Dr.

Maitai

PEPTIC ULCER DISEASE IN CHILDREN

Peptic ulcers occur at any age but are common between 12 and I8yrs. Boys are more

affected than girls. Most ulcers in children are secondary to underlying illness, toxins or

drugs causing break down of normal mucosa.

Causes:

i) Reduced mucosal protective mechanisms caused by drugs like Aspirin, NSAIDS,

Conditions like hypoxia and hypoperfusion

ii) Reduced metabolic activity of the mucosal cell which allows diffusion of

hydrogen ions into the mucosa (hypoxia, hypotension)

iii) Increased secretion of acid or pepsin due to Increased parietal cell mass,

increased vagal tone, or Increased postprandial secretion of gastrin

iv) Reflux form duodenum to stomach

v) Decreased neutralizing activity in duodenal secretion’s.

vi) Lifestyle issues is Tobacco and Alcohol use

vii) Physiologic stress e.g. burns.

viii) Infection of gastric antrum by Helicobacter pylori producing nodular antral

gastritis, duodenal ulcer and gastric ulcer.

Signs and Symptoms

1) In children younger than 6 yrs. Vomiting and upper GIT bleeding are the most

common symptoms of PU.

2) Burning pain in the abdomen between the breast bone and belly button

3) Nausea, vomiting, chest pain which is dull

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4) Burping or hiccupping with pain occurring after meals for gastric ulcer and 2-3 hours

after meals or before meals for DU, with loss of appetite.

5) The abdominal pain is vague and wakes the child at night.

6) Duodenal ulceration is more common than gastric. Vomiting occurs 1-2 hours after

food due to pyloro spasm or scarring.

7) There is usually a positive family history of 1st degree relative

8) Massive bleeding is uncommon but occasionally may vomit coffee (ground) color.

9) H. pylori Infection may be one of the causes but association not clear

10) H.pylori causes nodular antral gastritis which is associated with abdominal pain and

nausea.

There may, be evidence of malnutrition

Diseases which predispose to secondary ulcers; include the following:

i) CNS disease

ii) Burns, sepsis, Multi organ failure.

iii) Pulmonary Insufficiency

iv) Crohns disease, hepatic cirrhosis and Rheumatoid arthritis.

v) Upper GIT bleeding is more common in NSAIDS drug ulcers, than the others.

Complications:

i) Bleeding _ especially upper GIT bleeding.

ii) Perforation

iii) Pyloric stenosis

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Investigations:

1) Routine, FBC, u/e, stool for o/ c

2) Endoscopy to view pyloric antrum, duodenal mucosa + biopsy. Nodular

gastritis is suggestive of, H.pylori Infection

3) Identification of H. pylori _ a gram -ve organism It produces urease which

forms the basis for the lab test on biopsies and the 13 c breath Test following

administration of 13 c labeled urea by mouth.

4) Serological tests are unreliable in children.

Treatment.

a) Check for dehydration and anemia, Psychological or traumatic stress

and manage accordingly, as per the cause

b) Triple therapy regiments: Proton pump inhibitor, e.g. Omeprazole or

Lansoprazole, with clarithromycin and amoxicillin or metronidazole

for 1/52. Therapy is continued for, 2/52 to reduce relapse.

c) Dietary measures are taken as appropriate.

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GASTRO-0ESOPHAGEAL REFLUX DISEASE.

GE reflux is common in young Infants and usually resolves spontaneously by the age of

walking. Condition is usually harmless in young Infants but may cause severe conditions. _ .

Physiological, asymptomatic reflux may occur in any child or adult but is not common.

In normal Individuals, there is acidity from reflux of stomach contents for < 4% of a 24-hr

period. If It occurs more frequently than This, when there is a functional Immaturity.

Signs and Symptoms

i) Some babies may present with vomiting in the 1st week of life, Sometimes with

bloodstains.

ii) Sometimes there may be failure to thrive, esophagitis, blood loss, anemia,

esophageal stricture, and Inflammatory esophageal polyps.

iii) Aspiration pneumonia, chronic cough, wheezing, and asthmatic attacks are

reported. Dysphagia and colic after feedings and neck Contortions may occur.

(Sandier syndrome).

iv) Rumination may be a symptom; Apneic spells with position change after feeding

may be due to reflux.

v) GER is common in neurologically Impaired children.

vi) The recurrent aspiration, episodes lead to repeated Chest infections

vii) Usually there is immature development of the lower esophageal sphincter

leading to reflux. A short Intra-abdominal part of the esophagus also Con

tributes.

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viii) It is common in the 1st year of life and a sliding hiatus hernia may be present in

some children.

ix) By 12 months all symptomatic reflux will have resolved spontaneously; why?

x) Maturation of sphincter, assumption of upright posture, and more solids in the

diet.

xi) Severe esophageal reflux is uncommon but may be associated with the following:

Cerebral palsy, New borns with chronic lung disease of prematurity , following

surgery for diaphragmatic hernia, and after Diagnostic Tests.

xii) MANAGEMFNT

Diagnostic tests:

a) Which occurs in the following,

b) 24 hours esophageal. pH monitoring

c) Barium swallow to rule out anatomical abnormalities

d) Endoscopy and esophageal biopsy to demonstrates esophagitis

Treatment:

1) Position Infant in upright position after feeding.

2) Nurse baby prone with head up position -30°

3) Thicken milk with Rice cereal _ 2-3 tea spoons of formula

4) Thickening feeds if from 6 months of age. For the younger do

conservative upright positioning.

5) 85% of infants with GER resolve spontaneously by 12 months.

Coinciding with upright position and solid feedings

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6) H 2 antagonists e.g. Ranitidine 5 mg/ kg/day in 2 doses and a proton

pump inhibitor Omeprazole 0.5 -1.mg /kg, per day OD • May

Control pain and esophagitis

7) Hasten gastric emptying by giving metoclopramide, a pro kinetic

drug.

8) Indications for Surgery: a) Persistent vomiting + FTT, b) esophagitis

or stricture C) Apneic attacks. D) Chronic pulmonary disease not

responding to 3 months of medical therapy.

9) More than 18 Months old with hiatus hernia or neurological

handicaps respond well to medical therapy.

10) Finally, The Surgery is Fundoplication where stomach is wrapped

around the lower esophagus

e) Complications:

Failure to thrive

Esophageal stricture

Recurrent respiratory Symptoms, due to aspiration,

Feeding problems

Esophagitis pain. . Bleeding.