiaire du nord-ouest du Nigeria ont été récupérés et les données démographiques, les types d'ulcère peptique et leurs caractéristiques ont été extraits et analysés. Résultats: Sur une période de neuf ans, 171/1 958 (8,7 %) des patients ont reçu un diagnostic de PUD : âge moyen 48,8 ans (extrêmes 14 – 85), 68,4 % hommes, 70 % > 40 ans. 59,6 % étaient des ulcères gastriques (UG), 31,6 % des ulcères duodénaux (UD) et 8,8 % étaient les deux. L'âge moyen des patients avec GU était légèrement plus élevé que ceux avec DU (49,9 ans contre 46,6 ans, P = 0,29) ; les patients âgés de < 40 ans étaient significativement plus susceptibles d'être diagnostiqués avec DU que GU (54,7 % contre 33,9 %, P = 0,016) tandis que ceux de > 40 ans étaient significativement plus GU que DU (74,6 % contre 54,7 %, P = 0,016) . Il n'y avait pas de différences significatives entre les sexes entre GU et DU. Conclusion: La prévalence et le schéma du PUD dans la savane du nord du Nigéria ont changé - les patients étaient principalement des hommes et plus âgés, et les GU prédominaient.
Mots-clés: Ulcère peptique, épidémiologie, Kaduna-Nigeria, Ulcère gastrique, Ulcère duodénal
Keywords: Duodenal ulcer, epidemiology, gastric ulcer, Kaduna-Nigeria, peptic ulcer disease
Introduction 
Peptic ulcer disease (PUD) refers to a mucosal break in the stomach or duodenum at least 3 mm in its largest diameter with a visible depth and a distinct border.[1] It is a common condition; in a systematic review of global, regional, and national burden of the disease, Xie et al.[2] have estimated that PUD affected about 8 million people in 2019 worldwide, with an age-standardized prevalence rate of 99.4/100,000 population. The age-standardized prevalence rate was highest in South Asia (156.6/100,000) and lowest in Latin America and the Caribbean (41.8/100, 000). Peptic ulcers were once thought uncommon in Africans despite high Helicobacter pylori infection rates,[3] but this was attributed to lack of diagnostic facilities, and prospective endoscopic surveys have shown that PUD was as common in Africa as in many other countries[4] although there is substantial variation in prevalence within countries and across the continent.[5] PUD is a chronic and relapsing disease which may present with nonspecific symptoms of epigastric pain, which is worse after meals or in between meals, nausea, vomiting, belching, bloating, and fatty food intolerance, although it can be asymptomatic.[6] It can be associated with substantial morbidity and mortality: the direct and indirect costs of the disease, including treatment and lost time and productivity, can be enormous and have been estimated to be 5.65 billion dollars per year in the US.[7] Although hospitalization and mortality rates for PUD have declined worldwide in the last 20 years, complications such as bleeding, perforation, and gastric outlet obstruction still lead to hospitalizations and mortality with additional costs to the patient and the health system.[8]
Since the discovery of the strong relationship between H. pylori infection and PUD in 1984 by Warren and Marshall,[9] great progress has been made in understanding the pathogenesis of the disease and developing treatment strategies to eradicate the infection to allow the ulcers to heal. There is a complex interaction between the spiral bacterium and the host leading to not only PUD but also chronic gastritis, atrophy, dysplasia, and cancer.[10] The wider availability of acid-suppressive drugs and antibiotics to eradicate the disease has led to declining incidence and prevalence of PUD in many countries in the last 20 years.[8] An aging world population with accompanying increasing use of nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, are now assuming a greater importance in gastroduodenal diseases including PUD and its complications.[11] These changes are beginning to be observed in Africa as well.[12]
The purpose of the study is to provide an update on PUD as seen in a newly established endoscopy unit which serves a large cosmopolitan population in Kaduna, North-West region of Nigeria, and which has provided continuous uninterrupted upper gastrointestinal endoscopy (UGIE) services over almost 9 years. We will compare this with previous decades-old reports from the region as well as some other similar recent reports from Nigeria and other countries in Africa and the world at large. It is hoped that this will improve our understanding of time trends in the prevalence and pattern of the disease.
Methods Study type and setting
The study was a retrospective review of records of consecutive patients referred to the endoscopy unit of Barau Dikko Teaching Hospital, North-West Nigeria, for UGIE. Patients were referred from outpatient departments, the accident and emergency unit, and the medical and surgical wards of the hospital as well as from other public hospitals, private and faith-based institutions within and around Kaduna metropolis, and from other towns several kilometers away. The unit has provided services uninterrupted since January 2014.
Equipment and procedure
Peroral diagnostic UGIE was performed by the same endoscopist with a Huger 2600 gastroscope (Huger Medical Instruments, Shanghai, China) from January 2014 to May 2018 and Olympus GIF 140 and 170 gastroscopes (Olympus Optical, Ltd., Tokyo, Japan) from January 2014 to September 2022 after patients fasted overnight. The pharynx was anesthetized with 10% lignocaine spray in most cases, although sedation with small doses of intravenous midazolam was employed occasionally. Endoscopy was performed for all patients referred to the unit in the standard way[13] after preprocedure assessment, except children <10 years or those with severe cardiorespiratory disease (New York Heart Association Class IV). Mucosal biopsies were taken where appropriate. All patients gave their written informed consent.
Data retrieval and processing
We retrieved endoscopy request and completed preprocedure assessment forms, endoscopy registers, archived copies of printed reports and obtained age, gender, referring facility, indications for endoscopy, and provisional diagnoses and findings. We also obtained histology reports of biopsies done during the procedure. Records were from January 2014 and September 2022. We obtained descriptive statistics and analyzed our data using IBM SPSS version 22 (Armonk, New York, USA, 2013). Chi-squared tests were used to assess the significance of relationships between categorical variables while independent sample t-tests were used for continuous variables. P < 0.05 was considered statistically significant.
Results Over a 9-year period, out of 1958 patients who had diagnostic UGIE, 171 (8.7%) were found to have peptic ulcers. The basic characteristics of these patients are shown in [Table 1]. The mean age of patients was 48.8 years and their ages ranged from 14 to 86 years and almost 70% were 40 years or over. Two-thirds of the patients were male. Female patients were significantly older than male patients (mean age: 52.4 vs. 47.1 years, P = 0.043). Almost 60% of patients were referred for endoscopy because of dyspepsia while more than a third were referred for the evaluation of hematemesis and or melena. Only three patients were referred on account of suspicion of malignancy. Peptic ulcer disease was the most suspected condition prompting request for endoscopy. Upper gastrointestinal bleeding of unknown cause was the diagnosis in more than a quarter of patients. “Gastritis” (9.4%), gastroesophageal reflux disease (5.8%), and gastric or esophageal carcinoma (5.8%) were other diagnoses. [Table 2] shows the location and characteristics of ulcers observed. Almost 60% of the ulcers were in the stomach (75.4% – antrum, 21.5% – corpus, and 3.1% – fundus) and almost a third were in the duodenum (63% – anterior wall of bulb, 32.1% – posterior wall, and 4.9% – second part). Combined gastric ulcers (GU) and duodenal ulcers (DUs) were detected in 8.8% of patients. Most GU (85.3%) and DU (70.4%) were single. Majority of both GU and DU were small and most were superficial. Although the mean age of patients with GU was not significantly higher than patients with DU (49.9 years vs. 46.6 years, P = 0.29), patients younger than 40 years were significantly more likely to be diagnosed with DU than older patients (54.7% vs. 33.9%, X2 = 6.586, P = 0.016). On the other hand, patients older than 40 years were significantly more likely to be diagnosed with GU than younger patients (74.6% vs. 54.7%, X2 = 6.676, P = 0.016). Even though male patients were more likely to be diagnosed with DU than female patients (44.4% vs. 31.5%, X2 = 2.759), and female patients more likely to be diagnosed with GU than males (72.2% vs. 66.7%, X2 = 0.528), these did not reach statistical significance (P = 0.108 and P = 0.468, respectively). Patients who were being investigated for dyspepsia and for hematemesis and melena were equally as likely to be diagnosed with GU and DU. Other endoscopic findings were gastritis (83.6%), duodenitis (38.6%), gastric atrophy (23.4%), esophagitis (18.7%), and esophageal varices (12.3%). There were 17 (9.9%) patients who had features suggestive of gastric malignancy (irregular raised borders or large ulcers); the diagnosis was confirmed histologically in eight patients, in one patient, tissue was too small for diagnosis, while in the other, features of chronic active gastritis were seen but no malignancy. The rest of patients' histology reports were not available for analysis.
Table 1: Basic characteristics of 171 patients with peptic ulcer disease Discussion Our center in Kaduna (coordinates 10.5015° N, 7.4408° E, current population 1.7 million)[14] is located in the Savannah region of Nigeria and is the only public hospital which has provided regular open access endoscopy services in the metropolis and surrounding towns and villages since 2014. The only other similar closer unit was at Ahmadu Bello University Teaching Hospital, Shika, Zaria, 87 km to the north. In almost two thousand consecutive diagnostic endoscopies, we observed a low prevalence of peptic ulcers with GU making up twice as many as DU. High rates of PUD have previously been reported from all over the region: Malu et al.[15] in Zaria in reviewing records of endoscopy procedures done in 1978–1982 found that DU constituted 26.6% of 431 patients. Danbauchi et al.,[16] reporting from the same institution in Zaria between 1978 and 1993, found that 22.3% of 790 patients had DU while 9% had GU. Tijjani and Umar[17] reported that PUD made up 32.4% of 361 patients who had diagnostic UGIE in Kano (240 km to the north of our city) between 2004 and 2006 with 58.1% of cases being DU, 37.6% GU, and 4.3% both. Additionally, on the Jos Plateau in North-Central Nigeria, Malu et al.[18] found DU in 17.3% of 243 patients undergoing diagnostic UGIE in 1991–1992 while GU constituted 4.9%. This phenomenon of change in prevalence and pattern of endoscopically diagnosed PUD that we observed has also been reported from Nigeria and other parts of the world [Table 3]: Ijarotimi et al.[19] in Ile-Ife in South-West Nigeria reported a declining prevalence of DU: DU were found in 22.9% of 921 patients undergoing UGIE in 2000–2004 but in only 9.2% of 878 patients between 2005 and 2010. There was a slight increase in number of patients diagnosed with GU (12.7% in 2001–2004 vs. 13.7% in 2005–2010), with GU now constituting more cases of PUD than DU. Similarly, Nwokediuko et al.[20] in Enugu in South-East Nigeria reported a marked decline in the prevalence of DU at endoscopy from 9.7% of 575 cases in 1995–1999 to only 1.9% of 790 in 2006–2010. GU, on the other hand, tripled in prevalence from 2.1% of cases to 6% in the two time periods and were now three times as common as DU, consistent with our finding. This trend has also been reported from other African countries. Gyedu and Yorke[21] from Kumasi, Ghana, reported that out of 3110 patients examined for various indications from 2006 to 2011, 147 (4.7%) were diagnosed with GU and 94 (3%) with DU. Kayamba et al.[22] reporting on their experience of UGIE in 16,953 patients over a 38-year period in Zambia found a 22% rise in the diagnosis of GU per decade and an even higher (32%) fall in DU diagnosis per decade. Between 2003 and 2014, GU had consistently become more common than DU, and between 2011 and 2014, twice as many GU as DU were diagnosed.[22] Obayo et al.[23] from South-Western Uganda also reported in 2015 that GU constituted twice as many cases as DU. This phenomenon has also been observed in Asia. In a multiracial Asian population in Malaysia, Leow et al.[24] reported a progressively declining prevalence of DU at endoscopy over a 20-year period from 21.1% in 1989–1990, to 9.5% in 1999–2000, to 5% in 2009–2010. The prevalence of GU had declined only a little (11.9% [1989–1990], 9.4% [1999–2000], and 9.9% [2009–2010]) but was almost as twice as common as DU in the later period. In India, Dutta et al.,[25] in a study of 30,216 patients presenting with uncomplicated dyspepsia from 1998 to 2008, found DU progressively fell in frequency from 12% in 1998–2.9% in 2008 while GU showed a smaller decline from 4.5% in 1998 to 2.7% in 2008. This declining prevalence of PUD has also been reported in Europe[8],[26] and in North America[27] where ratios of DU to GU have not been as high as in Africa and Asia.
Table 3: Pattern of peptic ulcer disease in recent endoscopic reports from Nigeria, Africa, Asia, and the worldApart from a declining prevalence of PUD and the predominance of DU over GU, in contrast to previous reports from the region, we also observed that our patients were, on average, 10 years older than 20 - 30 years ago, a majority were above 40 years, and over half were at least 50. This phenomenon has also been reported from countries where the prevalence of PUD, and particularly DU, has fallen.[22],[23],[24],[25],[26],[27],[28] Our patients with PUD were also predominantly male, who tended to have more GU than females, as has been reported in Europe,[26] America,[27] and Australia,[28] in contrast to our patients with other gastroduodenal diseases who were predominantly female.[29]
There are many reasons that can be adduced for our observations and those of others. H. pylori infection is very common in dyspeptic Nigerian patients with PUD and has been strongly linked with the disease, although it is also commonly found in patients with other gastroduodenal diseases and in asymptomatic controls.[30] The etiology of PUD is likely multifactorial with H. pylori infection playing a significant but not the sole factor.[10] We have not tested H. pylori infection in our patients, and we do not know to what extent this infection is associated with our cases compared to previous reports from the region[31],[32] where high rates of H. pylori infection have been found among patients with PUD and other gastroduodenal diseases. A decline in the prevalence of H. pylori infection has been reported worldwide[1],[2],[8],[10] and mirrors the decline of PUD reported in many countries, although a birth-cohort effect has also been advanced to explain these changes.[33] It is possible this is also a factor in our patients including a declining prevalence in infection due to improvement of the standard of hygiene in our catchment area compared to 20–30 years ago. A more important factor in the decline of PUD in our patients may, however, be the widespread use of proton-pump inhibitors (PPIs). PPIs are now freely available in pharmacies in our region, are often obtained without a prescription, and are overprescribed or inappropriately used even in our tertiary centers.[34] Their widespread use for dyspepsia by patients could suppress acid production and alter the natural history of the infection. Broad-spectrum antibiotics (aminopenicillins and fluoroquinolones) and antiprotozoal agents (metronidazole and tinidazole) are also widely available and used indiscriminately to treat a variety of infections and any diarrheal illness;[35] their use at suboptimal doses and for shorter durations could suppress H. pylori infection without eliminating it entirely and alter the course of the infection. The observed marked decline in rates of DU in our report and those of others, a disease most closely associated with DU, is consistent with this observation. It is also instructive to note that endoscopic features of gastritis and duodenitis were very common in our patients irrespective of whether patients had a GU or DU: 83.6% of patients had gastritis, 38.6% had duodenitis, and 23% had gastric atrophy underscoring the importance of H. pylori infection in other gastroduodenal diseases other than PUD in our patients. We could confirm only eight cases of suspected gastric malignancy: many biopsy reports were not available for analysis because patients took specimens away to other centers and did not return for follow-up.
Our finding that GU now made up twice as many DU could also be explained by other conditions causing PUD now having a more prominent role. NSAIDs, including aspirin, are well-known causes of PUD all over the world,[11] including Africa.[12] A marked rise in prescription in primary care and in specialist settings has been reported in Nigeria. Awodele et al.[36] found that almost a quarter of more than 17 thousand prescriptions in a tertiary health-care center in Lagos in a 6-month period contained NSAIDs. These drugs, available over the counter in pharmacies and chemist shops in both urban and rural areas,[37] are also now extensively advertised on television[38] and other media as the go-to treatment for aches, pains, and tiredness. Their use is likely higher in older patients because of arthritis and other musculoskeletal abnormalities, and this can partly explain why majority (70%) of our patients were 40 years or older and were significantly more likely to be diagnosed with GU than DU. DU, a disease most closely related to H. pylori infection, were significantly more common in our younger patients (age <40 years), an age group in which the use of NSAIDs was likely to be less. Additionally, our center serves both a cosmopolitan and a rural population of diverse ethnic, social, and cultural backgrounds where alcohol is consumed more often than in the more northern parts of our region[39] and this could be a factor in the preponderance of males over females, and of GU over DU we noted.
Our study is retrospective and has limitations. We did not routinely assess H. pylori infection in our patients, and no studies of H. pylori infection in PUD patients have been done in Kaduna in the past, so we do not know whether the decline in prevalence of PUD is a reflection of a fall in infection rates. We also do not know precisely the influence of NSAIDs and aspirin in the causation of ulcers, but NSAIDs have been found to contribute to PUD in countries where this was specifically studied.[12]
Conclusion We have found a marked change in frequency and pattern of PUD in Kaduna, Nigeria. Peptic ulcers are observed much less frequently and affect an older population and predominantly males, and GU now predominate. These changes are probably due to increased and inappropriate use of PPIs, antibiotics, and NSAIDs and probably a declining prevalence of H. pylori infection. Studies are needed to assess the current epidemiology and characteristics of H. pylori infection in our region.
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Conflicts of interest
There are no conflicts of interest.
References 
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