Although these two scenarios might under- or overestimate the true bleeding incidences, both should be uncommon without seriously biasing our analysis, thanks to the easy accessibility and high coverage of the universal

health insurance in Taiwan.35 Furthermore, the comprehensiveness of NHIRD allows adjustment for various confounders in this research. Patients with liver cirrhosis constituted a unique subpopulation BGJ398 datasheet among all patients with PUB, and therefore were unsurprisingly different from their controls in several baseline characteristics, including H. pylori status, comorbidities, ulcerogenic drugs, and propranolol use. However, the compatible results from the multivariate Cox modeling and stratified analyses affirmed that these unmatched confounders

were appropriately accounted for. Of note, the association between antisecretory drugs and risk of recurrent PUB should be cautiously interpreted. In Taiwan, these medications cannot be prophylactically prescribed and are reimbursed only in patients with endoscopically proven peptic ulcers or erosive esophagitis, with drug duration confined within 4 months in most cases (up to 1 year in those with Los Angeles grade C/D esophagitis or poorly Selleckchem ALK inhibitor healed marginal ulcers on partially resected stomach). As a result, their use actually served as a surrogate marker for a proven UGI pathology documented during the observation period. Finally, the sample size of our cohort mitigated the concern for unmeasured confounders. Existence of any unmeasured factor that could have distorted the analysis was improbable, since it would have

to be either strongly linked to both cirrhosis and elevated rebleeding risk, or would have to be very common. How to reduce the recurrence rate of peptic ulcers remains unknown and scantly investigated in patients with liver cirrhosis. Although H. pylori eradication is unequivocally effective in preventing peptic ulcer recurrence in the general population,36 such effectiveness is not established in patients with cirrhosis.32, 37 Similarly, it has not been determined whether antisecretory maintenance lowers this website the long-term recurrence rate of ulcer bleeding in patients with cirrhosis. The efficacy of acid suppression in patients with cirrhosis appears questionable in that these patients are characterized by marked gastric hypoacidity,38 hence gastric acid may not play a crucial role in their ulcerogenesis. In light of the distinct ulcerogenic mechanism in patients with cirrhosis, agents that sustain reduction of portal pressure may be effective in decreasing ulcer bleeding. We uncovered concomitantly in this study that use of propranolol was linked to protection against recurrent PUB (adjusted HR, 0.78; 95% CI, 0.73-0.84).