CAPÍTULO II. METODOLOGÍA 3
3.1. Características psicopedagógicas de los mentorizados
3.2.2. De orientación académica
3.2.2.1. Cuestionario Proyecto de vida
36
Association between gender, gastroduodenal lesions, H.pylori infection and presence symptoms.
There was no association between gender, gastroduodenal lesions, H.pyloriand symptoms.Table8: Association between Gender, gastroduodenal lesions (GD), H.pylori infections and symptoms.
Asymptomatic Symptomatic X2 P
n=64 n=32
Sex
Female 43(67.2%) 24(75%) 0.618 0.432
Male 21(32.8%) 8(25%)
Patient’s diagnosis
Hypertension 32(35.2%) 59(64.8%)
Ischaemic stroke 0(0.0%) 5(100.0%) 2.637 0.104
GD lesions
Present 35(54.7%) 20(62.5%) 0.532 0.466
Absent 29(45.3%) 12(37.5%)
37
Association between symptoms and gender of the studied patients
There is no significant association between occurrence of symptoms and the gender of the studied patients. See table 9.
Table 9: Association between symptoms and gender
Symptoms Gender
Female (n=67) Male (n=29) X2 P
Abdominal pains 12(17.9%) 6(20.7%) 0.103 0.749
Heartburn 5(7.5%) 1(3.4%) 0.557 0.456
Bloating 2(3.0%) 1(3.4%) 0.014 0.905
Vomiting 2(3%) 0(0.0%) 0.884 0.347
Melaena 3(4.5%) 0(0.0%) 1.340 0.247
No symptoms 42(62.7%) 21(72.4%) 0.618 0.432
38
Table 10: Association between symptoms and age of the patients.
There was no significant association between symptoms and age of the studied populations.
Table 10: Association between symptoms and age of the patients
Symptoms Age Group X2 P
Less than 65 years (%) More than 65 years (%)
n=55 n=41
Abdominal pains 10(18.2) 8(19.5) 0.248 0.883
Heart burn 6(10.9) 0(0.0) 6.021 0.095*
Bloating 2(3.7) 1(2.4) 2.524 0.589*
Vomiting 0(0.0) 2(4.9) 4.402 0.201*
Melaena 1(1.8) 2(4.9) 2.524 0.589*
No symptoms 36(65.4) 28(68.3) 0.085 0.770
NB: *=Fishers’ exact test
39 Endoscopic findings in study populations
The pattern of oesophageal lesions are shown below. These were incidental findings. Short segment Barrett accounted for 13.5% of patients with oesophageal lesions. See table11.
Table 11: Oesophageal lesions
Oesophageal lesions Frequency n=96 %
Hiatus hernia 6 6.3
Varices 3 3.1
Short segment Barrett 13 13.5
No oesophageal lesions 74 77.1
40 Proportions of patients with gastroduodenal lesions
Proportions of studied populations with gastroduodenal lesions on upper GI endoscopy were 55(57.3%). See figure 2.
Figure 2: Proportions of patients with gastroduodenal lesions
Gastroduodenal lesions 55 (57.3%) No
Gastroduodenal lesions 41(42.7%)
41 Proportions of patients with erosions and ulcers.
Table 12 shows the proportions of patients with lesions. Thirty nine (40.6%) patients had erosions.Patients with ulcers and combination of erosions with ulcers were 9(9.4%) and 7(7.3%) respectively. Patients without lesions were 41(42.7%).
Table 12: Proportions of patients with erosions and ulcers
Lesions Frequency n=96 %
Erosion 39 40.6
Ulcers 9 9.4
Erosions and Ulcers 7 7.3
No Gastroduodenal lesions 41 42.7
42 Pattern and sites of gastroduodenal injury
Erosions were more prevalent in the antrum 37(38.6%) and body 21(21.9%) of the studied population while ulcers were documented more in the pyloric area 11(11.4%). The cardia and second part of the duodenum has no documented ulcers. See figure 3.
Figure 3: Pattern and sites of gastroduodenal lesions
15(15.6) 21(21.9) 20(20.8)
37(38.6)
18(18.8)
7(7.3)
3(3.1)
0 2(2.1) 2(2.1) 3(33.1) 11(11.4) 2(2.1) 0
81(84.6)
73(76) 74(77.1)
56(58.3)
67(69.8)
87(90.6) 93(96.9)
0 10 20 30 40 50 60 70 80 90 100
Cardia Body Fundus Antrum Pylorus Duodenum 1 Duodenum 2
Frequency of lesions(%)
Sites of lesions Erosions Ulcers Normal findings
43
Prevalence of H.pyloriinfection among studied population.
Using urea breath tests, 72.9% of the studied population were positive for H.pylori.See table 13.
Table 13: Percentage of patients with H.pylori infections using urea breath test
Urea breath test Frequency %
Positive 70 72.9
Negative 26 27.1
Total 96 100
Characteristics of subjects with endoscopic and non-endoscopic abnormality
The characteristics of subjects with endoscopic and non-endoscopic findings are shown in tables 14 and 15. The association between age and gastroduodenal lesionsis shown in table 14 and while table 15 shows the association between gender, H.pylori infection and gastroduodenal lesions.
There was no significant association between the mean age of the studied population and gastroduodenal lesions. See table 14.
Table 14: Association between age of the studied population and gastroduodenal lesions.
Endoscopic findings
Variable Gastroduodenal lesions No gastroduodenal lesions t P
Mean±SD Mean±SD
Age 61.20±12.041 62.05±10.469 0.329 0.719
44
Association between gender, H.pylori infection and gastroduodenal lesions of the studied population.
There is no association between gender, H.pylori infection and the gastroduodenal lesions.
See table 15.
Table 15:Association between gender, H.pylori infection and gastroduodenal lesions.
Endoscopic findings
Variable Gastroduodenal lesions No gastroduodenal lesions X2 P
n=55 n=41
Gender
Female 41(74.5%) 26(63.4%) 1.380 0.240
Male 14(25.5%) 15(36.6%)
Patient‘s Diagnosis
Hypertension 53(96.4%) 38(92.7%)
Ischaemic stroke 2(3.6%) 3(7.3%) 0.645 0.422
H.pylori infection
Positive 38(69.1%) 32(78.0%) 0.954 0.329
Negative 17(30.9%) 9(22.0%)
45
Relationship between symptoms and H.pyloriinfection.
There was no significant association between symptoms in patients who are H.pyloripositive and those who are H.pylorinegative. See table 16.
Table 16: Association between occurrence of symptoms andH.pyloripositivity
Symptoms H.pylori X2 P
Negative Positive
n= 26 n= 70
Abdominal pains 7(26.9%) 11(15.7%) 1.563 0.211
Heartburn 1(3.9%) 5(7.1%) 0.352 0.553
Bloating 1(3.9%) 2(2.9%) 0.061 0.805
Vomiting 0(0.0%) 2(2.9%) 0.759 0.384
Melaena 1(3.9%) 2(2.9%) 0.061 0.805
No symptoms 16(61.4%) 48(68.5%) 0.422 0.516
46
Association between gastroduodenal lesions and H.pyloriinfection.
Using urea breath test, there was no association between gastroduodenal lesions and the presence or absence of H.pyloriinfection. See table 17.
Table 17: Association between gastroduodenal lesions and H.pylori
Helicobacter pylori X2 P
Negative Positive Gastroduodenal lesions n=26 n=70
Erosions 12(46.2%) 27(38.6) 0.452 0.501
Ulcers 4(15.4%) 5(7.1%) 1.516 0.218
Erosions and Ulcers 1(3.8%) 6(8.6%) 0.626 0.429
No lesions 9(34.6%) 32(45.7%) 0.954 0.329
47
Relationship between symptoms and gastroduodenal lesions
There was no significant association between occurrence of symptoms in patients who had erosions with ulcers and those who did not. See table 18
Table 18: Association between occurrence of symptoms and gastroduodenal lesions
Symptoms Gastroduodenal lesions X2 P
Erosions and ulcers No Erosions and Ulcers
n=55 n=41
Abdominal pains 11(20.0%) 7(17.1%) 0.132 0.716
Heartburn 3(5.5%) 3(7.3%) 0.139 0.709
Bloating 1(1.8%) 2(4.9%) 0.726 0.394
Vomiting 2(3.6%) 0(0.0%) 1.523 0.217
Melaena 3(5.5%) 0(0.0%) 2.309 0.219
Asymptomatic 35(63.6%) 29(70.7%) 0.532 0.466
48 Association between symptoms and erosions
There was no significant association between symptoms in patients who have erosions and those who did not have erosions. See table 19.
Table 19: Association between symptoms and erosions
Symptoms Erosions present Erosions absent X2 P
n=39 n=57
Abdominal pains 7(18.0%) 11(19.3%) 0.028 0.868
Heartburn 2(5.1%) 4(7.0%) 0.141 0.707
Bloating 1 (2.6%) 2(3.5%) 0.068 0.794
Vomiting 1(2.6%) 1(1.8%) 0.074 0.785
Melaena 2(5.1) 1(1.8%) 0.871 0.351
Asymptomatic 26(66.6%) 38(66.6%) 1.238 0.941
49 Relationship between symptoms and ulcers
There was significant association between patients who complained of abdominal pains and the presence of ulcers. See table 20.
Table 20: Association between symptoms and ulcers
Symptoms Ulcers Present Ulcers Absent X2 P
n=9 n=87
Abdominal pains 5(55.6%) 13(14.9%) 8.831 0.003*
Heartburn 0(0.0%) 6(6.9%) 0.401 0.527
Bloating 0(0.0%) 3(3.5%) 0.320 0.571
Vomiting 0(0.0%) 2(2.2%) 0.211 0.646
Melaena 0(0.0%) 3(3.5%) 0.320 0.571
No symptoms 4(44.4%) 60(69.0%) 2.207 0.137
NB: *=P< 0.05
50
Association between age of the patients and gastroduodenal lesions
There was no association between age in the studied population and lesions. See table 21.
Table 21: Association between gastroduodenal lesions and age
Gastroduodenal Age group
lesion
< 65years ≥ 65 years X2 P
n=55 n=41
Erosions 24(43.6%) 15(36.6%) 0.484 0.487
Ulcers 4(7.3%) 5(12.2%) 0.733 0.693
Erosions/Ulcers 5(9.1%) 2(4.9%) 0.741 0.690
No lesions 22(40.0%) 19 (46.3%) 1.9502 0.591
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CHAPTER FIVE DISCUSSION:
The majority of the patients (81.2%) were middle aged and the elderly between the ages of 50 to 79 years.This was not surprising since people within these age groups are likely to have an increased risk of cerebrovascular and cardiovascular eventsrequiring prophylactic aspirin use.5,7 One third of the studied population were retired(33.3%) which is not surprising judging by the mean age of thestudy subjects.The geographical setting of the hospital reflects the predominance of Yoruba ethnicity (72.9%) among study subjects and the level of literacy of the studied populationwhich was 90.6% (at least a secondary education).LASUTH is a tertiary and a referral centre located in Ikeja which is an urban settlement and the capital of Lagos state with the Yorubas as the predominant ethnic group.
Ninety one (94.8%) patients of the studied population were hypertensive and while 5(5.2%) had ischaemic stroke. This explains the high number of patients recruited from cardiology clinic since their primary diagnosis was hypertension.
The prevalence of symptoms due to LDA in this study was 33.3%. The predominant symptom was abdominal pain (18.8%) and the epigastrium was the frequently complained area of the abdomen (7.3%). This finding is similar to other studies where the prevalence was documented to be between 15.4- 47.8%42, 43, 46. However, Cayla et al found gastroesophageal reflux symptoms (heartburn and regurgitations) more prevalent than abdominal pains.No reason was given for this finding.The JUPITER study by Yeoman and his colleaguesalso documented abdominal pains and epigastric region as the most predominant symptom and site respectively.The prevalence of symptoms in that study was however 20% which was lower than findings in this study. The severity of abdominal pain documented in the JUPITER study was noted to be predominantly mild to moderate in intensity. This finding is
52
similar to what was obtained in this study. Sixty one percent of the respondent in this study reported abdominal pains of mild severity.Abdominal pains of severe intensity was not documented in this study, this was not surprising, patients with severe pains would have presented to the emergency for further evaluation rather than this outpatient setting.
This study also has not shown any difference between subjects who developed symptoms and those asymptomatic following use of LDA in terms of their age, gender or underlying comorbidity. This may because this study was not designed to compare age, gender or underlying comorbidity in the patients recruited who were on LDA.
In the UGLA studyof over 8,000 respondents who were 50 years and above,Cayla and his colleagues also found no association between gender and symptoms due to LDA use.Similar to what was obtained in this study.42There was however no detail statistical analysis relating patient’s comorbidity, age and upper GI symptoms.
There is no significant association between symptoms developed while on LDA,gastroduodenal lesions and advanced age in this studied population. Some studies have shown that there is a significant association between the development of gastroduodenal lesions and age above 70 years. This is contrary to findings in other studies.126
The prevalence of H.pylori infection in this study was 72.9%. This is in line with findings obtained in several studies which was between 64.5-90%.102In the Southern part of the country, Ndububa et al found the prevalence to be 73%.101while in the Northern part of the country, Mustapha and his colleagues found the prevalence of H.pylorito be 78.5%.100However, several studies did not find any significant statistical association between endoscopic lesions in patients who are H.pyloripositive and those who are H.pylori negative.
Adeniyi and their colleagues found no significant association between H. pylori and PUD compared to non-ulcer dyspepsia.125 Mustapha et al did not document any significant
53
difference in the frequency ofH.pyloriinfection among patients with organic dyspepsiaand those with normal endoscopic findings (non-ulcerdyspepsia).100Jemilohunand their colleagues noted no statistically significant difference in the frequency of H. pylori infection among patients with abnormal endoscopic findings and those with normal findings.102This shows that H.pylori infection which is an independent risk factor for the development of gastric and duodenal ulcers in several studies was found not to be statistically significant in patients who had lesions and those who did not.Similarly, in this research there was no significant difference in the gastroduodenal lesions in those who wereH.pylori positive and those who wereH.pylorinegative.The reasons for this may be due to the high prevalence of H.pyloriinfection even in healthy patients in Nigeria (up to 90%) and so even with the background LDA use that may have had a synergistic effect in terms of development of ulcers,it was statistically insignificant considering that there was high H.pylori prevalence in those who had lesions were as well as those who did not develop any lesion. In Asia, several Japanese studies have shown that patients who were chronic LDA users and H.pyloripositive have fewer lesions or even similar prevalence to those who were H.pylori negative compared to what was obtained in Western studies.44,128The reasons for these findings was that patients were either normal, hypo or hyper acid secretors due to H.pyloriinfection and the pattern of gastritis (pan gastritis or antral predominant).93-95Hypo (low) acid secretors were associated with fewer lesions as compared to those who were hyper or normal.The suggestion was that Japanese patients were probably hypo acid secretors so they have fewer lesions compared to their Western patients.129-131Acid secretion was not measured nor was the type of H.pylori gastritis determined histologically as a remote plausible reason for the findings obtained in this study. The prevalence of gastroduodenal lesions documented in this study was 57.3%.
Erosions, ulcers and combinations of erosions and ulcers were 40.6%, 9.4% and 7.3%
respectively.The prevalence of erosions/ulcers and ulcers in these studies range between
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47.8% to 68% and 10.7% to 39.1% respectively. This finding was similar to what was obtained in other studies.43, 46, 47, 133
The pattern of gastroduodenal lesions in this study showed that no part of the stomach was resistant to LDA and that lesions were more prevalent in the stomach than in the duodenum.
The finding stated abovewere similar to what was obtained in other LDA studies.47, 50 Erosions were predominantly more in the antral area while ulcers were more predominant in the pyloric areas. The cardia and 2nd part of the duodenum did not document any ulcers but had erosions. Researchers agree that the most frequently and severely affected site is the gastric antrum in patients who use NSAID including low dose aspirin.50 which is in tandem to what was obtained in this study.
The endoscopic findings in the oesophagus were short segment Barrett, hiatus hernia and varies. Short segment Barrett and hiatus hernia are features of gastroesophageal reflux disease(GERD) and thevarices were due to background portal hypertension. These findings are incidental findings as LDA is not known to not cause varices or GERD.
There was a significant association between patients who had abdominal pains and endoscopic findings of ulcers in this study. However, there was no association between the other symptoms (heartburn, bloating, vomiting and melaena) and endoscopic lesions documented. Yeoman and his colleagues also found that there was an association between ulcers and epigastric discomfort but not with theother symptoms.46Symptoms due to adverse effects of LDA are not reflective or predictive of endoscopic lesions. This finding was similar to what was obtained in other studies that dyspepsia is clearly not predictive of endoscopic gastroduodenal lesions.17 There was no documentation of complicated ulcers such as bleeding or perforationin this study.This may be because patient recruitment was from the clinics, so life threatening complications may have presented in the emergencies.
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CHAPTER SIX CONCLUSION
1. The prevalence of the symptoms due to prophylactic aspirin use was 33.3% and that of gastroduodenal lesions was 57.3%. This was comparable to findings in other studies.
2. The pattern of endoscopic lesions were predominantly antral gastritis 37 (38.6%) and a few pyloric ulcers were predominantly pyloric 11(11.4%) These findings were similar to other studies. No complicated lesions such as bleeding or perforation was documented.
3. The prevalence of H.pylori was 70(72.9%) using Urea breath test which was higherthan western society’sprevalence but similar to what was obtained in several Nigerian studies.
4. There was no association between endoscopic lesions in patients who wereH.pylori positive and H.pylori negative on the background of prophylactic aspirin use. The reasons for this contrast could have been dueto the high prevalence of H.pylori infection even in healthy individuals.
5. There was significant association between ulcers and abdominal pains. However, there was no association between the other symptoms and endoscopic findings documented.
56 RECOMMENDATIONS
1. Risk stratification is important prior to commencing patients on long term low dose aspirin to minimize/prevent avoidable unnecessary complications.
2. Patients who developed abdominal pains even if mild while on LDA should be evaluated with gastroscopy for ulcers to prevent further complications.
3. Periodic clinical re-evaluation of patient’s risk factors is of important benefit to forestall complications due to LDA and endoscopic follow up when indicated, especially when the risk of LDA use in the long term may outweigh the benefits. The challenges may be the cost and expertise required in performing gastroscopy and the willingness of the seemingly well patients to undertake the procedure.
57 LIMITATIONS
This study was not powered to take endoscopic biopsies for histopathology, it would have provided more information concerning H.pyloriinfection and the relationship to endoscopic lesions.
58
59 APPENDIX II
INFORMED CONSENT
RESEARCH STUDY: Prevalence of the adverse effects of prophylactic dose of aspirin on the upper gastrointestinal tract of selected patients in LASUTH.
I………. hereby consent to participate in the above study.
DR………. has explained the nature of the study with its benefits and risks to me which may include discomfort during the upper GI endoscopy and when taking blood samples. I understand the study is to be carried out solely for the purpose of medical research and I am willing to act as a volunteer for that purpose. I recognize that the result of the study may be of significant benefit to mankind.
Date………Sign……….Witness………
…
Relationship to
witness………
I confirm that I have explained to the subject the purpose and nature of the study, including the fact that refusal to participate will not in any way affect his/her continuing management.
All information obtained in this study are confidential and the subject’s data will be identified by a study code number and names will not be used in this study. If any information is published, there will not be any link which will identify the subject as a participant.
………
DR. EKERE FRANCIS
60
APPENDIX III