U.S. Department of Health and Human Services

Burden of Digestive Diseases in the United States Report

James E. Everhart, M.D., M.P.H., Editor

National Institute of Diabetes and Digestive and Kidney Diseases
National Institutes of Health
United States Department of Health and Human Services

Copyright Information 
All material appearing in this report is in the public domain and may be reproduced or copied without permission: citation as to source, however, is appreciated.

Suggested Citation
[Author(s). Chapter title. In:] Everhart JE, editor. The burden of digestive diseases in the United States. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 2008; NIH Publication No. 09-6443 [pp. – ].

Table of Contents

FOREWORD

Acknowledgements

1. ALL DIGESTIVE DISEASE

2. GASTROINTESTINAL INFECTIONS

3. VIRAL HEPATITIS

4. DIGESTIVE CANCERS

5. CANCER OF THE ESOPHAGUS

6. CANCER OF THE STOMACH

7. CANCER OF THE SMALL INTESTINE

8. CANCER OF THE COLON AND RECTUM

9. PRIMARY LIVER CANCER

10. CANCER OF THE BILE DUCTS

11. CANCER OF THE GALLBLADDER

12. CANCER OF THE PANCREAS

13. HEMORRHOIDS

14. GASTROESOPHAGEAL REFLUX DISEASE

15. PEPTIC ULCER DISEASE

16. FUNCTIONAL INTESTINAL DISORDERS

17. APPENDICITIS

18. ABDOMINAL WALL HERNIA

19. INFLAMMATORY BOWEL DISEASE

20. DIVERTICULAR DISEASE

21. LIVER DISEASE

22. GALLSTONES

23. PANCREATITIS

24. INDICATIONS AND OUTCOMES OF GASTROINTESTINAL ENDOSCOPY

25. COSTS OF DIGESTIVE DISEASES

_. APPENDICES

1. ICD and SEER Codes

2. Summary of Surveys Used in The Burden of Digestive Diseases in the United States

3. Methodology for Tables and Figures

_. Index of Tables and Figures

Foreword

Digestive diseases include a wide spectrum of disorders affecting the oropharynx and alimentary canal, liver and biliary system, and pancreas. These disorders have diverse causes, including congenital and genetic anomalies, acute and chronic infections, cancer, adverse effects of drugs and toxins, and, in many cases, unknown causes. Some conditions, such as foodborne diarrheal diseases, are so common as to be considered a universal life experience, while many others are relatively uncommon or rare. The impact of these diseases ranges from the inconvenience of a transient diarrheal disease causing missed time from school or work, to chronic and debilitating illnesses requiring continuous medical care, or, all too frequently, to dreaded conditions such as pancreatic cancer that are usually fatal.

During the 20th century, there were dramatic changes in the incidence, prevalence, and overall impact of digestive diseases in the United States that were the result of many factors, including improved sanitation and an improved food supply; numerous research discoveries that led to the development of new drugs, vaccines, diagnostic tests, and minimally invasive procedures; and an economic and health care system capable of providing these advances to the majority of the population. Continued progress in improving the health welfare of the population of the United States requires a continued investment in digestive disease research, public health initiatives, the health care system, and the education of the general public about how to improve their health. Accurate descriptive statistical information is one of the most basic types of information required by those engaged in activities aimed at improving digestive health, including researchers, administrators, public officials, professional and patient-based organizations, and the general public.

In 1994, the National Institutes of Health (NIH) sponsored a publication, Digestive diseases in the United States: epidemiology and impact, that has served as a reference to meet these needs; the report had a limited update in 2001.1, 2 Because of continuing changes in the incidence and prevalence of digestive diseases, important changes in health care, such as the emphasis on outpatient care whenever possible, and the availability of new statistical resources, the time is right to generate a new report to capture the impact of digestive diseases in the United States. In addition, congressional report language accompanying the Fiscal Year 2005 appropriations bills in the House and Senate for Labor-Health and Human Services-Education and Related Agencies called for the creation of an advisory committee, the National Commission on Digestive Diseases, and tasked it with addressing the burden of digestive diseases and developing a long-range research plan. The resulting research plan from this charge, Opportunities and challenges in digestive diseases research: recommendations of the National Commission on Digestive Diseases, outlines a broad and ambitious agenda aimed at improving the health of the nation for digestive diseases through research; the research plan can be accessed at http://NCDD.niddk.nih.gov. The NIH sponsored the current report on the burden of digestive diseases to serve not only as a needed statistical reference, but also as a companion volume to inform research goals recommended in the Commission’s research plan.

Close examination of this report will reveal many interesting and provocative pieces of statistical information about trends in various digestive diseases. As outlined in the report, for any specific disease condition, there are numerous limitations on the types of data that can be obtained in the diverse and decentralized U.S. health care system. Despite the many limitations of the statistical information, there are several certainties. In spite of a century of progress, the burden of digestive diseases in numerical terms remains staggering in the United States; the numbers, however, convey in only a limited way the suffering of and impact on the millions of individuals affected. In addition, the limitations of the report and the statistical data mandate a strong digestive disease research effort aimed at improving health in the United States through pursuit of the many recommendations of the Commission’s research plan, improving our ability to capture needed statistical and epidemiological information, and spurring fundamental improvements in the health care system.

Stephen P. James, M.D.
Chair, National Commission on Digestive Diseases
Director, Division of Digestive Diseases and Nutrition
National Institute of Diabetes and Digestive and Kidney Diseases
National Institutes of Health
U.S. Department of Health and Human Services

1 Everhart JE, editor. Digestive diseases in the United States: epidemiology and impact. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 1994; NIH Publication No. 94-1447.
2 Sandler RS, Everhart JE, Donowitz M, Adams E, Cronin K, Goodman C, Gemmen E, Shah S, Avdic A, Rubin R. The burden of selected digestive diseases in the United States. Gastroenterology 2002;122:1500–1511.

Return To Table Of Contents

Acknowledgements

I wish to thank the following individuals for making this report possible: Danita Byrd-Holt, Constance Ruhl, Bryan Sayer, Sanee Maphungphong, Beny Wu, Laura Fang, Laura Spofford, Polly Gilbert, Julie Kale, and Katherine Merrell of Social & Scientific Systems, Inc., for programming, production of tables and figures, text and cover graphic design, copyediting, and production of the final report; Daniel Westbrook and Douglas Brown of Georgetown University for analysis of the cost of digestive diseases; David Lieberman and Nora Mattek of the Clinical Outcomes Research Initiative (CORI) for the national endoscopy data; Dedun Ingram at the National Center for Health Statistics for advice on age-adjustment; and Robert Kloos at Ohio State University for advice on recovery times from surgery.

James E. Everhart, M.D., M.P.H., Editor
National Institute of Diabetes and Digestive and Kidney Diseases
National Institutes of Health
U.S. Department of Health and Human Services

Return To Table Of Contents

CHAPTER 1

All Digestive Diseases
James E. Everhart, M.D., M.P.H.

For systematic coding, mortality and health care statistics rely on disease classification systems, of which the International Classification of Diseases (ICD) is the world standard. The diagnostic codes traditionally used for digestive diseases primarily code for chronic conditions that are neither infectious nor malignant. In the current ICD edition (ICD-10), these include K20 through K93 in chapter “K” (Appendix 1). Other digestive diseases of public health significance and of particular interest to practitioners and researchers are coded in other chapters: Intestinal Infectious and Parasitic Diseases (A00–A09); Viral Hepatitis (B15–B19); Malignant Neoplasms of Digestive Organs (C15–C26); Hemorrhoids (I84); Esophageal and Gastric Varices (I85, I86.4); Maternal Disorders (Digestive) Related to Pregnancy (O21–O22); Conditions (Digestive) Originating in the Perinatal Period (P53, P54, P57, and P59); Digestive System Disorders of Fetus and Newborn (P75–P78, P92); and Congenital Malformations, Deformations, and Chromosomal Abnormalities (Q39–Q45). For some of these groups of conditions, there were enough national data for individual sections in this report. For others, they and many other digestive system disorders were grouped under ”other digestive diseases,” so that a more complete impact of the total burden of digestive diseases could be estimated.

ICD-9 codes were used for mortality 1979–1998, and ICD-10 codes have been used subsequently, which has been noted on figures of mortality trends. As of the publication of this report, the United States had yet to switch from ICD-9-CM (Clinical Modification) to ICD-10 codes for coding morbidity, despite the publication of the newer edition in 1992. Therefore, all morbidity information from 1979 through 2005 was from ICD‑9-CM.

In 2004, there were an estimated 72 million ambulatory care visits with a first-listed diagnosis of a digestive disease and more than 104 million visits with an all-listed diagnoses, which equated to a rate of 35,684 visits per 100,000 U.S. population (Table 1). In other words, for every 100 U.S. residents, there were 35 ambulatory care visits at which a digestive disease diagnosis was noted. Visits were common for all age groups, with the highest rate among persons age 65 years and older. Age-adjusted rates were comparable for blacks and whites and were 20 percent higher for females than for males.

Digestive diseases were common all-listed diagnoses at hospital discharge in 2004 as well as first-listed diagnosis (Table 1). There were approximately 4.6 million discharges of patients with digestive disease as first-listed diagnosis and 13.5 million discharges as all-listed diagnoses. With a rate of all-listed diagnoses of 4,608 per 100,000, there were nearly five overnight hospital stays per 100 U.S. residents that included a discharge diagnosis of at least one digestive disease. These rates were nearly as high among children as among middle-aged adults and were higher in these two age groups than among younger adults. The highest rate was among persons age 65 years and older. In contrast to their ambulatory care visits, blacks had higher rates of hospitalization than did whites. Comparable or lower age-adjusted rates of ambulatory care visits among blacks, yet higher rates of hospitalization, were a common finding for a number of digestive diseases. Women had a 10 percent higher age-adjusted rate than men.

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown in Figure 1 by 3-year periods (except for the first period, which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Age-adjusted rates increased during this period by one-third, from 26.4 per 100 population to 35.3 per 100 population. This trend in increased rates of ambulatory care visits started at least as early as 1985, when there were 22.4 digestive disease diagnoses per 100 population.1 Rates of all-listed hospitalization with a digestive disease diagnosis fell between 1983 and 1988, a pattern that occurred for all hospitalizations in the United States. Hospitalization rates were stable for the next 10 years before rising to a rate in 2004 equal to the previous peak rate in 1982. The age-adjusted percent increase between 1998 and 2004 was 35 percent. This overall increase was the net of diagnoses whose rates increased and diagnoses whose rates decreased. The largest contributor to the increase was “other digestive diseases”—those conditions that do not have separate chapters in this report. The largest individual disease contributions to the increase were made by gastroesophageal reflux disease (GERD), with an increase over this period of 376 per 100,000 population; viral hepatitis C, with 79 per 100,000; chronic constipation, with 62 per 100,000; intestinal infections, with 41 per 100,000; and pancreatitis, with 23 per 100,000. Except for pancreatitis, each of these diagnoses was more likely to be listed as a secondary discharge diagnosis than as the first-listed diagnosis.

The recent increase in overnight hospital stays with a diagnosis of digestive disease is surprising for two reasons. A few common conditions were known to have declined as reasons for overnight hospitalizations, notably peptic ulcer disease (due to decreased frequency) and gallstones (due to shift to same-day surgery). Of greater significance was the modest rate of increase of hospital discharges for all diseases (from 11,569 per 100,000 in 1998 to 13,104 per 100,000 in 2004, a 13.3 percent increase) relative to the larger increase for digestive diseases. In 1998, 25.3 percent of all hospital discharges had a diagnosis of digestive diseases; this increased to 30.1 percent in 2004. Thus, rates of hospitalizations with digestive disease diagnoses increased both absolutely and as a proportion of all hospitalizations.

In 2004, there were more than 236,000 deaths in the United States with a digestive disease as the underlying cause (Table 2), which represented 9.8 percent of all deaths. A disproportionately lower proportion of deaths from digestive diseases occurred among children (4.1 percent) and a higher proportion occurred among middle-aged adults (15.1 percent). There was no major variation in the distribution of deaths from digestive disease as a proportion of all deaths by race or sex. However, blacks had a 29 percent higher death rate than whites, and men had a 53 percent higher rate than women.

There were 2 million years of potential life lost (YPLL) prior to age 75 years due to digestive diseases, representing 8.5 years per death with digestive disease as an underlying cause. Digestive diseases were more frequently listed as underlying cause than as contributing cause, mainly due to the large effect of deaths from cancer, which was usually listed as underlying cause. There was a gradual decline in digestive disease mortality between 1979 and 2004, both as underlying (18.2 percent) and as underlying or other cause (20.3 percent) (Figure 2). There have been many contributions to this decline, but the greatest determinant was the decrease in digestive disease cancer mortality by 19.8 percent as underlying cause and 24.0 percent as underlying or other cause.

The 10 costliest prescription drugs from retail pharmacies for digestive diseases, according to the 2004 Verispan database (Appendix 2), are shown in Table 3. Dominating the prescription market at 50.7 percent of total number of prescriptions and 77.3 percent of total cost were five proton pump inhibitors, which were mainly prescribed for GERD. The other costliest medications were mesalamine (for inflammatory bowel disease), ranitidine (another anti-acid agent), tegaserod [for irritable bowel syndrome (IBS) and constipation], and ribavirin and peginterferon alfa_2a (for hepatitis C). A deficiency of the drug data is lack of information on nonprescription medications, complementary and alternative medications, infusions, and drugs administered in the hospital.

Summary data for individual digestive diseases are shown in Table 4, ordered by underlying cause of death and type of disease. Five diseases each caused more than 10,000 deaths. These were liver disease and four cancers, led by colorectal cancer. Two common causes of death were transmissible infectious diseases: gastrointestinal (GI) infections and viral hepatitis C. Chronic viral hepatitis is also believed to be a significant contributor to liver and bile duct cancers, which accounted for more than 11,000 deaths.

The YPLL prior to age 75 years is the addition of the number of years prior to age 75 at which deaths occur.

A death at age 55 years, for example, contributes 20 YPLL, while a death at age 75 years contributes none. Malignancies were responsible for 6 of the top 10 digestive diseases that contributed the most to YPLL (Table 4). Liver disease was the second leading cause of death (after colorectal cancer), but contributed the greatest number of YPLL. Also among the 10 leading causes of YPLL were hepatitis C and pancreatitis.

The distribution of burden of medical care for digestive diseases is notably different from mortality from digestive diseases. The six leading diseases with diagnosis noted at ambulatory care visits were GERD, chronic constipation, abdominal wall hernia, hemorrhoids, diverticular disease, and IBS. At least three of these (GERD, constipation, and IBS) are largely caused by disordered function of the GI tract, and diverticular disease also may be in part a consequence of dysfunction. The six most common digestive diseases diagnoses on hospital discharge records were GERD, diverticular disease, liver disease, constipation, gallstones, and peptic ulcer disease. The main difference between the records for hospital discharge diagnoses and ambulatory care diagnoses was the high numbers of diagnoses with liver disease and peptic ulcer disease, which can be life-threatening, and gallstones, which are a common reason for surgery. Because GERD and constipation should rarely lead to hospitalization, it must be assumed that when listed on discharge, they either contributed to the reason for hospitalization or were listed in thousands of discharges simply because they were so common.

1 Everhart JE. Overview. In: Everhart JE, editor. Digestive diseases in the United States: epidemiology and impact. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 1994; NIH Publication No. 94-1447 pp. 1–53.

Return To Table Of Contents

Table 1. All Digestive Diseases: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

 

​Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

10,951

18,010

15,170

24,948

331

544

2,321

3,817

AGE (Years)
15–44

21,348

16,967

28,749

22,848

1,112

884

2,401

1,908

AGE (Years)
45–64

21,430

30,314

32,434

45,880

1,362

1,926

3,489

4,935

AGE (Years)
65+

18,342

50,483

28,437

78,268

1,779

4,897

5,313

14,622

Race 
White

59,506

24,317

85,798

34,953

3,526

1,412

10,242

4,108

Race
Black

8,733

24,076

13,339

37,784

531

1,655

1,702

5,142

Sex 
Female

39,531

25,827

59,553

38,648

2,545

1,592

7,593

4,753

Sex 
Male

32,540

23,017

45,236

32,159

2,023

1,483

5,909

4,335

Total

72,071

24,543

104,790

35,684

4,591

1,563

13,533

4,608

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 1. All Digestive Diseases: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Rates increased slightly from 26.4 per 100 population in 1992-1993 to 27.8 per 100 population in 1997-1999, and then more sharply to 35.3 per 100 population in 2003-2005. The trend in hospitalization rates was U-shaped. The rate in 1979 was 37.6 per 1000 population and remained relatively stable until 1983. From 1983 to 1988, rates fell to 29.6 per 1000 population. Rates were stable for the next 10 years before rising to 39.5 per 1000 population in 2004, equal to the previous peak rate in 1982. 

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 2. All Digestive Diseases: Number and Age-Adjusted Rates of Deaths, Years of Potential Life Lost (to Age 75), and Digestive Disease as a Percentage of All Deaths by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands
re

Underlying Cause
Digestive Disease 
As Percent of All Death

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

1,612

2.7

118.2

4.1

2,908

4.8

AGE (Years) 
15–44

11,036

8.8

397.3

6.9

17,915

14.2

AGE (Years) 
45–64

66,806

94.5

1,263.8

15.1

92,862

131.4

AGE (Years)
65+

156,706

431.3

228.2

8.9

252,709

695.5

Race
White

200,834

77.0

1,579.4

9.8

313,055

119.7

Race
Black

27,812

99.5

340.2

9.7

42,514

152.7

Sex
Female

111,264

63.6

723.3

9.2

177,811

100.7

Sex
Male

124,900

97.1

1,284.2

10.6

188,596

149.1

Total 

236,164

80.4

2,007.5

9.8

366,407

124.8

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 2. All Digestive Diseases: Age-Adjusted Rates of Death in the United States, 1979–2004

There was a gradual decline in mortality between 1979 and 2004, both as underlying cause and as underlying or other cause. Underlying-cause mortality per 100,000 decreased from 95.0 in 1979 to 77.8 in 2004. All-cause mortality per 100,000 decreased from 151.4 in 1979 to 120.6 in 2004.  

Source: Vital Statistics of the United States

Return To Table Of Contents

Table 3. All Digestive Diseases: Costliest Prescriptions

DRUG
Prescription (#)
Prescription
Retail Cost
Cost

Lansoprazole

20,989,993

15.5%

$3,104,963,208

25.2%

Esomeprazole

19,458,740

14.3

2,845,665,944

23.1

Pantoprazole

11,716,033

8.6

1,408,222,345

11.4

Rabeprazole

8,019,431

5.9

1,135,819,908

9.2

Omeprazole

8,582,644

6.3

1,038,622,087

8.4

Mesalamine

2,448,971

1.8

468,426,719

3.8

Ranitidine

13,171,338

9.7

319,418,374

2.6

Tegaserod

1,618,699

1.2

238,030,688

1.9

Ribavirin

221,035

0.2

229,351,616

1.9

Peginterferon alfa-2a

131,001

0.1

191,754,177

1.6

Other

49,378,593

36.4

1,351,443,116

11.0

TOTAL

135,736,478

100.0%

$12,331,718,182

100.0%

Source: Verispan

Return To Table Of Contents

Table 4. Burden of Selected Digestive Diseases in the United States, 2004

DIGESTIVE DISEASE

Deaths, 
Underlying Causea

Years of
Potential Life 
Lost to Age 75 Yearsa

Ambulatory 
Care Visits, 
All-Listed Diagnosisb

Hospital Discharges, 
All-Listed Diagnosisc

All Digestive Disease

236,164

2,007,500

104,790,000

13,533,000

All Digestive Cancer

135,107

945,200

4,198,000

726,000

Colorectal Cancer

53,226

333,000

2,589,000

255,000

Pancreatic Cancer

31,800

206,800

415,000

68,000

Esophageal Cancer

13,667

113,800

372,000

44,000

Gastric Cancer

11,253

84,200

141,000

31,000

Primary Liver Cancer

6,323

72,400

63,000

33,000

Bile Duct Cancer

4,954

32,900

17,000

Gallbladder Cancer

1,939

10,900

6,000

Cancer of the Small Intestine

1,115

9,300

9,000

Liver Disease

36,090

559,100

2,398,000

759,000

All Viral Hepatitis

5,393

101,800

3,510,000

475,000

Hepatitis C

4,595

87,500

2,747,000

419,000

Hepatitis B

645

11,800

729,000

69,000

Hepatitis A

58

800

10,000

Gastrointestinal Infections

4,396

12,800

2,365,000

450,000

Peptic Ulcer Disease

3,692

19,700

1,473,000

489,000

Pancreatitis

3,480

42,800

881,000

454,000

Diverticular Disease

3,372

8,600

3,269,000

815,000

Abdominal Wall Hernia

1,172

6,900

4,787,000

372,000

Gastroesophageal Reflux Disease

1,150

6,000

18,342,000

3,189,000

Gallstones

1,092

4,400

1,836,000

622,000

All Inflammatory Bowel Disease

933

9,100

1,892,000

221,000

Crohn’s Disease

622

7,000

1,176,000

141,000

Ulcerative Colitis

311

2,000

716,000

82,000

Appendicitis

453

5,000

782,000

325,000

All Functional Intestinal Disorders

423

2,500

11,648,000

1,241,000

Chronic Constipation

137

900

6,306,000

700,000

Irritable Bowel Syndrome

20

0

3,054,000

212,000

Hemorrhoids

14

200

3,275,000

306,000

Source: a Vital Statistics of the United States 
b National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) 
c
 Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

CHAPTER 2

Gastrointestinal Infections
James E. Everhart, M.D., M.P.H.

Most GI infections are self-limited and do not come to medical attention, although they are both extremely common and disruptive of daily activities, including school and work. GI infections are caused by viral and bacterial pathogens, but the minority that are most severe and for which causative agents are found are typically bacterial. The ICD-9 and ICD-10 codes match well, except for nonspecified organisms. The most significant differences are that Intestinal Infections Due to Other Organisms (008) and Ill-Defined Intestinal Infections (009) in ICD-9 were replaced by Other Bacterial Intestinal Infections (A04), Other Bacterial Foodborne Intoxications (A05), and Viral and Other Specified Intestinal Infections (A08) in ICD-10. Here is a breakdown of the codes for GI infections:

  ICD-9 ICD-10
Cholera 001 A00
Typhoid and Paratyphoid 002 A01
Other Salmonella 003 A02
Shigellosis 004 A03
Other Food Poisoning 005
Other Bacterial Intestinal Infections A04
Other Bacterial Foodborne Intoxications A05
Amebiasis 006 A06
Other Protozoal Intestinal Diseases 007 A07
Intestinal Infections Due to Other Organisms 008
Viral and Other Specified Intestinal Infections A08
Ill-Defined Intestinal Infections 009
Diarrhea and Gastroenteritis 
of Presumed Infectious Origin
A09
All GI Infections 001–009 A00–A09

As shown in Table 1, in 2004, more than half of ambulatory care visits for GI infections occurred in those under the age of 15 years. When first-listed, the rate in this age group (1,930 per 100,000 population), was at least 4 times that of any other age group. Age-adjusted rates were 45.7 percent higher among whites than blacks and 18.1 percent higher among females than males. Relative to the frequency of ambulatory care visits, hospitalizations were uncommon. In contrast to those in ambulatory care, persons over age 65 years had both the highest number and rate of hospitalizations, and blacks had rates similar to those of whites. GI infections were considerably more often a secondary diagnosis (272,000) than first-listed diagnosis (178,000). The rate of age-adjusted hospitalizations with a diagnosis of GI infections increased by 92.8 percent between 1979 (76.1 per 100,000) and 2004 (146.7 per 100,000) and by 43.3 percent between 1992 (102.4 per 100,000) and 2004 (Figure 1).

In 2004, there were 4,396 deaths with a GI infection listed as the underlying cause (Table 2). The large majority of these deaths occurred among persons age 65 years and older. The death rate among whites was 50 percent higher than that among blacks, and the rates were similar among females and males. Similar patterns were seen for GI infections as either underlying or contributing cause. Because the majority of deaths occurred in the elderly, the YPLL prior to age 75 years was small, less than 3 years per death. In recent years, there has been a remarkable increase in deaths from GI infections (Figure 2). Over the 20-year period between 1979 and 1999, the age-adjusted underlying cause mortality rate doubled from 0.21 per 100,000 to 0.42 per 100,000. But in the 5 years from 1999 to 2004, the rate more than tripled to 1.44 per 100,000. About two-thirds of the more recent increase is due to one bacterial cause, Clostridium difficile, which is coded under Other Bacterial Intestinal Infections as A04.7.

MEDICATIONS

The costliest prescriptions filled at retail pharmacies for GI infections in 2004, according to the Verispan database (Appendix 2), are shown in Table 3. Most were antimicrobial agents, such as ciprofloxacin, or they affected GI motility, such as promethazine. An estimated 938,000 outpatient prescriptions were filled.

Return To Table Of Contents

Table 1. Gastrointestinal Infections: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

1,174

1,930

1,222

2,010

47

77

83

137

AGE (Years)
15–44

579

460

672

534

31

25

65

51

AGE (Years)
45–64

266

377

311

440

34

47

86

122

AGE (Years)
65+

109

301

159

439

66

183

215

593

Race 
White

1,800

785

1,994

867

140

57

359

144

Race
Black

225

529

253

595

16

46

48

151

Sex 
Female

1,142

796

1,279

888

107

67

261

160

Sex 
Male

986

684

1,085

752

71

52

188

142

Total

2,128

725

2,365

805

178

61

450

153

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 1. Gastrointestinal Infections: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 increased from 676 in 1992-1993 to 817 in 2003-2005. Hospitalizations per 100,000 increased from 76.1 in 1979 to 101 in 2000, and then more sharply to 147 in 2004.  

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 2. Gastrointestinal Infections: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

32

0.1

2.3

40

0.1

AGE (Years) 
15–44

49

0.0

1.9

97

0.1

AGE (Years) 
45–64

353

0.5

6.0

577

0.8

AGE (Years)
65+

3,962

10.9

2.6

6,345

17.5

Race
White

4,104

1.5

10.7

6,552

2.5

Race
Black

241

1.0

1.6

422

1.6

Sex
Female

2,746

1.5

6.4

4,257

2.3

Sex
Male

1,650

1.4

6.4

2,802

2.4

Total 

4,396

1.5

12.8

7,059

2.4

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 2. Gastrointestinal Infections: Age-Adjusted Rates of Death in the United States, 1979–2004

In recent years, there has been an exponential increase in deaths. Over the 20-year period between 1979 and 1999, underlying-cause mortality per 100,000 doubled from 0.21 to 0.42. But in the 5 years from 1999 to 2004, the rate more than tripled to 1.44 per 100,000. The trend in all-cause mortality per 100,000 was similar, increasing from 0.36 in 1979 to 0.82 in 1999 to 2.32 in 2004.  

Source: Vital Statistics of the United States

Table 3. Gastrointestinal Infections: Costliest Prescriptions

DRUG
Prescription (#)
Prescription
Retail Cost
Cost

Vancomycin

14,507

1.5%

$28,375,011

62.9%

Promethazine

346,794

37.0

5,985,173

13.3

Ciprofloxacin

126,523

13.4

5,132,893

11.4

Metronidazole

184,090

19.6

2,986,288

6.6

Loperamide

112,285

12.0

865,924

1.9

Diphenoxylate

122,042

13.0

832,096

1.8

Levofloxacin

7,325

0.8

483,046

1.1

Acidophilus/Bulgaricus

20,432

2.2

275,062

0.6

Ciprofloxacin-Betaine Combination

1,215

0.1

109,988

0.2

Prochlorperazine

2,927

0.3

26,326

0.1

Other

67

0.0

5,788

0.0

TOTAL

938,207

100.0%

$45,077,595

100.0%

Source: Verispan

Return To Table Of Contents

CHAPTER 3

Viral Hepatitis
James E. Everhart, M.D., M.P.H.

The primary forms of viral hepatitis in the United States are hepatitis A, B, and C (see ICD codes in Appendix 1). Hepatitis A is common and can be serious or even lethal. It does not have a chronic form. Hepatitis B can cause both acute and chronic disease, whereas acute hepatitis C is often asymptomatic, and its burden is predominantly due to chronic disease.

HEPATITIS A

Although the infection is common, hepatitis A is infrequently recognized in the ambulatory care or hospital setting. It was too infrequent to appear in the office-based sample of the National Ambulatory Medical Care Survey (Table 1). Hospitalization rates declined by about 75 percent between 1979 and 1993, and remained relatively stable through 2004. An effective vaccine to prevent infection was introduced in the 1990s, but it has not had a noticeable effect on reducing hospitalizations (Figure 1). Mortality from hepatitis A was rare, with fewer than 100 deaths per year (Table 2). Unlike recently stable rates of hospitalizations, the death rate from viral hepatitis A was halved between 1999 and 2004 (Figure 2).

HEPATITIS B

Viral hepatitis B is a more significant disease than hepatitis A. In the United States, infections were most commonly recognized between ages 15 and 44 years, and hospitalizations with the diagnosis occurred across the age range of adults (Table 3). Rates of both ambulatory care visits and hospitalizations with hepatitis B were higher among blacks than whites and among males than females. Hepatitis B was rarely the first-listed hospital diagnosis. There has been a vaccine available for hepatitis B since the 1980s, but the rates of both ambulatory care and hospitalizations have increased markedly since 1999 (Figure 3). This increase has been attributed to increased rates of immigration of chronic carriers of hepatitis B virus. Although not a common cause of death, viral hepatitis B resulted in about 10 times as many deaths as hepatitis A (Table 4). The majority of deaths with hepatitis B as either underlying or contributing cause occurred in middle age, between age 45 and 64 years. As with other forms of infections, hepatitis B was more often listed as a contributing than as an underlying cause. Deaths from hepatitis B increased between 1979 and 1994, but mortality steadily declined thereafter, in spite of (or perhaps related to) the increased rates of medical care (Figure 4). As an underlying cause, rates in 2004 were similar to those in 1979, but as a contributing cause, rates were considerably higher in 2004 than they had been 25 years earlier. Age-adjusted mortality was higher among blacks than whites.

HEPATITIS C

The hepatitis C virus was discovered in 1989, and tests for it soon followed. Most prior cases of non-A, non-B hepatitis are believed to have been viral hepatitis C. In both the outpatient and inpatient setting, more than half the cases were in persons ages 45–64 years (Table 5). Rates were at least twice as high among blacks as whites and among males as females. Viral hepatitis C was rarely the first-listed diagnosis at hospital discharge, but was frequently listed as a secondary diagnosis. As a result, only 2.6 percent of hospital discharge diagnoses for hepatitis C listed it as the first-listed diagnosis. Where hepatitis C was not the first-listed diagnosis, the most common underlying (first-listed) causes were chronic liver disease and its sequelae (10.4 percent), mood disorders (4.5 percent), cellulitis (3.8 percent), complications of procedures (2.6 percent), pneumonia (2.5 percent), and HIV (2.4 percent). The majority of hospitalizations, however, appeared to be unrelated to hepatitis C, suggesting that the diagnoses may appear as a result of testing for hepatitis C, rather than as consequences of hepatitis C. Blacks and men had the highest age-adjusted rates.

Both outpatient and inpatient diagnoses have greatly increased since hepatitis C received its own ICD code in the early 1990s (Figure 5). The number of hospitalizations prior to 1992 was too small to provide estimates. Much of the increase can be attributed to increasing recognition of the disease. There was also the introduction of antiviral therapy that required frequent patient monitoring. It is not clear how much of the increase can be attributed to the consequences of disease burden due to longstanding infection.

In 2004, 85 percent of hepatitis-related deaths were from viral hepatitis C. Hepatitis C was listed as a contributing cause of death more often than as the underlying cause (Table 6). About two-thirds of deaths occurred between the ages of 45 and 64 years. Age-adjusted death rates among blacks were nearly twice those of whites, and males had more than double the death rate of females. Hepatitis C contributed a high number of YPLL before the age of 75 years (87,500), because of the large number of deaths and because few deaths are attributed to the disease after age 75. This number placed hepatitis C as the fifth leading digestive disease cause of YPLL, behind esophageal cancer and ahead of gastric cancer. In keeping with the growing identification and long-term consequences of the disease, mortality rates increased rapidly from 1990 to 2004 (Figure 6). (The few deaths recorded prior to 1990 were for non-A, non-B viral hepatitis.) Of note, the mortality rate for hepatitis C as underlying cause leveled off beginning in 2001 and as underlying or contributing cause in 2002.

ALL VIRAL HEPATITIS

The burden of all viral hepatitis primarily reflected that of hepatitis B in past years and, more recently, hepatitis C (Tables 7 and 8, Figures 7 and 8). For example, 97.5 percent of the YPLL prior to age 75 years due to viral hepatitis was a result of hepatitis B (11.6 percent) or hepatitis C (85.9 percent).

MEDICATIONS

The costliest prescriptions filled at retail pharmacies for viral hepatitis in 2004, according to the Verispan database (Appendix 2), are shown in Table 9. An estimated 637,000 outpatient prescriptions were filled, but these were represented by few drugs, which were prescribed exclusively for hepatitis B (adefovir and lamivudine) or hepatitis C (ribavirin and peginterferon). When used to treat hepatitis C, ribavirin was nearly always used with interferon. For a full course of therapy, each of the medications in Table 9 would have required multiple prescriptions.

Table 1. Hepatitis A: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

0

1

0

1

AGE (Years)
15–44

1

1

3

3

AGE (Years)
45–64

0

1

4

5

AGE (Years)
65+

0

1

2

6

Race 
White

2

1

7

3

Race
Black

0

0

2

4

Sex 
Female

1

1

5

3

Sex 
Male

1

1

5

3

Total

2

1

10

3

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 1. Hepatitis A: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004 (Ambulatory Care Visit Data Unavailable)

The number of ambulatory care visits during the time period was too small to provide estimates. Hospitalizations per 100,000 declined from 6.51 in 1979 to 1.67 in 1993, and remained relatively stable through 2004 when the rate was 1.30. 

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 2. Hepatitis A: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

AGE (Years) 
15–44

6

0.0

0.2

13

0.0

AGE (Years) 
45–64

27

0.0

0.6

61

0.1

AGE (Years)
65+

25

0.1

0.0

55

0.2

Race
White

48

0.0

0.7

101

0.0

Race
Black

7

0.0

0.1

20

0.1

Sex
Female

28

0.0

0.3

57

0.0

Sex
Male

30

0.0

0.5

72

0.0

Total 

58

0.0

0.8

129

0.0

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 2. Hepatitis A: Age-Adjusted Rates of Death in the United States, 1979–2004

The death rate was halved between 1999 and 2004. From 1979 through 1999, it was relatively stable. Underlying-cause mortality per 100,000 was 0.07 in 1979, 0.05 in 1999, and decreased to 0.02 in 2004. All-cause mortality per 100,000 was 0.09 in 1979, 0.10 in 1999, and decreased to 0.04 in 2004.  

Source: Vital Statistics of the United States

Return To Table Of Contents

Table 3Hepatitis B: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

AGE (Years)
15–44

385

306

2

1

26

21

AGE (Years)
45–64

277

392

1

2

33

47

AGE (Years)
65+

0

1

9

26

Race 
White

242

98

2

1

40

16

Race
Black

183

510

1

3

19

55

Sex 
Female

122

83

1

1

26

17

Sex 
Male

607

418

2

1

43

29

Total

448

152

729

248

4

1

69

23

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 3. Hepatitis B: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). The rates of both ambulatory care visits and hospitalizations have increased markedly since 1999. Ambulatory care visits per 100,000 rose from 88.4 in 1992-1993 to 247 in 2003-2005. Hospitalizations per 100,000 rose from 6.79 in 1979 to 12.2 in 1999, and then to 18.1 in 2004.  

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 4. Hepatitis B: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

1

0.0

AGE (Years) 
15–44

115

0.1

4.2

291

0.2

AGE (Years) 
45–64

346

0.5

7.1

962

1.4

AGE (Years)
65+

184

0.5

0.5

441

1.2

Race
White

424

0.2

7.6

984

0.4

Race
Black

124

0.4

2.5

390

1.2

Sex
Female

174

0.1

2.7

428

0.3

Sex
Male

471

0.3

9.1

1,267

0.9

Total 

645

0.2

11.8

1,695

0.6

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 4. Hepatitis B: Age-Adjusted Rates of Death in the United States, 1979–2004

Deaths increased between 1979 and 1994, but steadily declined thereafter. Underlying-cause mortality per 100,000 rose from 0.12 in 1979 to 0.44 in 1994 and then fell to 0.21 in 2004. All-cause mortality per 100,000 rose from 0.18 in 1979 to 0.81 in 1994 and then fell to 0.56 in 2004. As an underlying cause, rates in 2004 were similar to those in 1979, but as a contributing cause, rates were considerably higher in 2004 than they had been 25 years earlier. 

Source: Vital Statistics of the United States

Return To Table Of Contents

Table 5. Hepatitis C: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

0

0

AGE (Years)
15–44

382

304

791

628

2

2

127

101

AGE (Years)
45–64

918

1,298

1,603

2,268

7

10

248

351

AGE (Years)
65+

353

970

1

4

43

118

Race 
White

1,110

451

1,828

742

9

3

298

120

Race
Black

235

662

739

2,122

2

5

99

286

Sex 
Female

514

331

925

604

4

3

161

105

Sex 
Male

974

677

1,823

1,261

7

4

258

176

Total

1,487

506

2,747

936

11

4

419

143

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 5. Hepatitis C: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Both outpatient and inpatient diagnoses have greatly increased since the early 1990s. Ambulatory care visits per 100,000 rose from 116 in 1992-1993 to 914 in 2003-2005. The number of hospitalizations prior to 1992 was too small to provide estimates. Hospitalizations per 100,000 rose from 7.69 in 1992 to 120 in 2004.  

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 6. Hepatitis C: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

2

0.0

0.1

3

0.0

AGE (Years) 
15–44

547

0.4

18.6

1,445

1.1

AGE (Years) 
45–64

3,062

4.3

66.1

7,590

10.7

AGE (Years)
65+

984

2.7

2.7

2,253

6.2

Race
White

3,712

1.4

71.0

8,771

3.4

Race
Black

718

2.2

14.2

2,111

6.4

Sex
Female

1,625

1.0

26.8

3,448

2.2

Sex
Male

2,970

2.0

60.8

7,844

5.3

Total 

4,595

1.6

87.5

11,292

3.8

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 6. Hepatitis C: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality rates increased rapidly from 1990 to 2004. (Few deaths were recorded prior to 1990.) Underlying-cause mortality per 100,000 rose from 0.03 in 1990 to 1.50 in 2004, while all-cause mortality per 100,000 rose from 0.04 in 1990 to 3.68 in 2004. The mortality rate as underlying cause leveled off beginning in 2001 and as underlying or contributing cause in 2002. 

Source: Vital Statistics of the United States

Return To Table Of Contents

Table 7. All Viral Hepatitis: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

1

1

1

2

AGE (Years)
15–44

627

499

1,174

933

6

5

150

119

AGE (Years)
45–64

1,118

1,582

1,914

2,708

10

14

271

383

AGE (Years)
65+

399

1,099

2

6

53

147

Race 
White

1,260

509

2,101

852

14

6

330

133

Race
Black

315

869

919

2,625

3

9

113

326

Sex 
Female

620

404

1,071

703

8

5

185

121

Sex 
Male

1,356

936

2,439

1,685

11

7

290

198

Total

1,977

673

3,510

1,195

19

6

475

162

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 7. All Viral Hepatitis: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Both outpatient and inpatient rates have greatly increased since the early 1990s. Ambulatory care visits per 100,000 rose from 230 in 1992-1993 to 1,171 in 2003-2005. The hospitalization rate per 100,000 was 18.3 in 1979 and remained stable through 1992, after which it increased to 138 in 2004.  

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 8. All Viral Hepatitis: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

3

0.0

0.2

9

0.0

AGE (Years) 
15–44

684

0.5

23.7

1,674

1.3

AGE (Years) 
45–64

3,477

4.9

74.7

8,249

11.7

AGE (Years)
65+

1,229

3.4

3.2

2,723

7.5

Race
White

4,254

1.7

80.4

9,538

3.7

Race
Black

866

2.6

17.1

2,401

7.3

Sex
Female

1,872

1.2

30.5

3,850

2.4

Sex
Male

3,521

2.4

71.3

8,806

6.0

Total 

5,393

1.8

101.8

12,656

4.3

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 8. All Viral Hepatitis: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality increased slightly prior to 1990, after which it rose more rapidly. Underlying-cause mortality per 100,000 increased from 0.36 in 1979 to 0.66 in 1990 and then to 1.76 in 2004. All-cause mortality per 100,000 increased from 0.46 in 1979 to 0.98 in 1990 and then to 4.13 in 2004. The mortality rate as underlying cause leveled off beginning in 2001 and as underlying or contributing cause in 2002. 

Source: Vital Statistics of the United States

Return To Table Of Contents

Table 9 . All Viral Hepatitis: Costliest Prescriptions

DRUG
Prescription (#) Prescription Retail Cost Cost
Ribavirin

221,035

34.7%

$229,351,616

40.0%

Peginterferon alfa-2a

131,001

20.5

191,754,177

33.5

Peginterferon alfa-2b

64,398

10.1

84,943,979

14.8

Adefovir

86,784

13.6

43,120,493

7.5

Lamivudine

134,657

21.1

23,580,159

4.2

TOTAL

637,875

100.0%

$572,750,424

100.0%

Source: Verispan

Return To Table Of Contents


CHAPTER 4

Digestive Cancers
James E. Everhart, M.D., M.P.H.

The Surveillance, Epidemiology, and End Results (SEER) program provides considerable information on cancer burden not available for other digestive diseases. SEER statistics used in this report are number of cases and incidence in 2004, and the time trends for incidence and 5-year survival following diagnosis between 1979 and 2004. The codes used by ICD-9, ICD-10, and SEER are listed in Appendix 1.

ALL DIGESTIVE SYSTEM CANCERS

In 2004, approximately 233,000 persons were diagnosed with digestive system cancers (Table 1), which represented 18 percent of all cancers and was second only to genital system cancers for the most commonly affected organ system. Two-thirds of digestive system cancers occurred among persons age 65 years and older. The median age of diagnosis was 70 years, compared with 67 years for all cancers (http://seer.cancer.gov/csr/1975_2005/results_merged/topic_med_age.pdf (PDF, 28KB)) . Age-adjusted rates were highest among non-Hispanic blacks and lowest among American Indians. Males had slightly higher rates than females. Age-adjusted incidence declined by 13.2 percent between 1979 and 2004, with the entire decline coming after 1986 (Figure 1). Survival for all cancers and for individual cancers was calculated as absolute survival. Other reports may calculate survival relative to the general population with the same age and sex distribution, which would result in higher apparent survival. The same trends, however, would be seen for either approach. Five-year survival increased an absolute 6 percent to 34.6 percent; thus, for every 100 persons diagnosed with a digestive system cancer in 1999, 6 more survived at least 5 years longer than did those diagnosed 20 years earlier.

There were approximately 3.5 million ambulatory care visits for first-listed digestive system cancer in 2004 and 4.2 million all-listed visits. The elderly, whites, and males had the highest rates of ambulatory care visits (Table 2). Among all hospital discharges with digestive system cancers, about half were first-listed. The main demographic difference between ambulatory care diagnoses and hospital diagnoses was that blacks had a higher age-adjusted rate of hospital diagnoses. Rates of ambulatory care visits for digestive system cancers did not change appreciably over the period 1992–2004, but hospitalizations rates declined by 13.6 percent over that period (Figure 2).

In 2004, there were approximately 135,000 deaths due to digestive system cancers (Table 3), which represented 24 percent of all cancers and were second only to respiratory system cancers as cause of death due to cancer. As underlying cause, digestive system cancers constituted 57.2 percent of all digestive disease deaths. Death rates among persons 65 years and older were 5 times that of those aged 45–64 years. Age-adjusted death rates were higher among blacks and men. There were 945,000 YPLL due to digestive system cancer, the large majority occurring among males. Death rates from digestive system cancer declined steadily between 1979 and 2004 by an overall 19.8 percent (Figure 3).

MEDICATIONS

The costliest prescriptions filled at retail pharmacies for digestive system malignancies in 2004, according to the Verispan database (Appendix 2), are shown in Table 4. An estimated 879,000 outpatient prescriptions were filled. The costliest agents were either anti-neoplastic agents, such as capecitabine, or nonspecific pain and anti-nausea medications, such as fentanyl. Because the prescriptions were filled at retail pharmacies and do not capture all the settings where anti-cancer treatment is prescribed, this table both underestimates the number of prescriptions and likely misses many of the drugs used to treat digestive system malignancies. Medications are not shown for the individual malignancies in the following chapters.

Table 1. All Digestive Cancers: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Demographic Characteristics

Number of Cases

Incidence per 100,000
Unadjusted

Incidence per 100,000
Age-Adjusted

AGE (Years)
Under 15

293

0.5

AGE (Years) 
15–44

10,927

9.1

AGE (Years) 
45–64

78,215

111.6

AGE (Years)
65+

154,886

452.8

RACE/ETHNICITY
Non-Hispanic White

191,668

99.6

83.5

RACE/ETHNICITY
Non-Hispanic Black

26,748

78.3

109.0

RACE/ETHNICITY
Hispanic

15,921

39.3

81.8

RACE/ETHNICITY
Asian/Pacific Islander

8,914

72.4

84.4

RACE/ETHNICITY
American Indian/Alaska Native

1,009

54.5

75.0

Sex
Female

109,058

74.7

70.0

Sex
Male

123,967

88.7

105.1

Total 

233,239

81.6

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Figure 1. All Digestive Cancers: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 decreased from 99.6 in 1979 to 86.5 in 2004, with the entire decline coming after 1985. Five-year survival increased from 28.6 percent in 1979 to 34.6 percent in 1999, the last year for which it could be calculated. 

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Table 2. All Digestive Cancers: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

1

1

5

7

AGE (Years)
15–44

110

87

145

115

19

15

47

37

AGE (Years)
45–64

1,293

1,829

1,537

2,174

115

163

257

364

AGE (Years)
65+

2,034

5,600

2,472

6,805

200

550

418

1,149

Race 
White

3,149

1,235

3,771

1,479

263

102

572

222

Race
Black

240

802

313

1,040

40

141

89

307

Sex 
Female

1,740

1,081

2,218

1,375

167

100

374

226

Sex 
Male

1,741

1,309

1,980

1,485

168

128

351

267

Total

3,481

1,185

4,198

1,429

335

114

726

247

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 2. All Digestive Cancers: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Rates of ambulatory care visits did not change appreciably over the period, but hospitalization rates declined since the early 1990s. Ambulatory care visits per 100,000 were 1,032 in 1992-1993 and 1,395 in 2003-2005. Hospitalizations per 100,000 increased from 224 in 1979 to 260 in 1984, remained relatively stable through 1992, and then declined to 216 in 2004.  

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 3. All Digestive Cancers: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

43

0.1

3.0

57

0.1

AGE (Years) 
15–44

3,972

3.2

142.7

4,549

3.6

AGE (Years) 
45–64

35,968

50.9

648.1

41,599

58.8

AGE (Years)
65+

95,123

261.8

151.5

114,984

316.5

Race
White

113,468

43.5

737.8

136,231

52.2

Race
Black

16,907

62.2

161.7

19,587

72.3

Sex
Female

61,515

35.4

346.5

74,315

42.7

Sex
Male

73,592

57.9

598.7

86,876

68.8

Total 

135,107

46.0

945.2

161,191

54.9

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 3. All Digestive Cancers: Age-Adjusted Rates of Death in the United States, 1979–2004

Death rates declined steadily between 1979 and 2004. Underlying-cause mortality per 100,000 decreased from 55.6 in 1979 to 44.6 in 2004. All-cause mortality per 100,000 decreased from 69.9 in 1979 to 53.1 in 2004.  

Source: Vital Statistics of the United States

Return To Table Of Contents

Table 4. All Digestive Cancers: Costliest Prescriptions

DRUG
Prescription (#)
Prescription
Retail Cost
Cost
Capecitabine

77,376

8.8%

$76,943,103

53.6%

Fentanyl

80,768

9.2

21,519,990

15.0

Oxycodone

92,577

10.5

20,027,456

14.0

Hydromorphone

371,312

42.2

16,110,590

11.2

Oxycodone/Acetaminophen

215,506

24.5

4,516,077

3.1

Morphine

17,890

2.0

3,690,323

2.6

Gemcitabine

379

0.0

361,858

0.3

Hydrocodone/Acetaminophen

4,285

0.5

249,901

0.2

Bevacizumab

18

0.0

45,962

0.0

Cetuximab

15

0.0

27,876

0.0

Other

18,557

2.0

14,683

0.0

TOTAL

878,683

100.0%

$143,507,819

100.0%

Source: Verispan

Return To Table Of Contents

CHAPTER 5

Cancer of the Esophagus
James E. Everhart, M.D., M.P.H.

The two forms of esophageal cancer are squamous cell carcinoma, which occurs in the upper two-thirds of the esophagus, and adenocarcinoma, which occurs in the lower part of the esophagus. Because the epidemiology of the two cancers is quite different, the SEER results are presented separately. Other national data sources do not differentiate as well, and those data therefore are combined.

In 2004, the majority (67 percent) of new cases of esophageal squamous cell cancer occurred among persons 65 years and older (Table 1) and occurred most often among non-Hispanic blacks and males (61 percent). The incidence declined over 25 years to 2004, when it was about half the rate of 1979 (Figure 1). Five-year survival remained poor, but improved from about 3 percent to 12 percent over that period.

Esophageal adenocarcinoma had a younger age distribution than most other digestive system cancers, but the majority of cases (63 percent) still occurred at age 65 years and older (Table 2). Non-Hispanic whites and males had by far the highest risk. These race and sex differences were greater than for any other common digestive tract cancer. During the 25 years of observation, the incidence of esophageal adenocarcinoma increased more rapidly than any other common malignancy, rising approximately fivefold between 1979 and 2004 (Figure 2). Five-year survival remained poor, but had increased from less than 5 percent to more than 15 percent.

Combining the two esophageal cancers (Table 3 and Figure 3) obscures their dynamic differences. For example, incidence of all esophageal cancer increased modestly over the period, but in 1979, adenocarcinoma was about one-eighth as frequent as squamous cell carcinoma, whereas by 2004, adenocarcinoma had the higher incidence. These combined data can, however, be useful for comparison with other national data. In 2004, there were an estimated 372,000 ambulatory care visits and 44,000 hospital diagnoses for esophageal cancer; rates of ambulatory care visits were moderately higher among persons age 65 years and older (Table 4). There were only sufficient numbers of ambulatory care visits for whites and males to show in the table. Hospitalizations occurred predominantly among persons age 65 years and older. During the 25 years of reporting, the rates of hospitalization remained relatively stable, in keeping with the overall incidence figures (Figure 4). Ambulatory care visits were too uncommon to discern a trend.

Esophageal cancer was a frequent cause of cancer death, ranking third in 2004 among digestive system cancers (after colorectal and pancreatic cancer) and was responsible for more than 13,000 deaths (Table 5) and 113,000 YPLL prior to age 75 years. Cancers of the gastroesophageal junction and cardia accounted for 4.6 percent of these deaths (see Chapter 6, Cancer of the Stomach). In keeping with the SEER data, death rates were highest among persons age 65 years and older, blacks (modestly more than whites), and males. Death rates increased between 1979 and 2004, but not during the last 6 years of that period.

Table 1. Esophageal Squamous Cell Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Demographic Characteristics

Number of Cases

Incidence per 100,000
Unadjusted

Incidence per 100,000
Age-Adjusted

AGE (Years)
Under 15

AGE (Years) 
15–44

94

0.1

AGE (Years) 
45–64

1,655

2.4

AGE (Years)
65+

3,093

9.0

RACE/ETHNICITY
Non-Hispanic White

3,183

1.7

1.4

RACE/ETHNICITY
Non-Hispanic Black

1,108

3.2

4.4

RACE/ETHNICITY
Hispanic

263

0.7

1.4

RACE/ETHNICITY
Asian/Pacific Islander

210

1.7

2.0

RACE/ETHNICITY
American Indian/Alaska Native

Sex
Female

1,771

1.2

1.2

Sex
Male

2,828

2.0

2.4

Total 

4,612

1.6

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Figure 1. Esophageal Squamous Cell Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 declined from 3.09 in 1979 to 1.81 in 2004. Five-year survival improved from 3.48 percent in 1979 to 11.7 percent in 1999, the last year for which it could be calculated.  

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Table 2. Esophageal Adenocarcinoma: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Demographic Characteristics

Number of Cases

Incidence per 100,000
Unadjusted

Incidence per 100,000
Age-Adjusted

AGE (Years)
Under 15

AGE (Years) 
15–44

198

0.2

AGE (Years) 
45–64

2,420

3.5

AGE (Years)
65+

3,996

11.7

RACE/ETHNICITY
Non-Hispanic White

6,553

3.4

2.9

RACE/ETHNICITY
Non-Hispanic Black

143

0.4

0.5

RACE/ETHNICITY
Hispanic

268

0.7

1.4

RACE/ETHNICITY
Asian/Pacific Islander

54

0.4

0.5

RACE/ETHNICITY
American Indian/Alaska Native

Sex
Female

942

0.6

0.6

Sex
Male

5,318

3.8

4.5

Total 

6,309

2.2

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Figure 2. Esophageal Adenocarcinoma: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 increased rapidly from 0.66 in 1979 to 2.61 in 2004. Five-year survival increased from 5.08 percent in 1979 to 15.8 percent in 1999, the last year for which it could be calculated.  

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Table 3. All Esophageal Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Demographic Characteristics

Number of Cases

Incidence per 100,000
Unadjusted

Incidence per 100,000
Age-Adjusted

AGE (Years)
Under 15

AGE (Years) 
15–44

367

0.3

AGE (Years) 
45–64

4,712

6.7

AGE (Years)
65+

8,411

24.6

RACE/ETHNICITY
Non-Hispanic White

11,572

6.0

5.1

RACE/ETHNICITY
Non-Hispanic Black

1,394

4.1

5.5

RACE/ETHNICITY
Hispanic

638

1.6

3.4

RACE/ETHNICITY
Asian/Pacific Islander

299

2.4

2.9

RACE/ETHNICITY
American Indian/Alaska Native

Sex
Female

3,186

2.2

2.1

Sex
Male

9,605

6.9

8.1

Total 

12,863

4.5

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Figure 3. All Esophageal Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 increased modestly from 4.42 in 1979 to 5.17 in 2004. Five-year survival increased from 3.47 percent in 1979 to 13.3 percent in 1999, the last year for which it could be calculated.  

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Table 4. All Esophageal Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

AGE (Years)
15–44

1

1

2

2

AGE (Years)
45–64

215

304

217

308

8

11

17

25

AGE (Years)
65+

138

379

150

413

11

30

25

69

Race 
White

343

131

361

139

16

6

36

14

Race
Black

2

8

6

19

Sex 
Female

5

3

10

6

Sex 
Male

244

170

261

184

15

11

34

26

Total

354

120

372

127

20

7

44

15

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 4. All Esophageal Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 were 71.0 in 1992-1993 and 120 in 2003-2005, but were too uncommon to discern a trend. During the 25 years of reporting, the rate of hospitalizations remained relatively stable, at around 15 per 100,000. 

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 5. All Esophageal Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

AGE (Years) 
15–44

371

0.3

12.9

388

0.3

AGE (Years) 
45–64

4,650

6.6

82.6

4,929

7.0

AGE (Years)
65+

8,646

23.8

18.4

9,610

26.4

Race
White

11,850

4.6

94.6

12,953

5.0

Race
Black

1,561

5.5

17.0

1,696

6.0

Sex
Female

3,063

1.8

18.5

3,361

2.0

Sex
Male

10,604

8.1

95.4

11,566

8.9

Total 

13,667

4.7

113.8

14,927

5.1

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 5. All Esophageal Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

Death rates increased between 1979 and 2004, but not during the last 6 years of that period. Underlying-cause mortality per 100,000 rose from 3.91 in 1979 to 4.50 in 2004. All-cause mortality per 100,000 rose from 4.37 in 1979 to 4.92 in 2004.  

Source: Vital Statistics of the United States

Return To Table Of Contents

CHAPTER 6

Cancer of the Stomach
James E. Everhart, M.D., M.P.H.

SEER includes cancers of the gastroesophageal junction and gastric cardia with gastric cancer. Over the period 1979 to 2004, the incidence of cancers of the gastroesophageal junction and cardia approximately doubled, resulting in an increase in the proportion of gastric cancer at these sites from 14.9% in 1979 to 30.4% in 2004. However, for medical care and vital statistics, these sites were included with esophageal cancer.

In 2004, the stomach was the third most common anatomical site for digestive system cancer, after the colon/rectum and the pancreas. Cancer of the stomach, gastric cancer, had an older age distribution than did other GI cancers, with 68 percent of cases having occurred at age 65 years or older (Table 1). Median age of diagnosis was 71 years (http://seer.cancer.gov/csr/1975_2005/results_merged/topic_med_age.pdf (PDF, 28KB)). Asians and Hispanics had the highest age-adjusted incidence rates; non-Hispanic whites had the lowest rate. The incidence of gastric cancer, as reflected by mortality rates, has been declining for more than 70 years in the United States. Between 1979 and 2004, the incidence declined more than one-third (Figure 1).

During that period, 5-year survival following diagnosis increased by 50 percent.

Ambulatory care visits and hospital discharges with gastric cancer were relatively insubstantial (Table 2). Hospitalization rates declined more rapidly than the incidence rate (Figure 2). Because gastric cancer now has somewhat better survival than other digestive system
cancers, it was only the fourth leading cause of death among these cancers. Seventy percent of deaths with gastric cancer as the underlying cause occurred at age 65 years or older (Table 3). The large majority of deaths listed gastric cancer as the underlying cause. Age-adjusted mortality rates were more than twice as high among blacks as whites and nearly twice as high among men as women. If cancer of the gastroesophageal junction were included among gastric cancer, the number of deaths would have increased 5.6 percent to 11,883 in 2004. Reflecting the declining incidence rate and longer survival, the age-adjusted mortality rate of gastric cancer declined by 49 percent between 1979 and 2004 (Figure 3), the most rapid decline for any major digestive system cancer.

Table 1. Gastric Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Demographic Characteristics

Number of Cases

Incidence per 100,000
Unadjusted

Incidence per 100,000
Age-Adjusted

AGE (Years)
Under 15

AGE (Years) 
15–44

1,292

1.1

AGE (Years) 
45–64

6,610

9.4

AGE (Years)
65+

14,617

42.7

RACE/ETHNICITY
Non-Hispanic White

14,224

7.4

6.2

RACE/ETHNICITY
Non-Hispanic Black

2,727

8.0

11.4

RACE/ETHNICITY
Hispanic

2,425

6.0

12.3

RACE/ETHNICITY
Asian/Pacific Islander

1,419

11.5

13.8

RACE/ETHNICITY
American Indian/Alaska Native

123

6.6

9.1

Sex
Female

8,579

5.9

5.5

Sex
Male

12,888

9.2

11.1

Total 

21,519

7.5

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Figure 1. Gastric Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 declined from 12.0 in 1979 to 7.64 in 2004. Five-year survival increased from 12.5 percent in 1979 to 18.1 percent in 1999, the last year for which it could be calculated.  

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Table 2. Gastric Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

AGE (Years)
15–44

1

1

3

2

AGE (Years)
45–64

5

7

10

14

AGE (Years)
65+

107

295

10

29

19

52

Race 
White

99

40

11

4

21

8

Race
Black

3

11

6

21

Sex 
Female

7

4

14

8

Sex 
Male

59

44

9

7

17

13

Total

137

47

141

48

17

6

31

11

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 2. Gastric Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 declined from 66.8 in 1992-1993 to 48.2 in 2003-2005. Hospitalizations per 100,000 declined from 20.1 in 1979 to 9.28 in 2004.  

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 3. Gastric Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

AGE (Years) 
15–44

573

0.5

20.7

585

0.5

AGE (Years) 
45–64

2,809

4.0

51.8

2,942

4.2

AGE (Years)
65+

7,871

21.7

11.7

8,734

24.0

Race
White

8,494

3.3

58.0

9,271

3.6

Race
Black

2,008

7.5

18.7

2,177

8.1

Sex
Female

4,791

2.8

32.9

5,197

3.0

Sex
Male

6,462

5.2

51.3

7,064

5.7

Total 

11,253

3.8

84.2

12,261

4.2

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 3. Gastric Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

The mortality rate declined rapidly between 1979 and 2004. Underlying-cause mortality per 100,000 decreased from 7.27 in 1979 to 3.72 in 2004. All-cause mortality per 100,000 decreased from 8.10 in 1979 to 4.05 in 2004.  

Source: Vital Statistics of the United States

Return To Table Of Contents

CHAPTER 7

Cancer of the Small Intestine
James E. Everhart, M.D., M.P.H.

Cancer of the small intestine is often considered rare, but in 2004, there were more than 5,000 new cases diagnosed (exclusive of intestinal lymphomas), or about a third the total number of esophageal cancers or primary liver cancers, and more than the number of gallbladder cancers. Slightly more than half of patients were diagnosed at age 65 years or older (Table 1), with a median age of 67 years (http://seer.cancer.gov/csr/1975_2005/results_merged/topic_med_age.pdf (PDF, 28KB)), making this the digestive system cancer with the second youngest age of onset (after primary liver cancer). Nevertheless, rates were highest among the elderly and among blacks and males.

Age-adjusted incidence for cancer of the small intestine increased by 73 percent between 1979 and 2004 (Figure 1). Lack of awareness of the magnitude of this increase may be a reason for the perception that it remains a rare cancer. Over the same period, 5-year survival improved modestly, from about 33 percent to about 41 percent. National medical care systems do not adequately capture outpatient or inpatient visits (Table 2), although rates of hospital discharges have tended to increase in recent years (Figure 2). The number of hospitalizations prior to 1988 was too small to provide estimates.

Because of its relatively high survival rate, there were only 1,115 deaths from cancer of the small intestine in 2004, and fewer than 10,000 YPLL prior to age 75 years (Table 3). The majority of deaths occurred among persons age 65 years and older. Death rates were higher for blacks than whites and for males than females, reflecting the incidence rates. Age-adjusted death rates changed little between 1979 and 2004 (Figure 3).

Table 1.  Cancer of the Small Intestine: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Demographic Characteristics

Number of Cases

Incidence per 100,000
Unadjusted

Incidence per 100,000
Age-Adjusted

AGE (Years)
Under 15

AGE (Years) 
15–44

407

0.3

AGE (Years) 
45–64

1,987

2.8

AGE (Years)
65+

2,889

8.4

RACE/ETHNICITY
Non-Hispanic White

4,298

2.2

1.9

RACE/ETHNICITY
Non-Hispanic Black

756

2.2

3.0

RACE/ETHNICITY
Hispanic

295

0.7

1.4

RACE/ETHNICITY
Asian/Pacific Islander

107

0.9

1.0

RACE/ETHNICITY
American Indian/Alaska Native

Sex
Female

2,357

1.6

1.5

Sex
Male

2,703

1.9

2.2

Total 

5,065

1.8

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Figure 1. Cancer of the Small Intestine: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 increased from 1.08 in 1979 to 1.87 in 2004. Five-year survival improved modestly, from 36.8 percent in 1979 to 41.4 percent in 1999, the last year for which it could be calculated.  

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Table 2. Cancer of the Small Intestine: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

AGE (Years)
15–44

0

0

1

1

AGE (Years)
45–64

2

3

3

5

AGE (Years)
65+

3

9

5

14

Race 
White

5

2

7

3

Race
Black

1

3

1

5

Sex 
Female

3

2

4

3

Sex 
Male

3

2

5

4

Total

6

2

9

3

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 2. Cancer of the Small Intestine: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With Any‑L‑Listed Diagnoses in the United States, 1979–2004 (Ambulatory Care Visit Data Unavailable)

The number of ambulatory care visits during the period was too small to provide estimates. The number of hospitalizations prior to 1988 was too small to provide estimates. Rates of hospital discharges per 100,000 have tended to increase in recent years from 1.55 in 1988 to 2.37 in 2004. 

Source: Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 3. Cancer of the Small Intestine: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

AGE (Years) 
15–44

55

0.0

2.0

59

0.0

AGE (Years) 
45–64

329

0.5

6.0

358

0.5

AGE (Years)
65+

731

2.0

1.4

838

2.3

Race
White

908

0.3

6.9

1,021

0.4

Race
Black

175

0.6

2.1

194

0.7

Sex
Female

523

0.3

4.3

588

0.3

Sex
Male

592

0.5

5.0

667

0.5

Total 

1,115

0.4

9.3

1,255

0.4

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 3. Cancer of the Small Intestine: Age-Adjusted Rates of Death in the United States, 1979–2004

Death rates changed little between 1979 and 2004. Underlying-cause mortality per 100,000 was 0.39 in 1979 and 0.37 in 2004. All-cause mortality per 100,000 was 0.47 in 1979 and 0.41 in 2004. 

Source: Vital Statistics of the United States

Return To Table Of Contents

CHAPTER 8

Cancer of the Colon and Rectum
James E. Everhart, M.D., M.P.H.

For this report, cancers of the colon and rectum were combined (see Appendix 1 for ICD codes). Together, these cancers were responsible for an estimated 55 percent of all digestive system cancers diagnosed in 2004. In 72.5 percent of cases, the colon was the anatomical site. By themselves, colon cancer would be the most common digestive system cancer, and rectal cancer the second most common. Therefore, trends in colorectal cancer largely determine trends in digestive system cancers as a whole.

Two-thirds of new cases of colorectal cancer were among those age 65 years or older (Table 1). Among the major racial-ethnic groups, non-Hispanic blacks had the highest rate, followed by non-Hispanic whites. American Indians had the lowest rates, with Hispanics and Asians intermediate. Age-adjusted rates were about one-third higher among males than females. Colorectal cancer incidence has been falling for the past 20 years, declining by 27.1 percent from 1985 to 2004 (Figure 1). The proportion of newly diagnosed patients who survived for at least 5 years has climbed steadily since 1979.

Colorectal cancer is the digestive system malignancy with the most reliable data on medical care (Table 2). In 2004, there were an estimated 2.6 million ambulatory care visits for persons with colorectal cancer. Most visits were among persons age 65 years and older and among women. Blacks had two-thirds the age-adjusted rate of whites. Visit rates were similar for males and females. For hospitalizations, colorectal cancer was more often listed as a first-listed diagnosis than as a secondary diagnosis. Hospitalization rates were disproportionately higher among the 65 years and older group. Age-adjusted rates were higher for blacks than for whites and for males than for females. Hospitalization rates declined from the early 1980s through 1995, and subsequently increased slightly (Figure 2).

Colorectal cancer was the leading cause of death related to the digestive system, accounting for 22.5 percent of deaths (Table 3). Because the median age of death for colorectal cancer was 75 years (http://seer.cancer.gov/csr/1975_2005/results_merged/topic_med_age.pdf (PDF, 28KB)), colorectal cancer accounted for a smaller proportion of YPLL to digestive diseases (16.6 percent), second to liver disease. Because of declining incidence and improved survival, death rates declined 34.8 percent between 1979 and 2004. This decline accelerated during the latter part of that period (Figure 3).

Table 1.  Colorectal Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Demographic Characteristics

Number of Cases

Incidence per 100,000
Unadjusted

Incidence per 100,000
Age-Adjusted

AGE (Years)
Under 15

AGE (Years) 
15–44

6,019

5.0

AGE (Years) 
45–64

41,467

59.2

AGE (Years)
65+

87,872

256.9

RACE/ETHNICITY
Non-Hispanic White

111,509

58.0

48.5

RACE/ETHNICITY
Non-Hispanic Black

14,251

41.7

58.6

RACE/ETHNICITY
Hispanic

7,370

18.2

38.1

RACE/ETHNICITY
Asian/Pacific Islander

4,089

33.2

38.6

RACE/ETHNICITY
American Indian/Alaska Native

477

25.8

35.8

Sex
Female

64,080

43.9

41.1

Sex
Male

65,069

46.5

55.7

Total 

129,189

45.2

47.5

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Figure 1. Colorectal Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 was 62.4 in 1979; between 1985 and 2004 it declined from 66.3 to 48.3. Five-year survival climbed steadily from 40.5 percent in 1979 to 48.8 percent in 1999, the last year for which it could be calculated. 

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Table 2Colorectal Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

AGE (Years)
15–44

56

45

83

66

7

6

14

11

AGE (Years)
45–64

721

1,021

875

1,238

47

66

80

113

AGE (Years)
65+

1,321

3,636

1,627

4,477

97

268

160

441

Race 
White

1,892

747

2,323

915

118

45

195

76

Race
Black

127

426

177

601

17

59

30

107

Sex 
Female

1,134

705

1,456

902

76

45

127

75

Sex 
Male

969

736

1,133

856

76

58

127

98

Total

2,103

716

2,589

882

151

52

255

87

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 2. Colorectal Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 have been relatively stable during the period at 791 in 1992-1993 and 880 in 2003-2005. Hospitalization rates per 100,000 declined from 118 in 1979 to 72.3 in 1995, and subsequently increased slightly to 82.8 in 2004. 

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 3. Colorectal Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

1

0.0

0.1

2

0.0

AGE (Years) 
15–44

1,608

1.3

58.3

1,654

1.3

AGE (Years) 
45–64

12,262

17.3

219.9

13,056

18.5

AGE (Years)
65+

39,355

108.3

54.9

48,188

132.6

Race
White

45,340

17.3

263.0

53,979

20.6

Race
Black

6,592

24.7

57.7

7,446

28.2

Sex
Female

26,512

15.1

142.8

31,153

17.5

Sex
Male

26,714

21.5

190.2

31,747

25.9

Total 

53,226

18.1

333.0

62,900

21.4

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 3. Colorectal Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

Death rates declined between 1979 and 2004. This decline accelerated during the latter part of that period. Underlying-cause mortality per 100,000 decreased from 27.3 in 1979 to 17.8 in 2004. All-cause mortality per 100,000 decreased from 32.1 in 1979 to 21.0 in 2004.  

Source: Vital Statistics of the United States

CHAPTER 9

Primary Liver Cancer
James E. Everhart, M.D., M.P.H.

The major malignant neoplasm of the liver is liver cell cancer (hepatocellular carcinoma). Also included in this category in this report are the rare malignancies of hepatoblastoma and angiosarcoma as well as other primary specified and unspecified liver carcinomas. Intrahepatic bile duct carcinoma is included among bile duct cancers (see Appendix 1 for ICD codes).

In 2004, primary liver cancer occurred at an earlier age than any other digestive system cancer, with 50 percent of cases being diagnosed under the age of 65 years (Table 1). Hepatoblastoma, although the most common liver neoplasm among children, had minimal influence on this association because of its rarity. Incidence was lowest among non-Hispanic whites, intermediate among non-Hispanic blacks and Hispanics, and highest among Asians and American Indians. Males had more than 3 times the age-adjusted incidence of females.

The incidence of primary liver cancer rose modestly between 1979 and 1988 (14.5 percent) and more rapidly subsequently (90 percent over the period 1988–2004) (Figure 1). Liver cancer was one of the most lethal digestive system cancers, although 5-year survival did increase nearly fourfold during this period, albeit to only 8 percent.

Medical care visits and hospitalizations for liver cancer were too infrequent in 2004 to make firm statements about them. Hospitalization discharge rates (Table 2) had a demographic pattern similar to incidence rates (Table 1), with the highest rates among patients age 65 years and older, blacks, and males. Hospitalization rates more than doubled from 1984 to 2004 (Figure 2), also in keeping with the increase in incidence.

Death rates increased with age, but not as markedly as in other digestive system cancers (Table 3). Age-adjusted death rates were higher among blacks and males. Because of its increasing incidence and poor survival, primary liver cancer has contributed an increasing number and proportion of deaths, although it accounted for only 4.7 percent of all deaths from digestive system cancers in 2004. Because of the relatively early age of onset, it accounted for a higher proportion of YPLL due to digestive system cancers (7.7 percent). As with incidence, mortality rate increased, although not as quickly. The mortality rate increased 75 percent between 1979 and 2004 (Figure 3).

Table 1. Primary Liver Cancer: Number of Cases and Incidence Rate by Age, Race/Ethnicity, and Sex, 2004

Demographic Characteristics

Number of Cases

Incidence per 100,000
Unadjusted

Incidence per 100,000
Age-Adjusted

AGE (Years)
Under 15

165

0.3

AGE (Years) 
15–44

856

0.7

AGE (Years) 
45–64

7,863

11.2

AGE (Years)
65+

8,093

23.7

RACE/ETHNICITY
Non-Hispanic White

9,507

4.9

4.2

RACE/ETHNICITY
Non-Hispanic Black

2,244

6.6

8.3

RACE/ETHNICITY
Hispanic

1,894

4.7

9.0

RACE/ETHNICITY
Asian/Pacific Islander

1,414

11.5

12.9

RACE/ETHNICITY
American Indian/Alaska Native

151

8.2

10.0

Sex
Female

4,350

3.0

2.8

Sex
Male

11,827

8.5

9.4

Total 

16,260

5.7

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Figure 1. Primary Liver Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 rose modestly from 2.56 in 1979 to 2.93 in 1988 and then more rapidly to 5.56 in 2004. Five-year survival increased from 2.38 percent in 1979 to 8.12 percent in 1999, the last year for which it could be calculated.  

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Table 2. Primary Liver Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

0

1

2

3

AGE (Years)
15–44

1

1

2

2

AGE (Years)
45–64

6

9

15

21

AGE (Years)
65+

6

17

14

39

Race 
White

10

4

25

10

Race
Black

2

7

5

14

Sex 
Female

4

3

9

6

Sex 
Male

10

7

23

17

Total

63

21

14

5

33

11

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 2. Primary Liver Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The number of ambulatory care visits during the period was too small to provide estimates, except for 2003-2005 when the rate was 21.0 per 100,000. Hospitalizations per 100,000 increased from 3.02 in 1979 to 9.58 in 2004.  

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 3Primary Liver Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

33

0.1

2.3

34

0.1

AGE (Years) 
15–44

243

0.2

9.1

250

0.2

AGE (Years) 
45–64

2,781

3.9

53.9

3,069

4.3

AGE (Years)
65+

3,266

9.0

7.2

3,567

9.8

Race
White

4,742

1.8

49.8

5,204

2.0

Race
Black

944

3.1

14.7

1,021

3.4

Sex
Female

1,522

0.9

12.0

1,666

1.0

Sex
Male

4,801

3.5

60.4

5,254

3.9

Total 

6,323

2.2

72.4

6,920

2.4

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 3. Primary Liver Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

The mortality rate increased between 1979 and 2004. Underlying-cause mortality per 100,000 rose from 1.19 in 1979 to 2.08 in 2004. All-cause mortality per 100,000 rose from 1.33 in 1979 to 2.27 in 2004.  

Source: Vital Statistics of the United States

CHAPTER 10

Cancer of the Bile Ducts
James E. Everhart, M.D., M.P.H.

For this report, intrahepatic and extrahepatic bile duct cancers were combined (see Appendix 1 for ICD-9 and ICD-10 codes). Substantial differences between them are noted.

In 2004, 22 percent of bile duct cancer was coded intrahepatic and 45 percent extrahepatic; nearly all the remainder did not have a location specified. Rates were much higher in the oldest age group, with 74 percent of cases occurring at age 65 or older. Age-adjusted rates were highest among Hispanics and Asians (Table 1). Males had a higher rate and slightly higher number of cases than females. Incidence increased modestly between 1979 and 2004 (about 22 percent), all of which could be accounted for by an increase in the incidence of intrahepatic bile duct cancer. Five-year survival did not improve and was about 10 percent for the entire period (Figure 1). There were too few outpatient or inpatient diagnoses to draw inferences about medical care (Table 2), but hospitalization rates were relatively constant at about 5 per 100,000 U.S. population (Figure 2).

Because of low survival, bile duct cancer mortality was similar to incidence. As underlying cause, there were 4,954 deaths in 2004 and nearly 33,000 YPLL prior to age 75 years (Table 3). Rates were highest in the oldest age group. Age-adjusted mortality rates were slightly higher for whites and for males. Death rates for bile duct cancer rose 39 percent between 1979 and 2004 (Figure 3).

Table 1. Bile Duct Cancer: Number of Cases and Incidence Rate by Age, Race/Ethnicity, and Sex, 2004

Demographic Characteristics

Number of Cases

Incidence per 100,000
Unadjusted

Incidence per 100,000
Age-Adjusted

AGE (Years)
Under 15

AGE (Years) 
15–44

266

0.2

AGE (Years) 
45–64

1,655

2.4

AGE (Years)
65+

4,569

13.4

RACE/ETHNICITY
Non-Hispanic White

4,859

2.5

2.1

RACE/ETHNICITY
Non-Hispanic Black

523

1.5

2.1

RACE/ETHNICITY
Hispanic

519

1.3

2.8

RACE/ETHNICITY
Asian/Pacific Islander

332

2.7

3.3

RACE/ETHNICITY
American Indian/Alaska Native

Sex
Female

3,051

2.1

2.0

Sex
Male

3,133

2.2

2.7

Total 

6,186

2.2

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Figure 1. Bile Duct Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 increased from 1.85 in 1979 to 2.27 in 2004. Five-year survival was around 10 percent for the entire period through 1999, the last year for which it could be calculated.  

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Table 2.  Bile Duct Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

AGE (Years)
15–44

0

0

1

1

AGE (Years)
45–64

2

3

5

7

AGE (Years)
65+

6

17

11

30

Race 
White

7

3

14

5

Race
Black

1

3

1

5

Sex 
Female

4

3

8

5

Sex 
Male

5

4

9

7

Total

9

3

17

6

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 2. Bile Duct Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004 (Ambulatory Care Visit Data Unavailable)

The number of ambulatory care visits during the period was too small to provide estimates. Hospitalization rates during the period were relatively constant at about 5 per 100,000.  

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 3Bile Duct Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

2

0.0

0.1

3

0.0

AGE (Years) 
15–44

143

0.1

5.2

148

0.1

AGE (Years) 
45–64

1,245

1.8

21.9

1,308

1.9

AGE (Years)
65+

3,564

9.8

5.7

3,855

10.6

Race
White

4,348

1.7

27.6

4,657

1.8

Race
Black

366

1.4

3.4

401

1.5

Sex
Female

2,554

1.5

15.1

2,711

1.6

Sex
Male

2,400

1.9

17.8

2,603

2.1

Total 

4,954

1.7

32.9

5,314

1.8

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 3. Bile Duct Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

Death rates rose between 1979 and 2004. Underlying-cause mortality per 100,000 increased from 1.18 in 1979 to 1.64 in 2004. All-cause mortality per 100,000 increased from 1.33 in 1979 to 1.76 in 2004. 

Source: Vital Statistics of the United States

CHAPTER 11

Cancer of the Gallbladder
James E. Everhart, M.D., M.P.H.

About 3,000 cases of gallbladder cancer were estimated to have occurred in 2004 (Table 1). Gallbladder cancer was the only digestive system malignancy that occurred predominantly among women (nearly twice the age-adjusted rate of men) and was one of the few nongenital cancers that had a female predominance. It was predominantly a diagnosis of the elderly, with a median age of diagnosis of age 73 years, the highest of any digestive system cancer (http://seer.cancer.gov/csr/1975_2005/results_merged/topic_med_age.pdf (PDF, 28KB)). Age-adjusted rates were too low to draw inferences about ethnic differences in risk. Incidence of gallbladder cancer declined by 42.2 percent from 1979 to 1997, and was then stable through 2004 (Figure 1). Five-year survival increased modestly to about 9 percent. Outpatient and inpatient data were too sparse to draw inferences, except that the rate of hospitalization with gallbladder cancer declined substantially until the mid-1990s and has been stable since (Figure 2).

Because of low survival, gallbladder cancer mortality was similar to incidence. As underlying cause, there were nearly 2,000 deaths in 2004 and just under 11,000 YPLL prior to age 75 years (Table 3), which reflects the older age at which gallbladder cancer occurred. Rates were 6.8 times as high in the oldest age group (65 years and older) as among those ages 45–64 years. Age-adjusted mortality rates were higher for blacks than whites, and for females than males. The death rate for gallbladder cancer declined by 47 percent between 1979 and 2004 (Figure 3). Because gallstones are the major recognized risk factor for gallbladder cancer, it is of interest that there was a similar decline (56.1 percent) in gallstone disease-related mortality over that period.

Table 1. Gallbladder Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Demographic Characteristics

Number of Cases

Incidence per 100,000
Unadjusted

Incidence per 100,000
Age-Adjusted

AGE (Years)
Under 15

AGE (Years) 
15–44

79

0.1

AGE (Years) 
45–64

850

1.2

AGE (Years)
65+

2,257

6.6

RACE/ETHNICITY
Non-Hispanic White

2,129

1.1

0.9

RACE/ETHNICITY
Non-Hispanic Black

356

1.0

1.5

RACE/ETHNICITY
Hispanic

348

0.9

1.9

RACE/ETHNICITY
Asian/Pacific Islander

142

1.2

1.4

RACE/ETHNICITY
American Indian/Alaska Native

Sex
Female

2,180

1.5

1.4

Sex
Male

867

0.6

0.8

Total 

3,034

1.1

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Figure 1. Gallbladder Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 declined from 1.84 in 1979 to 1.07 in 1997, and was then stable through 2004. Five-year survival increased modestly from 7.84 percent in 1979 to 9.64 percent in 1999, the last year for which it could be calculated. 

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Table 2.  Gallbladder Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

AGE (Years)
15–44

0

0

AGE (Years)
45–64

1

1

1

2

AGE (Years)
65+

2

6

4

11

Race 
White

2

1

5

2

Race
Black

0

1

1

2

Sex 
Female

2

1

4

2

Sex 
Male

1

1

2

1

Total

3

1

6

2

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 2. Gallbladder Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004 (Ambulatory Care Visit Data Unavailable)

The number of ambulatory care visits during the period was too small to provide estimates. Hospitalizations per 100,000 declined substantially from 5.05 in 1979 to 1.35 in 1992 and have been stable since with a rate of 1.86 in 2004.  

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 3.  Gallbladder Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

AGE (Years) 
15–44

41

0.0

1.5

44

0.0

AGE (Years) 
45–64

422

0.6

7.1

443

0.6

AGE (Years)
65+

1,476

4.1

2.3

1,585

4.4

Race
White

1,600

0.6

8.5

1,715

0.7

Race
Black

227

0.9

1.6

239

0.9

Sex
Female

1,343

0.8

7.4

1,422

0.8

Sex
Male

596

0.5

3.5

650

0.5

Total 

1,939

0.7

10.9

2,072

0.7

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 3. Gallbladder Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

The death rate declined between 1979 and 2004. Underlying-cause mortality per 100,000 decreased from 1.22 in 1979 to 0.64 in 2004. All-cause mortality per 100,000 decreased from 1.34 in 1979 to 0.69 in 2004. 

Source: Vital Statistics of the United States

CHAPTER 12

Cancer of the Pancreas
James E. Everhart, M.D., M.P.H.

In 2004, 71 percent of newly diagnosed pancreatic cancers were among persons age 65 years and older (Table 1). Age at diagnosis was higher than for most other digestive system cancers, with the median being 72 years and 40 percent diagnosed at age 75 years or older (http://seer.cancer.gov/csr/1975_2005/results_merged/topic_med_age.pdf (PDF, 28KB)).

Incidence rates were highest among the elderly, non-Hispanic blacks, and males. Age-adjusted incidence was relatively stable from 1979 to 2004, being essentially the same in the first and last year (Figure 1). Survival from pancreatic cancer is the poorest of any major cancer, digestive system or otherwise. Nevertheless, 5-year survival increased modestly from 2 percent among persons diagnosed in 1979 to 3.8 percent among persons diagnosed in 1999.

In 2004, there were an estimated 415,000 ambulatory care visits for pancreatic cancer and 68,000 hospital discharges with a diagnosis of pancreatic cancer (Table 2). Hospitalization rates were highest among the elderly and age-adjusted rates were higher for blacks and males. While ambulatory care visits appear to have increased from 1992 through 2004, hospital discharge rates were stable from 1979 through 2004 (Figure 2).

Because of low survival, pancreatic cancer mortality was essentially the same as incidence in 2004. As underlying cause, there were 31,800 deaths in 2004 (third highest of all digestive diseases) and more than 200,000 YPLL prior to age 75 years (also third highest of all digestive diseases) (Table 3). Rates were highest in the oldest age group. Age-adjusted mortality rates were higher for blacks and for males. Death rates for pancreatic cancer remained steady between 1979 and 2004 (Figure 3).

Table 1. Pancreatic Cancer: Number of Cases and Incidence Rates by Age, Race/Ethnicity, and Sex, 2004

Demographic Characteristics

Number of Cases

Incidence per 100,000
Unadjusted

Incidence per 100,000
Age-Adjusted

AGE (Years)
Under 15

AGE (Years) 
15–44

878

0.7

AGE (Years) 
45–64

9,513

13.6

AGE (Years)
65+

21,681

63.4

RACE/ETHNICITY
Non-Hispanic White

25,873

13.5

11.2

RACE/ETHNICITY
Non-Hispanic Black

3,614

10.6

15.2

RACE/ETHNICITY
Hispanic

1,929

4.8

10.4

RACE/ETHNICITY
Asian/Pacific Islander

947

7.7

9.2

RACE/ETHNICITY
American Indian/Alaska Native

99

5.3

8.1

Sex
Female

15,709

10.8

10.0

Sex
Male

14,853

10.6

12.7

Total 

30,560

10.7

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Figure 1. Pancreatic Cancer: Age-Adjusted Incidence Rates and 5-Year Survival Rates, 1979–2004

Incidence per 100,000 was relatively stable from 1979 to 2004, being essentially the same in the first and last years at 11.5. Five-year survival increased modestly from 2.03 percent in 1979 to 3.76 percent in 1999, the last year for which it could be calculated.  

Source: Surveillance, Epidemiology, and End Results (SEER) Program

Return To Table Of Contents

Table 2.  Pancreatic Cancer: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

AGE (Years)
15–44

1

1

2

2

AGE (Years)
45–64

154

218

162

229

12

16

23

33

AGE (Years)
65+

230

634

251

690

21

59

43

119

Race 
White

383

148

409

158

28

11

55

21

Race
Black

4

15

8

30

Sex 
Female

214

129

237

144

17

10

34

20

Sex 
Male

173

124

178

128

17

13

34

26

Total

386

132

415

141

34

12

68

23

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 2. Pancreatic Cancer: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 appear to have increased from 32.9 in 1992-1993 to 137 in 2003-2005. Hospitalizations per 100,000 were stable at 22.8 in 1979 and 20.8 in 2004.  

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 3. Pancreatic Cancer: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

1

0.0

AGE (Years) 
15–44

596

0.5

20.6

606

0.5

AGE (Years) 
45–64

8,407

11.9

147.9

8,656

12.2

AGE (Years)
65+

22,796

62.7

38.2

23,825

65.6

Race
White

27,247

10.5

167.8

28,323

10.9

Race
Black

3,681

13.7

31.9

3,848

14.3

Sex
Female

16,004

9.2

83.3

16,602

9.6

Sex
Male

15,796

12.4

123.5

16,487

12.9

Total 

31,800

10.8

206.8

33,089

11.3

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 3. Pancreatic Cancer: Age-Adjusted Rates of Death in the United States, 1979–2004

Death rates remained steady between 1979 and 2004. Underlying-cause mortality per 100,000 was 10.6 in 1979 and 10.5 in 2004. All-cause mortality per 100,000 was 11.4 in 1979 and 10.9 in 2004. 

Source: Vital Statistics of the United States

CHAPTER 13

Hemorrhoids
James E. Everhart, M.D., M.P.H.

Hemorrhoids are classified as diseases of the circulatory system by ICD-9 and ICD-10 (Appendix 1), but are much more often diagnosed and treated by digestive disease specialists than by those with a primary interest in the circulatory system. Therefore, burden data for hemorrhoids are presented in this report. Hemorrhoids are subclassified by anatomical location (internal or external) and whether they are complicated with bleeding, prolapse, strangulation, or ulceration. Hemorrhoids are common, and their treatment is primarily in the ambulatory care setting. In 2004, there were an estimated 2 million ambulatory care visits with hemorrhoids as first-listed diagnosis and 3.2 million visits at which hemorrhoids were an all-listed diagnoses (Table 1), which made hemorrhoids the fourth or fifth leading outpatient digestive system diagnosis (after GERD, abdominal wall hernia, and functional disorders, and essentially tied with diverticular disease). Visit rates were highest among persons age 65 years and older and among whites. Age-adjusted rates were similar for males and for females. Most hospitalizations for hemorrhoids are for surgery, which is performed most often as same-day surgery; thus, the number of hospitalizations for hemorrhoids was small relative to the number of ambulatory care visits (Table 1). As opposed to rates of ambulatory care visits, age-adjusted hospitalization rates were higher for blacks than whites. Hemorrhoids were most often listed as a secondary diagnosis (87 percent).

Age-adjusted ambulatory care visits for hemorrhoids declined slightly between the periods of 1992–1993 and 2003–2005 (Figure 1). The rate of visits in this latter period was about 20 percent lower than in the early 1980s, continuing a trend in declining outpatient visits that began in the 1960s.1 Overnight hospitalizations with hemorrhoids listed as a diagnosis declined by about 60 percent from 1981 to 1994, and were relatively stable for the following 10 years. As a first-listed hospital diagnosis, hemorrhoids declined much more: from about 70 per 100,000 in 1979 to 13 per 100,000 in 2004.2

Death from hemorrhoids has always been exceedingly rare (Table 2 and Figure 2). There was a substantial decline from 1980 through 2004 in hemorrhoids noted as a diagnosis on death certificates.

Nearly 2 million prescriptions for hemorrhoids were filled at retail pharmacies in 2004, according to Verispan (Appendix 2), with topical medications such as pramoxine (pramocaine) and hydrocortisone and stool softeners such as psyllium most often prescribed (Table 3). Most persons with hemorrhoids do not seek medical care and are self-treated using nonprescription medications similar to those listed in Table 3; thus the totals in this table were a small portion of the number and cost of medications used to treat hemorrhoids.3

1 Johanson JF. Hemorrhoids. In: Everhart JE, editor. Digestive diseases in the United States: epidemiology and impact. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 1994; NIH Publication No. 94-1447 pp. 271–298.

2 Ibid.


3 Ibid.

Table 1.  Hemorrhoids: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

1

1

AGE (Years)
15–44

716

569

1,131

899

8

7

57

46

AGE (Years)
45–64

915

1,294

1,331

1,883

13

19

96

136

AGE (Years)
65+

387

1,065

790

2,174

16

45

152

418

Race 
White

1,819

724

2,915

1,161

29

11

245

96

Race
Black

145

421

234

656

6

19

45

150

Sex 
Female

944

621

1,745

1,132

19

12

179

110

Sex 
Male

1,092

751

1,531

1,061

19

14

127

95

Total

2,036

693

3,275

1,115

38

13

306

104

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 1. Hemorrhoids: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 declined slightly from 1,122 in 1992–1993 to 1,093 in 2003–2005. Hospitalizations per 100,000 declined from 139 in 1979 to 52.3 in 1994, and were relatively stable through 2004 when the rate was 59.9. 

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 2. Hemorrhoids: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

AGE (Years) 
15–44

2

0.0

0.1

5

0.0

AGE (Years) 
45–64

8

0.0

0.2

22

0.0

AGE (Years)
65+

4

0.0

0.0

30

0.1

Race
White

9

0.0

0.1

42

0.0

Race
Black

2

0.0

0.0

9

0.0

Sex
Female

3

0.0

0.0

21

0.0

Sex
Male

11

0.0

0.2

36

0.0

Total 

14

0.0

0.2

57

0.0

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 2. Hemorrhoids: Age-Adjusted Rates of Death in the United States, 1979–2004

Deaths declined substantially from 1980 through 2004. Underlying-cause mortality per 100,000 decreased from 0.01 in 1979 to less than 0.01 in 2004. All-cause mortality per 100,000 decreased from 0.07 in 1979 to 0.02 in 2004. 

Source: Vital Statistics of the United States

Return To Table Of Contents

Table 3Hemorrhoids: Costliest Prescriptions

DRUG​​​​
Prescription (#)
Prescription
Retail Cost
Cost

Pramoxine/Hydrocortisone

336,508

16.9%

$19,424,146

45.1%

Hydrocortisone

989,521

49.8

14,852,947

34.5

Hydrocortisone/Lidocaine

98,928

5.0

6,288,920

14.6

Docusate

511,791

25.7

1,672,743

3.9

Hydrocodone/Acetaminophen

15,223

0.8

437,436

1.0

Oxycodone/Acetaminophen

2,550

0.1

116,818

0.3

Psyllium

7,715

0.4

80,312

0.2

Polycarbophil

14,496

0.7

43,635

0.1

Bismuth subgallate/Zinc oxide/Balsam

4,099

0.2

42,819

0.1

Ibuprofen/Hydrocodone

858

0.0

25,637

0.1

Other

4,296

0.2

39,848

0.0

TOTAL

1,985,985

100.0%

$43,025,261

100.0%

Source: Verispan

Return To Table Of Contents

CHAPTER 14

Gastroesophageal Reflux Disease
James E. Everhart, M.D., M.P.H.

In 2004, GERD was by far the most frequently first-listed digestive system condition at ambulatory care visits (Table 1), constituting 17.5 percent of all digestive system diagnoses. There were at least 6 outpatient visits with a GERD diagnosis listed per 100 persons in the United States. GERD was a common diagnosis in all age groups, although the highest rate was for those age 65 years and older. Age-adjusted ambulatory care visit rates were higher among blacks than whites and were similar for females and males. As the first-listed diagnosis, hospitalizations with GERD were not especially common relative to the frequency of outpatient visits. However, GERD was the first-listed diagnosis on only 5 percent of hospital discharges on which it was mentioned. As a result, GERD was the most common digestive system disease noted at hospital discharge and was found on 23.5 percent of hospitalizations at which a digestive system condition was listed at discharge. The pattern by race and sex of rates of hospitalization with a diagnosis of GERD were similar to the rates of ambulatory care visits. About half of all hospital diagnoses were recorded at age 65 years and older.

Rates of both all-listed ambulatory care visits and hospital discharges increased several-fold from the early 1990s to 2004 (Figure 1). Among other digestive system diseases, only viral hepatitis C saw a similar increase in medical care, but much of that increase was a result of the fact that hepatitis C was not recognized as a disease with its own ICD code until 1992. The increases in medical care for GERD began at least as early as the mid-1970s.1 Between 1975 and 2004, the rate of all-listed ambulatory care visits for GERD increased approximately 2,000 percent. It was in the mid-1970s that better means to diagnose (flexible endoscopes) and treat (histamine-2 receptor blockers) became available, both of which stimulated recognition of the condition. Nevertheless, it is quite unlikely that all the increases in GERD-related statistics can be attributed solely to increased recognition.

Despite not being considered a fatal disease, GERD was listed as the underlying cause of more than 1,000 deaths in 2004 (Table 2), 83 percent of which occurred among persons age 65 years and older. GERD was much more often listed as a contributing cause of death, with the large majority at age 65 years and older. Mortality rates differed little by race and sex. Rates of GERD as a first-listed or contributing cause of death increased by 115 percent from 1979 to 2004, with the majority of the increase occurring during the last 9 years of that period (Figure 2).

More than 60 million prescriptions for GERD were estimated to have been filled at retail pharmacies in 2004 (Table 3), representing 48 percent of all prescriptions for digestive system disorders and more than 50 percent of their cost. The large majority of prescriptions and their cost were for proton pump inhibitors, which were the five most commonly prescribed and costliest medications. Because over-the-counter medications were not included in this tabulation, the total medication cost may have been considerably higher.

1 Sonnenberg A. Esophageal diseases. In: Everhart JE, editor. Digestive diseases in the United States: epidemiology and impact. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 1994; NIH Publication No. 94-1447 pp. 299–355.

Table 1.  Gastroesophageal Reflux Disease: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

693

1,139

1,504

2,473

20

33

110

182

AGE (Years)
15–44

2,083

1,656

4,064

3,230

28

22

463

368

AGE (Years)
45–64

2,463

3,484

6,961

9,847

53

75

1,050

1,486

AGE (Years)
65+

1,611

4,433

5,813

15,999

58

159

1,565

4,307

Race 
White

5,567

2,267

14,964

6,002

122

49

2,513

987

Race
Black

1,028

2,872

2,603

8,075

21

65

342

1,107

Sex 
Female

3,388

2,209

10,624

6,733

87

54

1,936

1,183

Sex 
Male

3,462

2,462

7,718

5,506

71

51

1,252

937

Total

6,849

2,332

18,342

6,246

158

54

3,189

1,086

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 1. Gastroesophageal Reflux Disease: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Rates of both ambulatory care visits and hospital discharges increased several-fold from the early 1990s to 2004. Ambulatory care visits per 100,000 rose from 2,036 in 1992-1993 to 6,146 in 2003-2005. The hospitalization rate per 100,000 was 152 in 1979 and remained relatively stable through 1992, after which it increased to 734 in 2004.  

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 2Gastroesophageal Reflux Disease: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

18

0.0

1.3

106

0.2

AGE (Years) 
15–44

43

0.0

1.6

228

0.2

AGE (Years) 
45–64

135

0.2

2.5

1,034

1.5

AGE (Years)
65+

954

2.6

0.6

6,669

18.4

Race
White

1,033

0.4

4.7

7,273

2.7

Race
Black

97

0.4

1.1

649

2.5

Sex
Female

653

0.3

2.2

4,470

2.4

Sex
Male

497

0.4

3.8

3,567

3.0

Total 

1,150

0.4

6.0

8,037

2.7

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 2. Gastroesophageal Reflux Disease: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality rates as a first-listed or contributing cause of death increased from 1979 to 2004, with the majority of the increase occurring during the last 9 years of that period. Underlying-cause mortality rates rose only slightly. Underlying-cause mortality per 100,000 was 0.28 in 1979 and 0.37 in 2004. All-cause mortality per 100,000 rose from 1.22 in 1979 to 1.88 in 1995 to 2.63 in 2004.  

Source: Vital Statistics of the United States

Table 3. Gastroesophageal Reflux Disease: Costliest Prescriptions

DRUG
Prescription (#)
Prescription
Retail Cost
Cost
Lansoprazole
14,233,183
22.0%
$2,187,235,735
28.4%
Esomeprazole
14,250,281
22.1
2,180,756,920
28.4
Pantoprazole
9,995,074
15.5
1,224,174,329
15.9
Rabeprazole
5,954,447
9.2
914,472,545
11.9
Omeprazole
6,630,268
10.3
840,514,740
10.9
Ranitidine
8,771,688
13.6
202,788,663
2.6
Famotidine
1,527,991
2.4
51,413,838
0.7
Metoclopramide
2,326,992
3.6
34,416,702
0.4
Nizatidine
187,276
0.3
26,124,573
0.3
Sucralfate
112,698
0.2
11,892,069
0.2
Other
622,786
0.8
15,976,940
0.2

TOTAL

64,612,684
100.0%
$7,689,767,054
100.0%
Source: Verispan

Return To Table Of Contents

CHAPTER 15

Peptic Ulcer Disease
James E. Everhart, M.D., M.P.H.

Peptic ulcers are coded by anatomical location (stomach, duodenum, gastrojejunum, and unspecified), chronicity, and by complication (hemorrhage or perforation). The ICD codes that cover peptic ulcers are shown in Appendix 1. In 2004, there were about 700,000 ambulatory care visits with peptic ulcer as the first-listed diagnosis and an equal number in which it was a secondary diagnosis (Table 1). Ambulatory care rates increased with increasing age, were higher for blacks than for whites, and were higher among women. When listed at hospital discharge, peptic ulcer was the first-listed diagnosis 37 percent of the time.

The frequency of outpatient and inpatient care declined for peptic ulcer disease (Figure 1), which continued a pattern that began in the 1970s, if not before.1 Within 12 years, age-adjusted ambulatory care visit rates with a peptic ulcer diagnosis declined 68 percent, and within 25 years, hospital discharge rates declined 51 percent.

Peptic ulcer was coded as the underlying cause among 3,692 deaths in 2004 and other cause among an additional 4,604 deaths (Table 2). Nearly 80 percent of these deaths occurred among persons age 65 years and older. Age-adjusted death rates were similar for blacks and whites and were higher for males than females. Between 1979 and 2004, mortality from peptic ulcer as underlying cause declined 62.6 percent and as underlying or other cause by 68.8 percent (Figure 2). This continued at least a century of decline in peptic ulcer mortality.2 Much of the decline in the medical significance of peptic ulcer has been attributed to the decline of Helicobacter pylori, which is a causative agent. This effect has likely been accelerated by the widespread adoption of acid suppressive medications (Table 3) and eradication of H. pylori infection by antimicrobial agents. Although antimicrobial agents are important for treatment of peptic ulcer disease, they do not appear among the most commonly used drugs, perhaps because of their short-term self-limited use. The high use of acid suppressant therapy does not differentiate indications for treatment from prophylaxis.

1 Sonnenberg A. Peptic ulcer. In: Everhart JE, editor. Digestive diseases in the United States: epidemiology and impact. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 1994; NIH Publication No. 94-1447 pp. 357–408.

2 Ibid.

Table 1.  Peptic Ulcer Disease: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

1

2

2

4

AGE (Years)
15–44

251

199

472

375

23

19

61

48

AGE (Years)
45–64

164

233

472

668

53

75

142

201

AGE (Years)
65+

295

812

525

1,444

104

285

283

780

Race 
White

420

171

926

371

134

52

361

141

Race
Black

71

251

149

491

21

70

65

218

Sex 
Female

389

242

898

574

92

55

259

154

Sex 
Male

323

230

575

408

89

68

229

176

Total

712

243

1,473

501

181

62

489

166

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 1. Peptic Ulcer Disease: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). The frequency of outpatient and inpatient care declined for peptic ulcer disease. Ambulatory care visits per 100,000 decreased from 1,535 in 1992-1993 to 493 in 2003-2005. Hospitalizations per 100,000 decreased from 287 in 1979 to 140 in 2004. 

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 2. Peptic Ulcer Disease: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

7

0.0

0.5

9

0.0

AGE (Years) 
15–44

118

0.1

4.3

221

0.2

AGE (Years) 
45–64

646

0.9

12.1

1,331

1.9

AGE (Years)
65+

2,921

8.0

2.7

6,733

18.5

Race
White

3,221

1.2

14.9

7,183

2.7

Race
Black

368

1.3

4.3

849

3.2

Sex
Female

1,995

1.1

7.4

4,287

2.3

Sex
Male

1,697

1.4

12.3

4,009

3.3

Total 

3,692

1.3

19.7

8,296

2.8

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 2. Peptic Ulcer Disease: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality declined between 1979 and 2004. Underlying-cause mortality per 100,000 decreased from 3.24 in 1979 to 1.21 in 2004. All-cause mortality per 100,000 decreased from 8.71 in 1979 to 2.72 in 2004.  

Source: Vital Statistics of the United States

Return To Table Of Contents

Table 3. Peptic Ulcer Disease: Costliest Prescriptions

DRUG
Prescription (#)
Prescription
Retail Cost
Cost

Drug

Prescription (#)

Prescription

Retail Cost

Cost

Lansoprazole

1,341,444

26.7%

$177,496,893

34.2%

Pantoprazole

1,128,002

22.5

123,697,885

23.9

Esomeprazole

680,009

13.6

85,753,825

16.5

Lansoprazole/Amoxicillin/Clarithromycin

130,482

2.6

40,749,140

7.9

Omeprazole

333,879

6.7

30,663,736

5.9

Rabeprazole

204,602

4.1

27,175,479

5.2

Ranitidine

727,492

14.5

13,039,236

2.5

Nizatidine

89,340

1.8

9,185,345

1.8

Sucralfate

157,770

3.1

5,342,588

1.0

Famotidine

135,865

2.7

3,072,170

0.6

Other

89,023

1.8

2,394,483

0.4

TOTAL

5,017,908

100.0%

$518,570,780

100.0%

Source: Verispan

Return To Table Of Contents

CHAPTER 16

Functional Intestinal Disorders
James E. Everhart, M.D., M.P.H.

Included in this chapter are separate entries on chronic constipation and irritable bowel syndrome (IBS). Other functional conditions that were either too uncommon or too nonspecific were functional diarrhea, neurogenic bowel and megacolon not elsewhere described, anal spasm, and other specified and unspecified functional intestinal disorders. These are included in the section All Functional Intestinal Disorders.

CHRONIC CONSTIPATION

In 2004, constipation was frequently noted at ambulatory care visits either as a first-listed diagnosis (3.1 million visits) or all-listed diagnoses (6.3 million visits) (Table 1), which made it the second most common ambulatory care diagnosis, after GERD. Persons under age 15 years had the highest number of visits for chronic constipation and nearly as great a rate as persons age 65 years and older. The number of ambulatory care visits for the younger age group was equal to that of intestinal infections (Chapter 2). Chronic constipation and GI infections were the two most common reasons for ambulatory care visits among children. Rates of visits with a chronic constipation diagnosis were also higher for blacks and for females. Hospitalizations with chronic constipation were uncommon, with first-listed diagnoses only 1–2 percent of ambulatory care visits. All-listed diagnoses of chronic constipation were more common—about one-tenth the rate of all-listed ambulatory care diagnoses. After many years of stable rates of medical care statistics for chronic constipation, there was a surge in both ambulatory medical care visits and hospitalizations between 1992 and 2004 (Figure 1), with more than a doubling of rates of ambulatory care diagnoses and nearly a fourfold increase in rates of hospital discharge diagnoses. The rate of ambulatory visits began to increase at least as early as 1985, when there were approximately 500 per 100,000 population.1

Mortality from chronic constipation is, of course, rare (Table 2). Nevertheless, in keeping with the increase in medical care, there was an increase in constipation as either underlying cause or underlying or other cause between 1989 and 2004 (Figure 2).

According to the Verispan database of retail pharmacy prescriptions (Appendix 2), in 2004, nearly half of all medications prescribed for chronic constipation were for the laxative polyethylene glycol (Table 3). Tegaserod (Zelnorm®), a medication for women with irritable bowel syndrome and constipation, was not as commonly prescribed, but was nearly as costly. Other medications were primarily stool softeners or motility agents. These data did not capture the very large number of nonprescription medications purchased for constipation.

IRRITABLE BOWEL SYNDROME

In 2004, there were 3 million ambulatory care visits with IBS noted as a diagnosis, and slightly more than half were first-listed diagnoses (Table 4). Unlike constipation, which was common among children, rates of visits with IBS increased with age only in later adulthood. Whites had more than twice the age-adjusted rate of visits as blacks. The rate of visits among females was more than 4 times that of males—the largest sex difference for any digestive disease. IBS was rarely noted as first-listed diagnosis on hospital discharge, but was much more commonly coded as a secondary diagnosis. The age, race, and sex patterns for all-listed discharge diagnosis were similar to ambulatory care diagnoses.

Age-adjusted rates of ambulatory care visits with an IBS diagnosis fell by about 20 percent between 1992–1993 and 2003–2005 (Figure 3), although the rate in the latest period was similar to rates in 1981, 1982, and 1985.2 In contrast, rates of hospital discharges with a diagnosis of IBS fell in the mid-1980s, leveled off through the mid-1990s, and then increased by 81 percent between 1999 and 2004. IBS as underlying or contributing cause of death was exceedingly rare (Table 5), and trend data were not meaningful (Figure 4).

According to the Verispan database of retail pharmacies, in 2004, tegaserod (Zelnorm®) contributed much to the cost of IBS and was the third most widely prescribed drug (Table 6). The anticholinergic drugs hyoscyamine and dicyclomine were the most commonly prescribed drugs.

ALL FUNCTIONAL INTESTINAL DISORDERS

As a group of conditions, functional disorders were common reasons for outpatient visits, such that there were estimated to be more than 11 million ambulatory care visits noting these diagnoses in 2004 (Table 7), or about 4 visits per every 100 persons in the United States. Eighty percent of these visits were for either chronic constipation or IBS. Hospitalizations for functional disorders were uncommon, but they did commonly appear as an all-listed diagnoses. Recent increases in diagnoses with a mention of functional disorders on ambulatory care visits and hospital discharge were almost entirely due to increased rates of diagnoses of constipation (Figure 5). Chronic constipation and IBS accounted for 73.5 percent of these diagnoses. Functional disorders were coded as an underlying cause of death for 423 persons in 2004, and listed as a contributing cause for 1,766 persons (Table 8). The death rate with mention of functional intestinal conditions was stable from 1979 to 1999, when the change to ICD-10 coding resulted in a 19 percent increase that was likely a coding artifact (Figure 6).

According to the Verispan database of retail pharmacies, in 2004, there were estimated to be more than 13 million prescriptions filled at retail pharmacies at a cost of nearly three-quarters of a billion dollars (Table 9). Nearly one-third of this cost was for tegaserod (Zelnorm®). Other agents were primarily for pain, including several acid-blocking agents, or for constipation.

1 Johanson JF. Constipation. In: Everhart JE, editor. Digestive diseases in the United States: epidemiology and impact. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 1994; NIH Publication No. 94-1447 pp. 567–593.

2 Sandler RS. Irritable bowel syndrome. In: Everhart JE, editor. Digestive diseases in the United States: epidemiology and impact. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: US Government Printing Office, 1994; NIH Publication No. 94-1447 pp. 595–612.

Table 1. Chronic Constipation: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

1,175

1,933

2,127

3,497

5

8

32

53

AGE (Years)
15–44

601

478

1,397

1,110

6

5

106

84

AGE (Years)
45–64

492

696

1,112

1,572

8

11

164

231

AGE (Years)
65+

880

2,423

1,671

4,599

18

50

399

1,097

Race 
White

2,582

1,064

5,057

2,100

28

11

534

209

Race
Black

430

1,011

990

2,620

5

15

98

322

Sex 
Female

1,955

1,267

4,050

2,655

23

14

434

260

Sex 
Male

1,194

866

2,256

1,657

14

11

266

206

Total

3,149

1,072

6,306

2,148

37

13

700

238

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 1. Chronic Constipation: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). After many years of stable rates of medical care for chronic constipation, there was a surge in both ambulatory medical care visits and hospitalizations between 1992 and 2004. Ambulatory care visits per 100,000 increased from 876 in 1992-1993 to 2,151 in 2003-2005. The hospitalization rate per 100,000 was 36.1 in 1979 and remained stable through 1992, after which it increased to 154 in 2004.  

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 2. Chronic Constipation: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

3

0.0

0.2

6

0.0

AGE (Years) 
15–44

11

0.0

0.5

22

0.0

AGE (Years) 
45–64

10

0.0

0.2

54

0.1

AGE (Years)
65+

113

0.3

0.1

500

1.4

Race
White

129

0.1

0.8

527

0.2

Race
Black

7

0.0

0.1

48

0.1

Sex
Female

98

0.1

0.4

381

0.3

Sex
Male

39

0.0

0.5

201

0.1

Total 

137

0.0

0.9

582

0.2

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 2. Chronic Constipation: Age-Adjusted Rates of Death in the United States, 1979–2004

There was an increase in mortality rates as either underlying cause or underlying or other cause between 1989 and 2004. Underlying-cause mortality per 100,000 was 0.01 in 1979, 0.02 in 1989, and rose to 0.04 in 2004. All-cause mortality per 100,000 was 0.06 in 1979, 0.08 in 1989, and rose to 0.19 in 2004.  

Source: Vital Statistics of the United States

Return To Table Of Contents

Table 3. Chronic Constipation: Costliest Prescriptions

DRUG
Prescription (#)
Prescription
Retail Cost
Cost
Polyethylene Glycol 3350

2,462,873

46.0%

$78,006,220

43.8%

Tegaserod

487,989

9.1

62,696,997

35.2

Lactulose

1,234,865

23.1

29,190,969

16.4

Docusate®

1,087,397

20.3

7,481,476

4.2

Methylcellulose

13,221

0.2

219,099

0.1

Magnesium Hydroxide

40,991

0.8

176,097

0.1

Psyllium

10,634

0.2

172,225

0.1

Senna®

4,085

0.1

139,618

0.1

Bisacodyl

10,271

0.2

57,569

0.0

Malt Extract

535

0.0

37,774

0.0

Other

3,432

0.0

66,635

0.0

TOTAL

5,356,293

100.0%

$178,244,679

100.0%

Source: Verispan

Return To Table Of Contents

Table 4.  Irritable Bowel Syndrome: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

0

1

1

2

AGE (Years)
15–44

724

575

1,169

929

8

6

61

48

AGE (Years)
45–64

363

514

979

1,384

5

7

73

103

AGE (Years)
65+

469

1,290

792

2,179

4

11

77

213

Race 
White

1,459

593

2,803

1,138

15

6

180

72

Race
Black

212

534

1

4

12

36

Sex 
Female

1,322

867

2,531

1,649

14

9

177

112

Sex 
Male

283

201

523

373

4

2

35

26

Total

1,605

547

3,054

1,040

18

6

212

72

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 3. Irritable Bowel Syndrome: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 fell from 1,240 in 1992-1993 to 1,032 in 2003-2005. In contrast, rates of hospital discharges fell in the mid-1980s, leveled off through the mid-1990s, and then increased between 1999 and 2004. The hospitalization rate per 100,000 was 91.2 in 1979 and remained stable through 1983, after which it decreased to 31.6 in 1990 and remained stable until 1999, and from there it increased to 54.8 in 2004.  

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 5. Irritable Bowel Syndrome: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands

Underlying or Other Cause
Number of Deaths

Underlying or Other Cause
Rate per 100,000

AGE (Years)
Under 15

AGE (Years) 
15–44

7

0.0

AGE (Years) 
45–64

1

0.0

0.0

21

0.0

AGE (Years)
65+

19

0.1

0.0

188

0.5

Race
White

19

0.0

0.0

210

0.1

Race
Black

1

0.0

0.0

5

0.0

Sex
Female

16

0.0

0.0

164

0.1

Sex
Male

4

0.0

0.0

52

0.0

Total 

20

0.0

0.0

216

0.1

Source: Vital Statistics of the United States

Return To Table Of Contents

Figure 4. Irritable Bowel Syndrome: Age-Adjusted Rates of Death in the United States, 1979–2004

IBS as underlying or contributing cause of death was exceedingly rare and trend data were not meaningful. 

Source: Vital Statistics of the United States

Return To Table Of Contents

Table 6. Irritable Bowel Syndrome: Costliest Prescriptions

DRUG
Prescription (#)
Prescription
Retail Cost
Cost
Tegaserod

1,101,880

18.6%

$171,155,138

58.1%

Hyoscyamine

1,574,929

26.5

34,810,797

11.8

Dicyclomine

1,317,179

22.2

20,669,937

7.0

Glycopyrrolate

222,748

3.8

19,877,577

6.7

Clidinium/Chlordiazepoxide

731,965

12.3

11,525,984

3.9

Diphenoxylate

372,133

6.3

7,711,178

2.6

Pantoprazole

45,496

0.8

7,384,419

2.5

Omeprazole

76,680

1.3

5,384,300

1.8

Esomeprazole

38,526

0.6

4,546,806

1.5

Methscopolamine

70,911

1.2

4,393,505

1.5

Other

383,137

6.3

7,201,054

2.4

TOTAL

5,935,584

100.0%

$294,660,695

100.0%

Source: Verispan

Return To Table Of Contents

Table 7All Functional Intestinal Disorders: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Ambulatory Care Visits
First-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
First-Listed Diagnosis
Rate per 100,000

Ambulatory Care Visits
All-Listed Diagnosis
Number in Thousands

Ambulatory Care Visits
All-Listed 
Diagnosis
Rate per 
100,000

Hospital Discharges
First-Listed Diagnosis
Number in Thousands

Hospital Discharges
First-Listed Diagnosis
Rate per 100,000

Hospital Discharges
All-Listed Diagnosis
Number in Thousands

Hospital Discharges
All-Listed Diagnosis
Rate per 100,000

AGE (Years)
Under 15

1,347

2,215

2,384

3,921

10

17

48

79

AGE (Years)
15–44

1,710

1,359

3,256

2,588

29

23

248

197

AGE (Years)
45–64

1,127

1,594

2,700

3,820

30

42

341

483

AGE (Years)
65+

1,762

4,851

3,308

9,104

45

124

603

1,660

Race 
White

5,039

2,057

9,690

3,980

86

35

944

373

Race
Black

633

1,513

1,391

3,702

16

54

169

546

Sex 
Female

3,886

2,518

7,778

5,074

76

47

808

496

Sex 
Male

2,059

1,484

3,871

2,815

39

29

432

328

Total

5,945

2,025

11,648

3,967

115

39

1,241

423

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Return To Table Of Contents

Figure 5. All Functional Intestinal Disorders: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Rates of both ambulatory care visits and hospitalizations have increased in recent years. Ambulatory care visits per 100,000 rose from 2,732 in 1992-1993 to 3,955 in 2003-2005. Hospitalizations per 100,000 decreased from 195 in 1979 to 131 in 1990 and then rose to 299 in 2004.  

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Return To Table Of Contents

Table 8. All Functional Intestinal Disorders: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Demographic Characteristics

Underlying Cause
Number of Deaths

Underlying Cause
Rate per 100,000

Underlying Cause
Years of 

Potential Life Lost in Thousands