The Digestive system
L2
Stomach and Intestines
Peptic Ulcer Disease in Children
Ulcers
are deep lesions that breech the integrity of the epithelium and penetrate
through the muscularis mucosae, whereas erosions are superficial and stop short of
the muscularis propria. Both lesions often occur in the presence of gastric
inflammation or gastritis. Gastric ulcers are generally located on the lesser curvature
of the stomach, and 90% of duodenal ulcers are found in the duodenal bulb.
In children can be classified as:
1. primary peptic ulcers: are chronic and more often duodenal, most often
associated with Helicobacter pylori infection. Idiopathic primary peptic ulcers
account for up to 20% of duodenal ulcers in children.
H. pylori is a gram-negative spiral organism that lives primarily in the mucus layer
covering gastric epithelial cells. To survive in the harsh environment of the acidic
stomach, H. pylori produces urease, an enzyme that catalyzes the conversion of urea
in the gastric juice to ammonia and bicarbonate. These products buffer the gastric
acid and create a friendly microenvironment for H. pylori.
The route of transmission may involve fecal-oral, gastric-oral (in vomitus), or oral-
oral routes. Crowding and poor sanitary conditions are risk factors for acquisition of
H. pylori. In children, H. pylori infection can present with abdominal pain or vomiting,
and less often, refractory iron deficiency anemia or growth retardation
.
2. Secondary peptic ulcers: are usually more acute in onset and are more often
gastric. It can result from stress due to sepsis, shock, or an intracranial lesion
(Cushing ulcer) or in response to a severe burn injury (Curling ulcer). Also occur
because of aspirin or nonsteroidal anti-inflammatory drug (NSAID) use,
hypersecretory states like Zollinger-Ellison syndrome.
Clinical Manifestations
The presenting symptoms of peptic ulcer disease varies with the age of patient.
The classic symptom of peptic ulceration, epigastric pain alleviated by the ingestion
of food, is present only in a minority of children.
In the 1st mo of life, the two main manifestations are gastrointestinal hemorrhage
and perforation.
Between the neonatal period and 2 yr of age, recurrent vomiting, slow growth, and
gastrointestinal hemorrhage are the major symptoms.
In preschool-aged children, periumbilical postprandial pain. Vomiting and
hemorrhage.
After 6 yr of age, the clinical features of ulcer disease are like those in adults and
commonly include epigastric abdominal pain, acute or chronic gastrointestinal
blood loss (hematemesis, hematochezia, or melena) often leading to iron-
deficiency anemia.
The pain is often described as dull or aching rather than sharp or burning. It may
last from minutes to hours, and patients have frequent exacerbations and
remissions lasting from weeks to months.
Nocturnal pain is common.
Rarely, in patients with acute or chronic blood loss, penetration of the ulcer into
the abdominal cavity or adjacent organs produces shock, anemia, peritonitis, or
pancreatitis.
Diagnosis
*Esophagogastroduodenoscopy is the method of choice to diagnose peptic ulcer in
children. It allows for the direct visualization of esophagus, stomach, and
duodenum and to take biopsy samples for histologic assessment as well as to
screen for the presence of H. pylori infection.
*For detection of H. pylori infection
- Noninvasive tests
1. serologic assays include:
A. detection of H. pylori antibody (IgG) in serum, whole blood, urine, or saliva. This
tests do not distinguish between past and present infection.
B. detection of H. pylori antigens in stool.
C) is
13
led with an isotope of carbon (
: in which urea labe
test (UBT)
. Urea breath
2
ingested by the patient. Samples of exhaled air are then collected to detect the
presence of labeled carbon dioxide released from the breakdown of urea in the
stomach.
- Invasive tests
1. histologically by demonstrating the organism in the biopsy specimens
2. Rapid urease tests: In this test, biopsy specimens are placed in a well containing
agar with a pH-sensitive dye. Presence of urease-producing organisms in the
sample is signaled by a color change.
Treatment
Goals of Ulcer therapy:
1. ulcer healing
2. elimination of the primary cause.
3. relief of symptoms and prevention of complications.
Treatment of Primary peptic ulcer
1. H. pylori–related peptic ulcer
Recommended Eradication Therapies include 2 options:
First-Line Options
*Amoxicillin 50 mg/kg/day up to 1 g bid
Clarithromycin15 mg/kg/day up to 500 mg bid
Proton pump inhibitor: omeprazole 1 mg/kg/day up to 20 mg bid
*Amoxicillin
Metronidazole 20 mg/kg/day up to 500 mg bid
Omeprazole
*Clarithromycin
Metronidazole
Omeprazole
Second-Line Options
Bismuth subsalicylate1 tablet (262 mg) qid or 15 mL
Metronidazole 20 mg/kg/day up to 500 mg bid
Omeprazole
Amoxicillin or Clarithromycin
*These Antibiotics given for 2 weeks, and Omeprazole for 1 month.
2. Idiopathic ulcers:
Acid suppression alone is the preferred effective treatment. Either proton pump
inhibitors or H
2
receptor antagonists (Cimetidine, Ranitidine) may be used.
Surgical therapy
indications:
*uncontrolled bleeding
*perforation
* obstruction
Secondary peptic ulcer
1. Stress ulceration
Usually occurs within 24 hr of onset of a critical illness in which physiologic stress is
present. In infants, are usually caused by sepsis, respiratory or cardiac
insufficiency, trauma, or dehydration. In older children, they are related to trauma
or other life-threatening conditions (burns, head trauma).
2. Drug-Related Peptic Disease.
Nonsteroidal anti-inflammatory drugs, including aspirin, are common causes of
gastritis and erosions. Corticosteroid, iron, calcium salts, potassium chloride, and
antibiotics, including chloramphenicol, penicillin, tetracyclines, and cephalosporins,
rarely cause gastritis.
Treatment of secondary peptic ulcer
1. The inciting cause should be removed if possible.
2. Control of gastric acidity (should continue for 6 wk if the patient has active
disease)
*Antacids (1 mL/kg/dose)
)
ranitidine
,
Cimetidine
(
receptor antagonists
2
H
*
*proton pump inhibitors (omeprazole)
3. Endoscopy can be used therapeutically to control bleeding not responding to
medical therapy.