Where have all the helicobacter gone? etiologic factors in patients with duodenal ulcers (DU) presenting to a university hospital

Previous studies have documented that nearly 90% or more of patients with DU have concomitant Helicobacter pylori (Hp) gastritis. This has resulted in the widespread use of testing for and treatment of patients with gastric and duodenal ulcers in the community. Our aim was to determine if this practice has altered the natural history of patients with DU presenting to a tertiary referral hospital. Methods: We reviewed the endoscopic and medical records of all patients with DU as confirmed by endoscopy in a one year period from Nov 1995 to Nov. 1996. The following parameters were specifically evaluated: 1) the presence of Hp either by gastric biopsies or serology 2) recent antibiotic use 3) recent use of proton pump inhibitors (PPi) 4) recent use of bismuth 5) NSAID use. Results: Of 114 patients with DU, 34 were excluded from analysis because the presence of Hp could not be evaluated. Of the remaining 80 patients, 31 (39%) tested positive for Hp whereas 49 (61%) tested negative for Hp. After exclusion for prior antibiotic and bismuth use there 39 patients (50%) patients who were Hp negative. NSAID use was identified in 15 of these patients. There were no differences in mean age or gender ratio in Hp positive vs. negative patients. However, only about 25% of white patients with DU were Hp positive as compared with nearly 50% of African American patients (P = 0.02). Conclusions: The present profile of patients with DU at a tertiary referral hospital appears to have changed when compared to historic reports. DU is associated with Hp in 50% or less of patients. NSAID use may be responsible only for some of the Hp-negative cases. Although no definite etiology could be identified in most of the others, the race of the patient may play an important role in that white patients with DU are more likely to be Hp-negative.