PEPTIC ULCER PREVALENCE AMONG PATIENT ATTENDING INTERNATIONAL UNIVERSITY TEACHING HOSPITAL IN BUSHENYI MUNICIPALITY

BY

NAMUGERWA JULIANA DCM /0020/143/DU

A RESEARCH REPORT SUBMITTED TO SCHOOL OF ALLIED HEALTH SCIENCES IN PARTIAL FULFILLMENT

OF THE REQUIREMENTS FOR THE AWARD

OF DIPLOMA IN CLINCAL MEDICINE

AND COMMUNITY HEALTH AT

KAMPALA INTERNATIONAL

UNIVERSITY

JUNE, 2017 DECLARATION

I, Namugerwa Juliana (REG. No: DCM/ / /DU) declare that this thesis is my own work and that all the sources that I have used or quoted have been indicated and acknowledged by mean of complete reference.

SIGNATURE………………………..

DATE…………………………………

SUPERVISOR’S APPROVAL

This research proposal/report has been done under my supervision and is ready to be submitted for examination with my approval.

SUPERVISOR: MR. TASHOBYA DANIEL KAMUGISHA

Signature………………………………

Date……………………………………

ACKNOWLEDGEMENT

First and foremost I am thankful to the almighty God for the gift of life and good heath that has enabled me to reach this far in my studies and work as well.

Special appreciation to my research supervisor Mr. Tashobya Daniel Kamugisha for all the help and guidance he has accorded me throughout my research and without whose efforts this work would be in vain.

My sincere gratitude also goes to the entire academic staff, School of Allied Health Sciences (SAHS), Kampala International University- Western Campus, for their coordinated effort and commitment to ensure that we acquire necessary competences both in class and in the field.

I do extend my infinite gratitude to my …family members (name them)………………………………whose prayers, moral, social and financial support has brought me this far.

Last but not least, I extend my special thanks to all my classmates 14 series for the encouragement during the course of our study.

Thank you all so much.

DEDICATION

The research is dedicated to my family members, all my friends and more importantly to my supervisor Mr. Tashobya DanielKamugisha for his kindness, generosity and guidance. I appreciate every little contribution every one of you rendered towards this research report. Am humbled and God bless you all.

TABLE OF CONTENTS SUPERVISOR’S APPROVAL ...... 3 ABBREVIATIONS AND ACRONYMS ...... 8 ABSTRACT...... 10 CHAPTER ONE ...... 11 1.0 INTRODUCTION ...... 11 1.1 BACKGROUND ...... 11 1.2 PROBLEM STATEMENT ...... 12 1.3 OBJECTIVES ...... 13 1.3.1 Broad objective ...... 13 1.3.2 Specific objectives ...... 13 1.4 Research questions ...... 13 1.5 STUDY JUSTIFICATION...... 13 1.6 SCOPE OF THE STUDY ...... 13 1.6.1 Geographical scope ...... 13 1.6.2 Content scope...... 14 1.6.3 Time scope...... 14 CHAPTER TWO ...... 15 LITERATURE REVIEW...... 15 2.0 INTRODUCTION ...... 15 2.1 EPIDEMIOLOGY OF PUD ...... 15 2.2 GENDER DISTRIBUTION ...... 17 2.3 AGE DISTRIBUTION...... 18 CHAPTER THREE ...... 18 METHODOLOGY ...... 19 3.0 Introduction ...... 19 3.1 Study Design ...... 19 3.2 Study Area ...... 19 3.3 Study Population...... 20 3.4 Sample Size ...... 20 3.5 Sampling Method...... 21 3.6 Inclusion Criteria ...... 21 3.6.1 Exclusion criteria ...... 21 3.7 Ethical considerations ...... 21 3.8 Data collection ...... 21 3.9 Data analysis and presentation ...... 21 3.10 Study Limitations ...... 21 CHAPTER FOUR ...... 22 STUDY FINDINGS ...... 22 4.0 Introduction ...... 22 4.1 Socio-demographic characteristics ...... 22 4.2 Clinical presentation ...... 22 4.3 Respondents’ gender distribution ...... 22 4.4 Respondents’ age distribution ...... 23 4.5 Diagnosis of PUD ...... 24 4.6 PUD specific gender distribution ...... 24 4.7 PUD specific age distribution...... 25 4.8 PUD main symptoms...... 25 CHAPTER FIVE...... 27 DISCUSSION...... 27 5.0 Introduction ...... 27 5.1 Prevalence of PUD ...... 27 5.2 PUD gender distribution ...... 27 5.3 PUD age distribution ...... 27 5.4 Conclusion...... 28 5.5 Recommendations...... 28 REFERENCES ...... 29 APPENDIX: III ...... 35

ABBREVIATIONS AND ACRONYMS

CDC Centers for Disease Control

DU Duodenal Ulcer

EGD Esophagogastroduodenoscopy

GERD Gastroesophageal Reflux Disease

GU Gastric Ulcer

H.Pylori Helicobacter pylori KIU-TH Kampala International University-Teaching Hospital

KIU-WC Kampala International University-Western Campus

MCH Maternal Child Health

NSAIDs Non SteroidalAnti inflammatory Drugs

PPI Proton Pump Inhibitor

PUD Peptic Ulcer Disease

ABSTRACT.

The study assessed the prevalence of peptic ulcer disease among patients attending of Kampala International University Teaching Hospital and the objectives of study were to find out the gender distribution of peptic ulcer disease and to find out which age group is more affected by peptic ulcer disease among patients attending of Kampala International University Teaching Hospital

It was a retrospective study in which quantitative methods were used to collect data from the patients and later described, compared and analyzed different variables

The study found out that PUD is highly prevalent among patients attending KIUTH (14.8%) and is highest among the middle age group of 31-40 years (32.7%), with females (66.7%) being more affected than males (33.3%).

In conclusion, although some interventions have been put in place to manage PUD, its prevalence is still high and more interventions are required therefore the following were the recommendations made after the study, Community sensitization on causes of PUD should be enforced at hospitals and also better diagnostic techniques should be used for early diagnosis of PUD

CHAPTER ONE

1.0 INTRODUCTION This chapter will contain background of the study, problem statement, study objectives, study questions and justification of the study and scope of the study.

1.1 BACKGROUND Ulceration of the Gastric or Duodenal mucosa occurs in many individuals. The term peptic ulcer disease includes both the gastric and duodenal ulcers. Among the mechanisms that may contribute to ulcer formation are diminished effectiveness of the gastric mucosal barriers, hyper secretion of acid, and infection by Helicobacter pylori bacteria.

PUD is a common disorder that affects millions of individuals in the United States each year. Peptic ulcer disease has a major impact on our health care system by accounting for roughly 10% of medical costs for digestive diseases (WHO, 2003). In the last two decades, major advances have been made in the understanding of the pathophysiology of peptic ulcer disease, particularly regarding the role of Helicobacter pylori and non-steroidal anti-inflammatory drugs (NSAIDs). This has led to important changes in diagnostic and treatment strategies, with potential for improving the clinical outcome and for decreasing health care costs (CDC, 2006)

The geographical distribution of a disease may provide valuable clues with regard to its aetiology. Likewise any historical changes in prevalence, associated with changes in the mode of living, may give additional information. The worldwide ulcer prevalence differs, with duodenal ulcers dominating in Western populations and gastric ulcers being more frequent in Asia, especially in Japan (Park et al, 2011). Although the incidence of peptic ulcer disease in Western countries has declined over the past 100 years, around 1 in 10 Americans are still affected (Dwayne et al, 2010). The annual financial burden of peptic ulcer disease in the US, including direct and indirect costs, is estimated as US$3.4 billion (CDC, 2010). Since peptic ulcer disease is still common, and peaks in the elderly, it is expected that its impact on human health and health economics will remain an important issue in the future.

Tovey&Tunstall, (2005)have shown that there is a definite geographical pattern to the distribution of duodenal ulcer in sub‐Saharan Africa, with a high incidence being reported in the Nile/Congo watershed and coastal regions of West Africa. High incidence rates of duodenal ulcer have also been reported in a number of major cities of Africa (Johannesburg, Durban, (Robbs&Moshal, 2009)Nairobi, and Mombasa) (Tovey&Tunstall, 2005). In a recent study by Kidd et al, (2009) 26% of patients with dyspepsia had DU, and of these H. pylori was present in 90%.

Gastric ulcer is uncommon in Africa, occurring 6–30 times less commonly than DU (Tovey&Tunstall, 2005). In developed nations, the ratio of DU:GU is between 3:1 and 4:1. In Africa, a wide range of DU:GU ratios has been reported varying from 3:1 to 15–20:1 (Mohamed et al, 2010). A retrospective endoscopic review of dyspeptic patients from 12 African countries found that 7% had GU, and that H. pylori was present in 75% of these patients (Kidd et al, 2009).

1.2 PROBLEM STATEMENT In Africa, the highest prevalence was reported to be in the great lakes region, (Borin et al, 2004), where duodenal ulcer surgery forms the major part of all abdominal surgery. The area includes Rwanda and Burundi, eastern DRC around Lake Kivu, extreme western Tanzania adjacent to Burundi, and south-western (Taylor, 1965), where , Kampala International University teaching Hospital (KIUTH) in particular are located. In Uganda, PUD prevalence is estimated to range between 12% and 25% (UBOS, 2010).

PUD is common in developing countries in general and Uganda in particular (Opoiet al, 2009). There is a higher prevalence of Helicobacter pylori infection (MoH, 2006). There are many difficult problems to overcome in trying to establish the prevalence of a disease with a low mortality such as PUD. These problems are considerable in developed countries and much greater in developing countries. Despite the scarcity of recent accurate data on prevalence and the reported increase in PUD cases in Uganda, (MOH, 2006) many health facilities including hospitals are without x-ray facilities. Surgical statistics can be selective and misleading. As a result, very little has been done to document the prevalence of PUD in various populations including the predictors for susceptibility. There this study on prevalence of peptic ulcer disease among patients attending KIUTH will bridge the existing information gap.

1.3 OBJECTIVES

1.3.1 Broad objective i. To estabish the prevalence of peptic ulcer disease among patients attending of Kampala International University Teaching Hospital.

1.3.2 Specific objectives This includes the following;

1. To find out the gender distribution of peptic ulcer disease among patients attending Kampala International University Teaching Hospital 2. To find out which age group is more affected by peptic ulcer disease among patients attending of Kampala International University Teaching Hospital.

1.4 Research questions 1. What is the gender distribution of peptic ulcer disease among patients attending Kampala International University Teaching Hospital? 2. Which age group is most affected by peptic ulcer disease among patients attending of Kampala International University Teaching Hospital

1.5 STUDY JUSTIFICATION This study wasdesigned to determine the prevalence of PUD among patients of KIUTH so that the prevalence & predictors are better documented in the study population. This study is therefore expected to contribute to the building of the much needed data on prevalence of PUD.

1.6 SCOPE OF THE STUDY

1.6.1 Geographical scope The study was meant to find the prevalence of PUD among patients who attended KIUTH during the months of April 2017 to May 2017.

1.6.2 Content scope PUD which is Ulceration of gastro-duodenal mucosa tends to be chronic and recurrent if untreated, caused by Helicobacter pylori infection and hyperacidity due to drugs (NSAIDS e.g. acetylsalicylic acid, corticosteroids), irregular meals among others. It is characterized by epigastric pain typically worse at night and when hungry(duodenal ulcer) alleviated by food, milk, or antacid, epigastric pain, worse with food (gastric ulcer), vomiting, nausea, regurgitation and discomfort on palpation of the upper abdomen

1.6.3 Time scope. The study was meant to be conducted from March 2017 to June 2017

CHAPTER TWO

LITERATURE REVIEW

2.0 INTRODUCTION This chapter reviews the available literature about PUD, epidemiology and gender differences and its distribution between rural and urban areas

2.1 EPIDEMIOLOGY OF PUD The lifetime risk for developing a peptic ulcer is approximately 10% (Hein et al, 2007). Globally, as of 2010, approximately 250,000 people died of peptic ulcer disease down from 320,000 in 1990 (Kang et al, 2011)

In Western countries the prevalence of Helicobacter pylori infections roughly matches age (i.e., 20% at age 20, 30% at age 30, 80% at age 80). Prevalence is higher in third world countries where it is estimated at about 70% of the population, whereas developed countries show a maximum of 40% ratio. Overall, H. pylori infections show a worldwide decrease, more so in developed countries. Transmission is by food, contaminated groundwater, and through human saliva (such as from kissing or sharing food utensils) (Thomson et al, 2003).

Peptic ulcer disease had a tremendous effect on morbidity and mortality until the last decades of the 20th century, when epidemiological trends started to point to an impressive fall in its incidence (Kaltz et al, 2008). The reason that the rates of peptic ulcer disease decreased is thought to be the development of new effective medication and acid suppressants and the discovery of the cause of the condition, H. pylori.

In the United States about 4 million people have active peptic ulcers and about 350,000 new cases are diagnosed each year. Four times as many duodenal ulcers as gastric ulcers are diagnosed. Approximately 3,000 deaths per year in the United States are due to duodenal ulcer and 3,000 to gastric ulcer (Jeffers et al, 2009). The literature on the epidemiology of PUD shows that PUD remains a relatively common condition worldwide, with annual incidence ranging from 0.10% to 0.19% for physician-diagnosed PUD and from 0.03% to 0.17% for PUD diagnosed during hospitalization. The 1-year prevalence of physician diagnosed PUD was 0.12–1.5%, and the 1-year prevalence of PUD diagnosed during hospitalizations was 0.10–0.19%. The data show that the incidence of PUD has decreased over recent decades in many countries, most likely as a result of the decrease in H. pylori infection, particularly in Western populations. However, it is possible that the situation may be different in Asian countries; a recent study in Korea revealed that the prevalence of H. pylori infection in association with GU was increasing with time, whereas H. pylori infection in DU was decreasing (Jang et al, 2008). Further work is required to confirm if the results of this study can be extrapolated to the Asian population in general.

The most reliable study of physician-diagnosed prevalence was from Sweden, reporting cross- sectional data representative of the general population (Aro et al, 2006) the study thus included both symptomatic and asymptomatic PUD. The overall prevalence of PUD observed in this study was 4.1%; 19.5% of all PUD cases identified were asymptomatic. Comparing this prevalence with the lower rates obtained from other studies of physician-diagnosed PUD in primary care suggests that a proportion of individuals with PUD remain undiagnosed. In individuals with asymptomatic PUD, severe complications, such as gastrointestinal haemorrhage, may be the first signs of the disease. Haemorrhage is associated with mortality approaching 10% and high recurrence (Christensen et al, 2007). This is particularly relevant for elderly patients who are less likely to have symptoms, possibly because of the analgesic effects of ASA and NSAIDs.

Overall, a review of the literature shows that the reported incidence and prevalence of PUD have decreased over time in recent decades. However, temporal trends in the rate of hospitalizations for complications of PUD varied in studies, remaining unchanged or increasing in recent decades in two studies in Finland and the Netherlands, (Post et al, 2006) but declining over time in one study in Scotland (Kang et al, 2006).

Management of PUD has improved substantially following the introduction of PPIs and therapy for H. pylori eradication. This is reflected in the decrease in prevalence of H. pylori-associated PUD, the change in the proportion of H. pylori-positive PUD, and the lower proportion of H. pylori infection, particularly in complicated PUD. The continued occurrence of PUD is probably due, at least in part, to the widespread use of low-dose ASA and NSAIDs, especially in Western countries and among older patients and those with comorbidities. Use of these medications may also explain why the rate of hospitalizations for PUD complications has not decreased in some studies (Post et al, 2006) and the general lack in reduction of mortality from PUD bleeding (Thomopoulos et al, 2004). Use of traditional NSAIDs in Western countries has increased since the withdrawal of some cyclooxygenase-2-selective inhibitors and PPIs have been shown to produce a marked and consistent reduction in the risk of gastrointestinal symptoms in patients receiving NSAIDs and non-ASA anti-platelet agents (Goldstein et al, 2006). The common occurrence of PUD in users of NSAID or low-dose ASA, despite wide availability of guidelines on the use of gastroprotective agents in NSAID users, is likely to be due to incomplete application of these guidelines in clinical practice and incomplete adherence of patients to prescribed gastroprotective medication (Van Soest et al, 2007)

Our review has several strengths, including the wide and comprehensive set of data identified and the focus on publications from the last decade or so, which provides an update on current status. Limitations include a lack of capture in most studies of asymptomatic patients with PUD and the range of methodologies used in the publications identified, including the different definitions of peptic ulcer used by the different studies. Also, the secondary care studies may miss a large number of PUD patients, especially if they only counted the number of inpatients.

In terms of future work, an estimate of the global population prevalence of symptomatic as well as asymptomatic PUD, including the associated risk symptoms and potential risk factors, would yield important information on burden of the disease and aid its management. Such data, although scarce, are available from Europe, whereas similar data from Asia are still lacking.

2.2 GENDER DISTRIBUTION In the United Kingdom the incidence of peptic ulcers in men has fallen in recent years and in 2007 the sex ratio (male: female) was only 19:1.126 (Cole, 2005). In India the ratio of male to female in 11 reported series was as high as 17.6:1 (range 9:1 to 33:1). In the high-incidence areas of black Africa the ratio (male: female) in 18 reported series is 9:1 (range 2 1:1 to 30:0). In addition 25 out of 26 replies from these areas in response to enquiries,in which the sex distribution is specifically mentioned, say that male patients greatly predominate without giving exact figures (Almer et al, 2004) In developing countries men tend to come to hospital more readily than women (although in India many hospitals were founded specifically for women and still admit a greater percentage of females), but even allowing for this tendency the marked male predominance is probably real.

2.3 AGE DISTRIBUTION. In the United Kingdom the peak age incidence at present is between 45 and 55 years. the reports from East Africa give the peak age as a decade earlier. The mean peak age of six published reports from Uganda is 34 years and in 22 replies to their enquiries from the same area the mean peak age is 25.Many reports mention the occurrence of duodenal ulcer in teenagers, not infrequently associated with pyloric stenosis. (Kang JY, 2011).

A study by Aro P, Storskrubb T, Ronkainen et al in 2006on prevalence of PUD among the nomadic pastolists of Ethiopia , in which 800 participants were recruited found out that PUD was 3.4 % higher in young adult women above 30 to 35 years than in eldery and adolescents parts, similary the young adult men of above had a higher prevalence at 0.8 % PUD prevalence higher in eldery men and adolscents.

CHAPTER THREE

METHODOLOGY

3.0 Introduction This chapter included the study area, study population, sample size determination, sampling technique, study variables, data collection tools, data analysis and presentation, sample size determination, ethical considerations and limitations.

3.1 Study Design A retrospective study was carried out to determine the prevalence of peptic ulcer disease among patients attending KIUTH. Quantitative methods will be used to collect data from the patients and later described, compared and analyze different variables.

3.2 Study Area Kampala International University's Western Campus [KIU-WC] is situated on about 70 acres of land at Ishaka town in Bushenyi District, along –Kasese Road in Western Uganda. This spacious campus was opened in November 2004. The School Allied of Health Sciences [SAHS] is located at the KIU-WC. It offers a number of courses in bachelors, diplomas and certificates.

The presence of the university has strongly led to the development of various businesses in Ishaka town, with the students and staff of the university comprising of the major clientele of these businesses. Businesses range from boutiques, restaurants, supermarkets, bars, and night clubs.

Bushenyi District is one of the oldest districts in Uganda. It was created in 1974, curved out of Mbarara District Administration then. In 2009, it was split into five districts (4 new districts of Buhweju, , Sheema and Rubirizi districts) with one new Municipal Council of Bushenyi- Ishaka. This has drastically reduced the size of Bushenyi District from five counties to one of Igara that includes the municipality. Bushenyi District lies between 0 0 N and 0 0 46’ S of the equator and 29 0 41’ East and 30 0 30’ East of Greenwich.

Bushenyi District headquarters is located 340 kms from Kampala in the South Western part of Uganda. Bushenyi District is neighboring with the districts of Rubirizi in theNorth, Buhweju and Sheema in the North East, Sheema in the East, Mitooma in the South West and Sheema in the South. The district has a land area of 3’949 square kilometers and lying between 910 – 2,500 meters above sea level. The main physical features within the district include natural tropical forests of Karinzu and Imaramagambo covering an area of 784 km. Arable land covers 2,215 square kms, open water bodies cover 372 square kms and wetlands covering 183 square kms.

Bushenyi District has a population of 241,500 people made up of 117,000 males and 124,000 according to the projected population estimates of 2010.

The economy of the district depends mainly on agriculture. Agriculture is a source of food for the population, subsistence income for most families, and provides direct employment to 86.7% of the district population, as well as supplying raw materials for industries.

3.3 Study Population KIUTH serves a population of about 252000 people from districts of Ankole sub region and neighboring area but the target population study was patients attending KIUTH from the month of May to June 2017.

3.4 Sample Size To get the sample size, fisher’s statistical formula was used,

n=Z2 PQ

D2

Where n= desired sample size

Z= standard deviation at the desired degree of accuracy which was 1.96

P= proportion of target population estimated to have the same characteristics, therefore p was taken to be 50% (constant) or 0.5

Q= 1-P

D= degree of error

N= (1.96)2 X 0.5 X (1-0.5)/0.052

=3.8416 X 0.5 X (0.5)/0.0025

= 0.9604/0.0025 =384.16

n = 384.16

3.5 Sampling Method Simple random sampling method was used for this study where by one respondent was randomly selected and a process repeated upto when a desired sample size was obtainsed.

3.6 Inclusion Criteria Current patients attending KIUTH were the target for this study

3.6.1 Exclusion criteria Patients who declined to consent for the study

Patients who were severely ill and needed urgent medical attention

3.7 Ethical considerations i. An introductory letter was sought from the SAHS administrator. ii. All results were treated with utmost confidentiality by ensuring that only authorized people have access to them.

3.8 Data collection A data was got from the KIUTH records within the months of April 2017 to May 2017.

3.9 Data analysis and presentation Data was analyzed using simple calculators, windows Excel-2007, and presented in form of tables, graphs and charts.

3.10 Study Limitations The following limitations will be encountered during the study;

 Poor recording keeping hence limited data available  Some patients were not willing to give some important information during the study.

CHAPTER FOUR

STUDY FINDINGS

4.0 Introduction This chapter consists of findings from the study on social demographic characteristics, prevalence of PUD, PUD diagnosis, gender and age distribution. Out of 385 patients records whose record was reviewed presented with peptic ulcer disease (PUD) during the study period, 6 patients underwent emergency laparotomy for perforated peptic ulcers.

4.1 Socio-demographic characteristics

Of the total record reviewed 151 (39.2%) were males and females were 234 (60.8%). The patient's age ranged from 12 to 72 years with a median of 32.4 years. The peak incidence was in the 4th decade (31-40 years).

4.2 Clinical presentation

The duration of symptoms ranged from 1 to 12 days with a mean duration of 6.5 ± 2.3days. The median was 5.8 days. 28.6% presented within twenty-four hours of onset of symptoms, 29.8% between 24 and 48 hours and 35.7% over 48 hours afterwards. The commonest presenting symptoms were sudden onset of severe epigastric pain in 97.6%, abdominal distention in 76.2% and vomiting in 36.9% PUD patients.

4.3 Respondents’ gender distribution FIGURE 1: GENDER DISTRIBUTION 39.2% Female Male 60.8%

60.8% of the patients were female and 39.2% were males

4.4 Respondents’ age distribution FIGURE 2:AGE DISTRIBUTION OF PUD

5.5%

15.8% 11 to 20 20.3% 21-30 13.0% 31-40 41-50

12.7% 51-60 32.7% above 60

In this case, the majority of the patients were between the ages of 31-40 (32.7%) followed by 21- 30 (20.3%) likewise above 60 (15.8%) in that order and the least being between the ages of 11- 20(5.5%). 4.5 Diagnosis of PUD FIGURE 3: PUD DIAGNOSIS

14.8%

PUD NO PUD

85.2%

For this case, those who were found to have PUD were 14.8% and those without PUD were 85.2%

4.6 PUD specific gender distribution 4: GENDER SPECIFIC DISTRIBUTION OF PUD (n=57)

33.3% FEMALE MALE 66.7%

66.7% of PUD were found in females and 33.3% of PUD found in males. 4.7 PUD specific age distribution. FIGURE 5: AGE SPECIFIC DISTRIBUTION OF PUD

33.3% 35.0% 30.0% 22.8% 25.0% 19.3% 20.0% 15.0% 10.5% 8.8% 10.0% 5.3% 5.0% 0.0% 11 to 20 21-30 31-40 41-50 51-60 above 60

This shows that the age specific distribution of PUD is higher in the age group between 31-40, followed by 51-60 in that order and the least affected age group being between 11-20.

4.8 PUD main symptoms.

FIGURE 6: MAIN PRESENTING SYMPTOMS

36.9% Sudden severe epigastric pain 97.6% Abdominal distension Vomiting 76.2%

The main presenting symptoms were sudden severe epigastric pain (97.6%) followed by abdominal distension (76.2%) and finally vomiting (36.9%).

CHAPTER FIVE

DISCUSSION

5.0 Introduction

This chapter consists of the discussion of the study findings which include the prevalence of PUD, gender and age distribution among patients who were attending KIUTH during the period of study

5.1 Prevalence of PUD

In this review, a total of 57 (14.8%) patients were found to have been diagnosed with PUD. This figure is similar to what was reported by Schein et al 2007. In their study, 15.1% of the patients were reported to have been diagnosed with PUD. Mienyet al 2006 in South Africa reported a low incidence of PUD. They reported a 6.3 prevalence of PUD in their study population. These differences reflect differences in the rate of risk factors for perforated peptic ulcer disease from one country to another. The figures in our study may actually be an underestimate and the magnitude of the problem may not be apparent because of high number of patients excluded from this study.

5.2 PUD gender distribution

In the present study, peptic ulcer disease were found to be most common in the fourth decade of life and tended to affect more females (66.7%) than males (33.3%). This finding is however not comparable with other studies in developing countries. For example Opolot et al, 2004 reported a 59.2% prevalence of PUD among males and 40.8% in females. Similarly Camara et al, 2009 in their study of PUD among a Senegalese rural population found a higher PUD prevalence among male (61.4%).

5.3 PUD age distribution

PUD predominance in this age group (31-40) could be attributed to excessive alcohol consumption and smoking which is common in the study environment. Alcohol consumption and smoking have been reported to be associated with increased risk for peptic ulcer. Alcohol, as a noxious agent causes gastric mucosal damage, stimulates acid secretion and increases serum gastrin levels (Ray et al, 2003) and smoking inhibits pancreatic bicarbonate secretion, resulting in increased acidity in the duodenal bulb. It also inhibits the healing of duodenal ulcers (CDC, 2006).

These study findings are in agreement with a study by Kang JY in 2011 whereby in the United Kingdom the peak age incidence at present is between 45 and 55 years. the reports from East Africa give the peak age as a decade earlier. The mean peak age of six published reports from Uganda is 34 years and in 22 replies to their enquiries from the same area the mean peak age is 25.Many reports mention the occurrence of duodenal ulcer in teenagers, not infrequently associated with pyloric stenosis.

The result indicates that the rate of H. pylori infection in patients with peptic ulcers ranges from 50%-80% and H. pylori infection, as a risk factor for PUD, appears to be more relevant in younger patients (Geogezet al, 2010).

This is in sharp contrast to Nuhuet al, 2008 in Nigeria who reported that 71% of cases had previous history of peptic ulcer disease. It has been reported that in many developing countries, the diagnosis of PUD is first made in many instances after perforation (Freyers et al, 2004). The present study confirms this observation because more than sixty percent of the patients with perforation were not diagnosed previously as cases of PUD and therefore were not on treatment. Patients with no previous diagnosis of peptic ulcer have a higher risk of PUD perforation than patients with a known history of ulcer disease. This may be because preventative measures are more likely to have been taken in patients with a known history of ulcer. Furthermore, these patients are perhaps more likely to seek treatment earlier.

5.4 Conclusion PUD is highly prevalent among patients attending KIUTH (14.8%) and is highest among the middle age group of 31-40 years (32.7%), with females (66.7%) being more affected than males (33.3%).

5.5 Recommendations i. Community sensitization on causes of PUD should be enforced at hospitals. ii. Better diagnostic techniques should be used for early diagnosis of PUD

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APPENDICES

APPENDIX I

WORK PLAN

ACTIVITY TIME FRAME REQUIREMENTS PERSON RESPONSIBLE Proposal writing FEBRUARY 2017 Computer, stationery, Researcher internet access Presentation of proposal, March-April 2017 Researcher Corrections Supervisor Letter from SAHS April 2017 Researcher Administrator Data collection May 2017 Questionnaire Researcher / assistant Data analysis and May-June 2017 Stationery, computer Researcher presentation of results Research Defence June 2017 Research Book Researcher Printing and Submission June 2017 Stationery, computer Researcher of Corrected Research Report

APPENDIX II

BUDGET

ITEM UNIT UNIT COST (UGX) TOTAL (UGX) Pens 06 700 4,200 Pencils 03 400 1200 Paper 02 reams 13,500 27,000 Secretarial work 60 pages 500 30,000 Printing 60 pages 500 30,000 Internet bundles 04 months 25,000 100,000 Airtime 20,000 20,000 Research assistant 100,000 Consumables 30,000 Miscellaneous 100,000 GRAND TOTAL 442,400

APPENDIX: III MAP OF MBARARA – BUSHENYI ROAD, ISHAKA, UGANDA SHOWING THE STUDY SITE.

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