H pylori gastritis

ً ‫ مسببة التهابا‬،‫الملوية البوابية أو جرثومة المعدة نوع من البكتيريا من العصيات سلبية الغرام أليفة الهواء القليل التي تستعمر مخاطيات المعدة واالثنا عشر‬
‫ وترتبط بتطور القرحات الهضمية في المعدة واالثنا عشر وسرطان المعدة‬،‫في المخاطية‬

Case scenario 10yrs old girl ,1year Hx of epigastric pain (nocturnal), vomiting & pallor (Hb 9gm/dl -hypo)
F/H of peptic ulcer disease. ( Red flag – nocturnal pain – pallor –F/H of PUD)
Features H pylori ( Hp) is the most common bacterial infections in humans
It is a gram-ve, S-shaped rod, microaerophilic bacteria, colonize the gastric mucosa
chronic active gastritis but are often asymptomatic.
Recurrent abdominal pain or vomiting (recent –no)
Refractory iron deficiency anemia or growth retardation.
Chronic autoimmune thrombocytopenia.
Duodenal ulcer, Gastric cancer, or gastric MALT oma
Pathogenesis The most common bacterial infections in humans.
It is a gram-ve ,S-shaped rod that produces urease, catalase, and oxidase enzyme
Affect stomach (antrum – duodenum)
Has several adaptive features:(its shape, motility, ↓O2 requirement, adhesion, urase production)
Pathology Gastric inflammation (acute – chronic)
Chronic inflammation → trigger immune response → extraintestinal manifestation
Incidence 50% of the world population
50% of children < 5y
90% in adult (developing countries)
In Egypt:
• prevalence of infection in pediatric age is 38-72% (infection not a disease)
• 26% < 5y , 60%> 5y
Mode of Fecal-oral or oral- oral.( ‫عبر اللعاب الذى يعتبر مصدر أساسي‬- ‫( استعمال نفس الكوب‬
transmission
Risk factors low socioeconomic status (overcrowded home)
Affected family members) ‫)خاصة االم والجدة واالخوة‬
Contaminated water
Rural > urban area
‫وجود حيوانات بالمنزل مثل الكالب‬

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Development of virulence & type of organism (pathogenic – nonpathogenic)
the disease Genetic predisposition
(depends on)
Immune response of the host
The time of exposure (childhood, adulthood)
Environmental factors (Rural, overcrowded, contaminated water)
Clinical There is no H pylori disease; there is H pylori associations (or related diseases)
@Localized epigastric pain or tenderness on ex
@Nausea, vomiting, hematemesis, melena
، ‫الم موضع بمنطقة فم المعدة يوقظ الطفل من نومه أو يؤثر في نشاطه أو ينتشر للظهر أو قيئ دموي أو تغوط دموي‬
) ‫األلم يزيد مع الجوع ويخف مع تناول الطعام أو مضاد الحموضة( عالمات القرحة‬
@+ Ve occult blood in stools )micro-bleeding )
@Others: chronic ITP , refractory IDA (unresponsive after 3mo with good tx & compliance)

Intestinal • Acute & Chronic gastritis mostly asymptomatic

• Gastric ulcers(pain relieved by food),(hematemesis, melena, anemia )
• MALT oma ( adult)
• F. recurrent abdominal pain ?X =Epigastric, dull, may be nocturnal
• GERD (? =debatable )?X =Nausea , vomiting , heart burn
Extraintestinal • Unexplained refractory IDA .
• Chronic ITP
• Idiopathic urticarial ?X Reported
• Migraine & others ?X
• Growth failure ?X

When to test Peptic ulcer disease features

For H pylori ‫الم بمنطقة فم المعدة يوقظ الطفل من نومه أو يعوق نشاطه أو ينتشر للظهرأو قىء دموى أو تغوط دموى‬
Unexplained refractory IDA (full course, good compliance, no obvious cause)
Chronic ITP (pt with Hp + chronic ITP are resistant to Rx of ITP& needs Hp eradication)
F/H of gastric cancer ‫تاريخ مرضى إيجابي لقرحة هضمية عند أقارب الدرجة االولى للطفل‬
Don’t test in Functional recurrent abdominal pain
Asymptomatic (even with +ve F/H of infected adult)
Short stature
Food allergy
GERD

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Investigations

Nodularity of mucosa (Macroscopically) Organism in the biopsy specimens

Nodularity→ antrum (PUD), pangastric (malignancy)
‫) يجب أن يكون المريض منقطعا ً عن تناول أي مضاد‬stool Ag ‫أو‬Biopsy ‫ أو‬urea breath test‫قبل إجراء اختبارات فحص الجرثومة (في النفس‬
‫ ساعة‬24 ‫ قبل أسبوعين و مضادات الحموضة قبل‬PPI ‫ وعن أدوية‬،‫حيوي قبل شهر‬

Non invasive Stool H pylori Ag test : + ve or – ve √√√( for follow up after Rx to confirm eradications)
Follow up
Serum H pylori antibodies ( not used in pediatrics)
Urea breath test (available in large centers)
Invasive Endoscopy: Nodularity or ulcers. (1st time for diagnosis)
Diagnosis
Biopsy : ) 6 gastric biopsies at least) ‫ عينات على األقل‬6
• Histopathology: demonstrating the organism √√
• Urease ( Rapid urase test) is diagnostic
• Culture ( difficult )
• PCR
Test Sensitivity Specificity
Urea breath test 98% 89%
Stool Ag 94 81
H pylori Ab 50%

Indication @Peptic ulcer disease (gastric/duodenal)

for Tx @Refractory /recurrent IDA (full course, good compliance , no obvious

cause)
@Chronic ITP (pt with Hp + chronic ITP are resistant to Rx of ITP& needs Hp
eradication)
Weak recommendations:
• H pylori infected children > 5 y diagnosed by a test for active infection
• H pylori infected children who underwent diagnostic upper Endoscopy for abd . symptoms
• H pylori infected children with histological evidence of chronic gastritis in absence of
ulcers
• Incidental finding at endoscopy ( biopsy based ) may be considered after discussion with
the parents

‫كان بيعمل منظار لسبب آخر( سيلياك مثال) وتم اكتشاف جرثومة المعدة بالمصادفة في العينة لطفل العرضى‬
• H pylori infected Child with F/H of gastric cancer ( 1st or 2nd degree relatives)

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Treatment for H pylori
‫الم بمنطقة فم المعدة يوقظ الطفل من نومه أو يؤثر في نشاطه أو ينتشر للظهر أو مترافق مع قيئ دموي أو براز‬
) ‫ األلم يزيد مع الجوع ويخف مع تناول الطعام أو مضاد الحموضة(عالمات القرحة‬، melena ‫دموي‬
• PPI + Amox+ Metro for 14 days, (PPI--> 8-12wks in PUD)

Dose regimen
Drug Body weight Morning Evening Notes
PPI 15-24kg 20 mg 20mg Nexium: 1-3mg/kg/day BID
Eso/omep 25-34 30 30 preparation: sachets 10, tab 20mg
>35 40 40 ‫صباحا ومساء ق االكل بنصف ساعة‬

Amox 15-24kg 500 500 Cap 500 , susp 125/250 , alemox tab 750mg,
1gm
classic 25-34 750 750
>35 1000 1000
Amox 15-24kg 750 750 High dose Amox : for resistance organism
High 25-34 1000 1000 or unknow sensitivity ‫مناسب لنا‬
>35 1500 1500
Clari 15-24kg 250 250 Klacid : susp ( 125,250mg) tab ( 250,
25-34 500 250 500mg)
>35 500 500
Metro 15-24kg 250 250 Falgyl/amrizol : tab 250, 500 mg ,
25-34 500 250 amrizole susp (200mg)
>35 500 500

Approved PPI in pediatrics

Drug Dose Age Forms
Omeprazole 0.7- 3.3 1-17 y Cap: 10, 20, 40 mg→gastrozol, Epirazol, hyposec, omepral
Lansoprazol mg/kg/day Cap: 15, 30 mg→ Gastrocure, peptazol, lanzor
Esomeprazole sachets 10mg , tab: 20 mg ( Nexium) , 20 mg cap (Esmatec‫)حبيبات مرة‬
Rabeprazol 20 mg /day ➢ 12 Y tab : 10,20 mg ( Pariet , Rabezole , Rabicid , Bepra)

Contraindications for PPI : liver impairment

Egyptian guideline
PPI + Amoxil + Klacid (strains are sensitive to klacid or sensitivity is Unknown)
PPI + Amoxil + flagyl (strains are resistant to klacid)
Probiotic role is questionable but it ↓ side effect of drugs including diarrhea
Duration: 7-14 days
Resistance ‫ ويمكن االستمرار الى أسبوعين طبقا لقرار الطبيب المعالج اذا كان هناك احتماليه لوجود‬، ‫المدة األساسية هي أسبوع‬

Repeat stool antigen test after 4wks after completion of therapy

) ‫يعاد التحليل بعد مرور شهر من اكتمال العالج (من آخر يوم في العالج‬
Confirm eradications:
By stool antigen test ( not by relieving symptoms)
After 1-2 mo of stopping therapy ( ‫) متوسط شهر ونصف‬

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 H pylori suspected
(peptic ulcer disease features, Refractory IDA , chronic ITP)
Yes Biopsy based H Pylori test
Eradication therapy
Stool Ag after 1mo
Consider FGID
No
If there is red flag → refere
No red flag -> Room criteria for specific FGID & Tx

✔✔✔✔Combinations:
➢ Helicure tablets: klacid 250mg +tinidazol 500mg +omeprazole 20mg & peptic care
➢ Helicocin tablets: amoxicillin 750 mg + flagyl 500mg