Current issues of ACP Journal Club are published in Annals of Internal Medicine


NSAIDs, smoking, and alcohol were risk factors for gastrointestinal perforation

ACP J Club. 1997 Sep-Oct;127:47. doi:10.7326/ACPJC-1997-127-2-047

Related Content in this Issue
• Companion Abstract and Commentary: NSAIDS but not aspirin or acetominophen reduced the risk for Alzheimer disease

Source Citation

Lanas A, Serrano P, Bajador E, et al. Evidence of aspirin use in both upper and lower gastrointestinal perforation. Gastroenterology. 1997 Mar;112:683-9.



To determine whether aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with gastrointestinal (GI) perforation.


Case-control study.


A university hospital in Spain.


76 consecutive patients (mean age 61 y, 66% men) who were hospitalized with GI perforation (60 upper and 16 lower perforations). Patients were excluded if the primary abdominal disease was an inflammatory process followed by perforation. Control patients were matched for age, sex, and neighborhood; 76 were hospitalized (no peptic ulcers, GI bleeding, or painful musculoskeletal disease), and 76 were from the community.

Assessment of risk factors

Participants were interviewed to determine age, sex, living environment (rural or urban), presence of arthritic disease, prevalence of smoking, alcohol and coffee use, and use of aspirin and other NSAIDs (dose and brand names). Aspirin use was confirmed by laboratory testing (platelet cyclooxygenase activity), and Helicobacter pylori status was determined by an ELISA kit.

Main outcome measures

Acute GI perforation (total and upper and lower perforations). Perforation was based on clinical symptoms and physical findings and was confirmed by surgery.

Main results

Total (upper and lower) GI perforation was associated with aspirin use alone (odds ratio [OR] 3.7, 95% CI 2.0 to 6.5); nonaspirin NSAID use (OR 6.7, CI 3.1 to 14.5); diclofenac use (OR 4.5, CI 1.5 to 13.5); coffee consumption (OR 2.3, CI 1.3 to 4.3); peptic ulcer history (OR 3.3, CI 1.7 to 6.2); smoking (OR 3.9, CI 2.2 to 7.0); and a combination of NSAID use, smoking, and alcohol consumption (OR 10.7, CI 3.8 to 30). Upper GI perforation was associated with NSAID use (OR 6.3, CI 3.3 to 12.2); coffee consumption (OR 2.2, CI 1.1 to 4.1); ulcer history (OR 4.1, CI 2.1 to 8.0); smoking (OR 3.7, CI 2.0 to 6.9); and a combination of NSAID use, smoking, and alcohol consumption (OR 12.6, CI 4.4 to 36). Lower GI perforation was associated with current use of NSAIDs (OR 8.1, CI 2.5 to 27). Multivariate analysis showed that independent risk factors for GI perforation were NSAID use, smoking, alcohol consumption, and a history of arthritis.


Independent risk factors for GI perforation were nonsteroidal anti-inflammatory drug use, smoking, alcohol consumption, and a history of arthritis.

Sources of funding: Asociación de Investigaciones Gastroenterológicas de la Provincia de Zaragoza and University of Zaragoza.

For article reprint: Dr. A. Lanas, Servicio de Aparato Digestivo, Hospital Clínico Universitario, 50009 Zaragoza, Spain. FAX 34-976-761236.


Aspirin has been used since 1982 to prevent heart disease and even before that to treat rheumatic disorders and other aches and pains. With new evidence that NSAIDs might also protect against the development of Alzheimer disease, the use of anti-inflammatory drugs could increase. In addition to benefits, aspirin and other NSAIDs have associated risks. These 2 studies from very different journals and areas of medicine once again open the debate on the need for balance between the risks and benefits of NSAID use.

The hypothesis that NSAIDs might protect against Alzheimer disease arose from observations that the neuritic plaques, a cardinal feature of the disease, contain proteins that are characteristic of an inflammatory process. Thus, anti-inflammatory drugs might influence the disease process. In support of this theory, observational studies have found reduced NSAID use in patients with Alzheimer disease.

By design, these observational studies were not able to exclude the obvious explanation for apparently reduced NSAID use (underreporting of drug use by patients with Alzheimer disease) or the less likely possibility of selection bias. Patients with Alzheimer disease who are still alive may have been healthier at disease onset (i.e., not NSAID users) than those patients who have already died of the disease.

Both these biases were avoided in the cohort study by Stewart and colleagues because data on drug use were collected prospectively over a 16-year period. The diagnosis of Alzheimer disease was based on a standardized neuropsychological assessment applied to all participants in the cohort. However, the authors did not collect details of the dose of aspirin and precise duration of use of NSAIDs. Nevertheless, they did categorize use as < 2 years and ≥ 2 years and showed a lower risk for Alzheimer disease with longer use of nonaspirin NSAIDs. In contrast, aspirin use showed only a weak inverse association with the development of Alzheimer disease. This association may be because of the lower dose used for heart disease prophylaxis in the 1980s. The anti-inflammatory dose of aspirin tends to be higher than that used for heart disease or stroke prophylaxis. Another possibility is that aspirin was taken on an over-the-counter basis and therefore used only occasionally, whereas other NSAIDs tend to be prescribed more often and are therefore used more regularly. The association with acetaminophen is consistent with its lack of anti-inflammatory effects.

Most of what is known about GI risks of NSAID use comes from studies of patients with bleeding peptic ulcers. The study by Lanas and colleagues confirms that use of aspirin and other NSAIDs increases the risk for both upper and lower GI perforation, with the increase in risk being similar to that for upper GI bleeding.

An unusual feature of the study by Lanas and colleagues was testing for aspirin use with thromboxane B2. They detected unreported aspirin use in 21% of patients compared with 12% of community controls and 5% of hospital controls. We do not know the amount taken and whether some of the excess use might have been to relieve pain from the GI perforation. Nevertheless, it is reassuring that the use of aspirin < 500 mg/d was not associated with perforation.

GI perforation is much less frequent than GI bleeding, and this study is not large enough to detect whether risks differ with particular nonaspirin NSAIDs. Overall, the level of aspirin use by patients (47%) was high compared with the 22% use by participants who were community controls. 60% of this use was nonprescribed. Thus, attempts to decrease ulcer complications must address both prescription and nonprescription use.

Lower GI perforation is even less frequent than upper perforation (only 16 patients in this study) and was predominantly perforated colonic diverticula. Nevertheless, an association with NSAID use was as strong for lower perforation as for upper perforation, which suggests systemic rather than local effects of NSAIDs. The findings add to previous evidence that shows associations with ileal and colonic ulceration, bleeding and perforated diverticular disease, and exacerbations of inflammatory bowel disease. In all these situations, physicians need to be aware of the possible contribution of aspirin and other NSAIDs.

Richard F. Logan, MD
University of Nottingham Medical SchoolNottingham, England, UK

Richard F. Logan, MD
University of Nottingham Medical School
Nottingham, England, UK