| Background and aimsThe discovery of Helicobacter pylori has revolutionized the management of peptic ulcer disease. In the last 15 years, H pylori infection was the most important cause of peptic ulcers and ulcer relapse worldwide.With the declining prevalence of H pylori infection in Western countries, the proportion of patients with Hpylori–negative idiopathic ulcers is increasing. Several studies in North America have shown that between 11%and 44% of peptic ulcers are not associated with H pylori infection or the use of nonsteroidal anti-inflammatory drugs (NSAIDs).so as in Hongkong. But the clinical significance of these observations is uncertain . Because the prevalence of H pylori infection is also declining in our country ,after the wildly used eradication therapy, it is anticipated that the pattern of ulcer disease may follow that of the United States. Little is known about the characteristics and longterm outcome of patients with H pylori–negative idiopathic ulcers.So the primary aim of this study was to examine the proportion und natural history of Hpylori–negative idiopathic bleeding ulcers. The clinical features of H pylori bleeding ulcers. The secondary aim was to study whether it is necessary to re-examine the patients with H pylori–negative bleeding ulcers.Materials and MethodsThis was a prospective,multiple-center, cohort study conducted at 26 Endoscopy Center (Hospitals) in China, We screened consecutive patients with a clinical diagnosis of upper gastrointestinal bleeding. All patients provided informed written consent. All patients who were diagnosed to have upper gastrointestinal bleeding underwent endoscopy within 24 hours of onset of bleeding. When ulcer was found,biopsy specimens were taken from the antrum (2 biopsies), corpus (2biopsies), and ulcer edge (4 quadrant biopsies) to determine Hpylori infection .H pylori infection was assessed by a biopsy urease test and histology using H&E stain and Giemsa stain if necessary. H pylori infection was considered to be present if either the biopsy urease test or histology was positive for thebacterium. The features of ulcers, the sites and diameters of ulcers , and grade of Forrest Classification were recorded. Negative H pylori infection patients were asked to perform 13C or14C breathe test a month later. Statistical Analysis:The patients'baseline characteristics were presented as descriptive data. We used Student t test ,Fisher test to compare means,χ2 test to compare categorical data. Dates were analysised by SAS .ResultsSix hundred and seventeen patients were enrolled in this study.Peptic ulcer with bleeding (n=263), ulcers without bleeding (control group)(n=354)are all confirmed by endoscopy. There is no significant difference found in gender ,age ,weight and H pylori infection rate between two groups(P>0.05). No NSAIDs used cases. In peptic ulcer with bleeding group 7.3%of patients hat history of cardologic or pulmonary system disease, that was significantly higher than that of control group(P<0.05).In peptic ulcer with bleeding group 3.8%and 73.4%patients were haematemesis and melena ,respectively. 22.8% patients manifested both.As for the accompanied symptoms, incidence of abdominal pain in bleeding group was significantly lower than that of control group, 82.8% vs 55.1%(P<0.001).Association between H pylori–negative idiopathic ulcers and bleeding: Among the 263 evaluable PUB patients, 61.2% were positive for H pylori, and38.8%had H pylori–negative idiopathic bleeding ulcers .That indicated the proportion of H pylori–negative idiopathic bleeding ulcer might be high in our country.In control group 87.9% of cases were positive for H pylori, that was significantly higher than that of PUB group(P<0.001). H pylori–negative idiopathic ulcers might trended to bleed.Clinical features of H pylori–negative idiopathic bleeding ulcers: There was no significant difference found in age and rate of haematemesis between H pylori–negative idiopathic bleeding ulcer and H pylori–positive bleeding ulcer groups(P>0.05). the incidence of complex ulcer in H pylori–positive bleeding ulcer group is 7.5%, that was significantly higher than that of H pylori–negative idiopathic bleeding ulcers(P<0.05)In these two groups, Duodenal ulcers accounted the great part of causes of bleeding, gastric ulcers were less, 78.9% and 74.5% vs 28.6%and 26.5%respectively.Among Duodenal ulcers , most popular site is on anterior wall,48.4%and 44.1% in two groups respectively. Among gastric ulcers , most popular site is on annum. There was no significant difference found in diameters of ulcer between H pylori–negative idiopathic bleeding ulcer and H pylori–positive bleeding ulcer groups(0.78±0.45cm vs 0.75±0.37cm,P>0.05).The proportion of Forrest III grade in H pylori–negative idiopathic bleeding ulcer group was significantly lower , DU 85.5%vs 92.1%,GU 74.1%vs 87.6% (P<0.05).Results of re-examinination for H pylori–negative idiopathic bleeding ulcer : Among 102 cases of H pylori–negative idiopathic bleeding ulcer ,97 cases performed 13C or 14C breathe test ,no H pylori–positive case found.ConclusionIn this prospective multiple-center case-control study, we have demonstrated a rise in the incidence of Hpylori–negative idiopathic bleeding ulcers, it was showed that idiopathic ulcer was not rare, and might have higher trendcy to bleed. That was important for clinical gastrointestinal practice.Clinical features of Hpylori–negative idiopathic bleeding ulcers are not significantly different from those of Hpylori–positive bleeding ulcers. Neither the location nor the appearance of ulcers predicted their etiology.But patients with idiopathic bleeding ulcers had a considerable risk of severe bleeding and recurrent ulcer complications.Many patients with so-called H pylori–negative ulcers were subsequently found to have false-negative tests for H pylori because of poor sensitivity of diagnostic tests because of bleeding. But in our study we did not find false-negative results. RUT and biopsy are golden standard for H pylori–infection in PUB patients.
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