Peptic ulcers, gastritis, and duodenitis (pediatrics): Clinical sciences

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Introduction0:00–0:38

Peptic ulcers, gastritis, and duodenitis belong to a spectrum of conditions known as acid peptic disease. These conditions are characterized by excessive gastric acid production and weakened gastric or duodenal mucosa, which lead to superficial inflammation and erosions known as gastritis or duodenitis.
When damage progresses deeper and invades the muscularis mucosa layer, a peptic ulcer forms. Treatment of acid peptic disease depends on the presence or absence of a coexisting Helicobacter pylori infection.
Now, if a pediatric patient presents with a chief concern suggesting a peptic ulcer, gastritis, or duodenitis, first perform an ABCDE assessment to determine if they are stable or unstable.

Unstable Patient0:38–1:53

If unstable, stabilize their airway, breathing, and circulation. Next, obtain IV access and consider administering IV fluids or a transfusion of packed red blood cells.
Put your patient on continuous vital sign monitoring, including blood pressure, heart rate, and pulse oximetry; and provide supplemental oxygen if needed.
Consider placing a nasogastric tube, with or without nasogastric lavage. Also, if the patient has active bleeding or hypotension, obtain an emergent esophagogastroduodenoscopy, or EGD.
Finally, consider an infusion of proton pump inhibitor or vasopressin. Here’s your first clinical pearl!
Peptic ulcers, gastritis, and duodenitis can be complicated by bleeding, in the form of hematemesis or melena, as well as gastrointestinal perforation, stricture, and obstruction.
Ulcers that cause heavy or brisk bleeding may require emergent intervention, such as coagulation therapy or vasopressor support.

Stable Patient1:53–4:57

Now that we’ve discussed unstable patients, let’s return to the ABCDE assessment and take a look at stable ones. First, obtain a focused history and physical examination.
Caregivers of younger children typically describe irritability, poor feeding, and regurgitation or vomiting; whereas older children report gas or bloating, nausea, and retrosternal chest or abdominal pain and burning.
Additionally, patients might experience symptom relief with antacid use. History may also reveal the use of high-dose non-steroidal anti-inflammatory drugs or corticosteroids, which weaken mucosal defenses.
Physiologic stress from severe trauma, burns, major illness, or surgery can also injure the gastric mucosa. Finally, your patient might report contact with an individual who has tested positive for Helicobacter pylori.
Time for a clinical pearl! Helicobacter pylori, or H.
pylori, is a spiral- or U-shaped gram-negative bacillus that is transmitted by a fecal-oral or oral-oral route. Most individuals with H.
pylori infection are asymptomatic, but in some cases, H. pylori produces toxins and urease, which overwhelm the gastric mucosal defenses and lead to chronic gastritis and potentially, peptic ulcer, lymphoma, and gastric adenocarcinoma.
Alright, back to our patient. The physical exam usually reveals epigastric tenderness, and for younger patients, the growth chart might demonstrate suboptimal weight gain or weight loss.
With these findings, you should suspect acid peptic disease, which includes peptic ulcer, gastritis, and duodenitis. To confirm the diagnosis and guide treatment, you’ll need to order an EGD with biopsy and H.
pylori tissue culture. Here’s a couple of clinical pearls!
In some cases, you can diagnose and treat patients without any further testing, but you should always obtain an upper endoscopy for any patient with alarm features, like weight loss, chronic vomiting, microcytic anemia, and abdominal or chest pain that awakens the patient at night.
To rule out other causes, you might also consider obtaining a CBC; erythrocyte sedimentation rate, amylase and lipase levels; liver function tests; and an abdominal ultrasound.
When it comes to H. pylori infection, a tissue culture is considered the gold standard for confirmation but not your only choice.
You could also use histopathologic findings combined with a rapid urease test, polymerase chain reaction, or fluorescent in situ hybridization test.
However, unless you’re checking for H. pylori eradication after treatment, avoid noninvasive testing, like a urea breath test or stool antigen.
Keep in mind that serologic testing for H. pylori should not be used during an evaluation for acid peptic disease in children.
Now, let’s assess the EGD and biopsy results. If there’s no evidence of peptic ulcer, gastritis, or duodenitis; consider an alternative diagnosis, such as pancreatitis, celiac disease, lactose intolerance, inflammatory bowel disease, or eosinophilic esophagitis.

EGD and Biopsy4:57–6:03

On the other hand, the EGD might demonstrate mucosal erythema, erosions, and subepithelial hemorrhage in the stomach; and biopsy may reveal inflammatory cells.
When confined to the stomach, these findings confirm gastritis. However, if you see mucosal erythema, erosions, and subepithelial hemorrhage in the duodenum; with inflammatory cells on duodenal biopsy, diagnose duodenitis.
Finally, in more severe cases, EGD may reveal mucosal ulceration, and the biopsy will identify damage extending into the muscularis mucosa.
In this case, your patient has a peptic ulcer regardless of its location. Now that you’ve confirmed the diagnosis, it’s time to assess the H.

H. pylori culture6:03–7:58

pylori tissue culture results. If H.
pylori tissue culture is negative, you should discontinue any offending medications, such as NSAIDs; and treat any contributing causes, like burns or major illness.
Then, start your patient on acid suppression therapy. The most effective is a proton pump inhibitor, or PPI, such as omeprazole; but you could also use a H2-receptor antagonist, like cimetidine.
Additionally, you can consider adding cytoprotective agents such as sucralfate or bismuth if mucosal lesions are present.
Here’s one more clinical pearl! Peptic ulcers can be triggered or aggravated by systemic infections, such as cytomegalovirus or Cryptosporidium, both of which are most commonly found in immunocompromised patients.
Ulcers can also be caused by inflammatory bowel disease; excessive histamine production due to systemic mastocytosis, and hypercalcemia due to hypoparathyroidism and chronic renal disease.
Lastly, Zollinger-Ellison Syndrome is a condition associated with gastrin-secreting tumors called gastrinomas, which can lead to multiple, severe gastric ulcers and chronic diarrhea.
Okay, let’s switch gears and talk about positive H. pylori culture results.
Again, you should first discontinue any offending medications and treat contributing causes. Then, initiate H.
pylori eradication therapy, which consists of “triple therapy” with a PPI plus 2 antibiotics. First-line antibiotics include amoxicillin and a macrolide such as clarithromycin, but if your patient is allergic to one of these antibiotics, you can use metronidazole instead.
You can also consider adding cytoprotective agents such as sucralfate or bismuth if mucosal lesions are present. Next, assess for H.

H. pylori eradication7:58–8:45

pylori eradication 4 weeks after your patient has completed triple therapy. To do so, order a C-urea breath test or stool antigen test.
A negative C-urea breath test or stool antigen test indicates that the triple therapy effectively eradicated the H. pylori infection.
At this point, your patient should continue the current treatment and avoid NSAIDs. On the flip side, a positive C-urea breath test or stool antigen test indicates that the triple therapy failed, and H.
pylori has not been eradicated. In this case, repeat triple therapy using a PPI plus amoxicillin and metronidazole, or appropriate antibiotics according to H.
pylori susceptibility. Alright, as a quick recap… If you suspect a peptic ulcer, gastritis, or duodenitis in a pediatric patient, order an EGD with biopsy and an H.

Review8:45–9:28

pylori tissue culture. If the culture is negative, discontinue any offending medications, treat contributing causes, and start acid suppression therapy.
On the flip side, a positive culture confirms H. pylori infection, so start triple therapy with a PPI plus 2 antibiotics.
Then, use C-urea breath test or stool antigen test to check for H. pylori eradication.
If negative, the treatment was successful, and your patient should continue current management. If these tests are positive, treatment has failed, so repeat the triple therapy.
Peptic ulcers, gastritis, and duodenitis (pediatrics): Video | Osmosis