Peptic ulcer disease in children

Peptic ulcer of the stomach and/or duodenum in children is a chronic, cyclical disease characterized by ulceration in the stomach, duodenum, and less often in the postbulbar regions.

Epidemiology

Ulcer disease is one of the most common diseases among the adult population. According to foreign and domestic statistical studies, every 10th resident of European countries suffers from gastric ulcer and duodenal ulcer. Currently, more than 3.5 million patients with this pathology are registered with gastroenterologists.

The prevalence of peptic ulcer disease in children varies in different countries of the world, there are no exact statistics. Thus, according to the British Columbia Children's Hospital (Canada), annually out of 4 million patients, 4-6 children are diagnosed with new cases of peptic ulcer disease. According to the Nizhny Novgorod Research Institute of Pediatric Gastroenterology in Russia, the prevalence of peptic ulcer disease is 1.6±0.1 per 1000 children. The latest data indicate that the ulcerative process in children is localized in the duodenal bulb in 99%, in the stomach in 0.5-0.75%, and in 0.25% of cases, combined localization is diagnosed. The ulcerative process in the stomach in children is often acute in nature and has various etiologies (stress, trauma, infection, drug-induced lesions, etc.). The data are confirmed by the results of long-term (more than 3 years) regular planned clinical and endoscopic observation, which made it possible to exclude a chronic ulcerative process in the stomach.

Epidemiological studies based on a thorough study of anamnestic data, clinical, endoscopic and functional parallels allow us to establish the frequency of duodenal ulcer depending on the age and sex of the child. Cases of duodenal ulcer detection in children of the first year of life have been recorded; in preschool age, the incidence is 0.4 per 1000, and in schoolchildren - 2.7 per 1000 of the child population. In this case, peptic ulcer disease in girls is more often detected at the age of 10-12 years, and in boys - at 12-15 years. Gender differences are not noted up to 4-8 years, but with age, a tendency is formed for the predominance of the number of boys suffering from duodenal ulcer over girls in a ratio of 3:1, reaching 5:1 by the age of 18.

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ]

Causes peptic ulcer disease in a child

Peptic ulcer disease (PUD) has various causes; however, Helicobacter pylori-associated PU and NSAID-associated PU account for the majority of the disease etiology. [ 6 ]

Common reasons

• H. pylori infection
• NSAIDs
• Medicines

Rare causes

• Zollinger-Ellison syndrome
• Malignant neoplasms (stomach/lung cancer, lymphomas)
• Stress (acute illness, burns, head injury)
• Viral infection
• Vascular insufficiency
• Radiation therapy
• Crohn's disease
• Chemotherapy

Helicobacter Pylori-associated peptic ulcer disease

H. pylori is a gram-negative bacillus that is found in the epithelial cells of the stomach. This bacterium is responsible for 90% of duodenal ulcers and 70% to 90% of gastric ulcers. H. pylori infection is more common in individuals with lower socioeconomic status and is usually acquired during childhood. The organism has a wide range of virulence factors that allow it to adhere to the gastric mucosa and cause inflammation. This results in hypochlorhydria or achlorhydria, which leads to gastric ulcers.

NSAID-associated peptic ulcer disease

The use of nonsteroidal anti-inflammatory drugs is the second most common cause of PUD after H. pylori infection. [ 7 ], [ 8 ] Prostaglandin secretion normally protects the gastric mucosa. NSAIDs block prostaglandin synthesis by inhibiting the enzyme COX-1, resulting in decreased production of gastric mucus and bicarbonate, as well as decreased blood flow through the mucosa.

Medicinal causes of gastric ulcer

In addition to NSAIDs, corticosteroids, bisphosphonates, potassium chloride and fluorouracil have been implicated in the etiology of peptic ulcer disease.

Smoking also plays a role in duodenal ulcers, but the correlation is not linear. Alcohol can irritate the stomach lining and cause increased acidity.

A hypersecretory environment occurs under the following conditions:

• Zollinger-Ellison syndrome
• Systemic mastocytosis
• Cystic fibrosis
• Hyperparathyroidism
• Antral G cell hyperplasia

Read more in this article: Causes and pathogenesis of gastric ulcer

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Symptoms peptic ulcer disease in a child

Signs of peptic ulcer disease in a child may vary depending on the location of the disease and age. Gastric and duodenal ulcers can be differentiated by the time of onset of symptoms in relation to food intake. Night pain is common with duodenal ulcer. Children with gastric outlet obstruction usually report abdominal distension or fullness.

Read more in this article: Symptoms of gastric ulcer

Forms

In English-language literature, the terms "peptic ulcer" and "ulcer" are used as synonyms, applying to both erosions and ulcers of the stomach and duodenum. Erosion is a defect in the mucous membrane that does not penetrate to the muscular plate, while an ulcer is a deeper lesion that goes into the submucosa.

Ulcer disease is divided into primary and secondary. There are primary peptic ulcers associated with H. pylori, and Helicobacter-negative (idiopathic), which are chronic and tend to recur.

The causes of secondary peptic ulcers are varied: physiological stress, burns, hypoglycemia, traumatic brain injury, use of drugs, infections, autoimmune diseases, hypersecretory and immune-mediated conditions, vascular insufficiency, liver cirrhosis, etc. Secondary peptic ulcers, depending on the etiological causes, can have both acute and chronic course.

The domestic medical school clearly distinguishes between peptic ulcer disease and symptomatic ulcerations of the mucous membrane of the gastroduodenal zone, which occur in various diseases and conditions.

In pediatric practice, the most widely used classification of peptic ulcer disease is that of A.V. Mazurin.

The pathological process can be localized in the stomach, duodenum (bulb and postbulbar sections), and a combination of lesions is also possible. The following phases of the disease are distinguished: exacerbation, incomplete clinical remission and clinical remission. Uncomplicated and complicated forms of peptic ulcer disease are distinguished, the latter includes bleeding, penetration, perforation, pyloric stenosis and perivisceritis. The functional state of the gastroduodenal zone is subject to assessment (acidity of gastric contents, motility can be increased, decreased or normal). Clinically and endoscopically, peptic ulcer disease is classified as follows:

• Stage I - fresh ulcer;
• Stage II - the beginning of epithelialization of the ulcerative defect:
• Stage III - healing of the ulcer defect in severe gastroduodenitis;
• Stage IV - clinical and endoscopic remission.

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Complications and consequences

Peptic ulcer disease, if not diagnosed and treated in time, can lead to serious complications. The following complications may occur with PU:

• Upper gastrointestinal bleeding.
• Gastric outlet obstruction.
• Perforation.
• Penetration.
• Stomach cancer.

Diagnostics peptic ulcer disease in a child

Diagnosis of gastric ulcer in a child requires history, physical examination, and invasive/noninvasive medical tests. A thorough history should be taken and any complications noted. Children who report epigastric pain, early satiety, and satiety after eating raise suspicion for gastric ulcer. Gastric ulcer pain is worse 2–3 hours after eating and may lead to weight loss, whereas duodenal ulcer pain is better after eating, which may lead to weight gain. Any child with anemia, melena, hematemesis, or weight loss should be further evaluated for complications of gastric ulcer, primarily bleeding, perforation, or cancer. Physical examination may reveal epigastric tenderness and signs of anemia.

Read more in this article: Diagnosis of gastric ulcer

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Differential diagnosis

During the initial clinical examination of a sick child, there are no clear criteria for peptic ulcer disease, and therefore it is necessary to carry out differential diagnostics of abdominal pain and dyspeptic syndromes with the clinical picture of other diseases of the gastrointestinal tract, lungs, and heart:

• esophagitis, including erosive;
• exacerbation of chronic gastroduodenitis;
• gastric ulcer and duodenal ulcer;
• erosive gastroduodenitis, duodenitis:
• acute cholecystitis and exacerbation of chronic cholecystitis;
• acute pancreatitis and exacerbation of chronic pancreatitis;
• heart disease (rheumatism, cardialgia, cardiomyopathy);
• pneumonia, pleurisy.

Differential diagnosis of peptic ulcer disease is also carried out with symptomatic (acute) ulcers.

Acute ulcerations of the mucous membrane of the digestive tract do not have typical clinical manifestations, are very dynamic and, on the one hand, quickly scar, and on the other hand, often lead to severe complications - bleeding, perforation. Depending on the cause of ulceration, acute ulcers are distinguished:

• stress ulcers are most often localized in the body of the stomach and occur with burns, after injuries, and with frostbite;
• Allergic ulcers most often develop with food allergies;
• drug-induced ulcers that occur after taking medications that disrupt the barrier functions of the mucous membrane (non-steroidal and steroidal anti-inflammatory drugs, cytostatics, etc.);
• Endocrine ulcers in children are rare - with hyperparathyroidism, diabetes mellitus, and Zollinger-Ellison syndrome (hyperplasia of gastrin-producing cells in the antrum of the stomach or pancreas).

The latter disease manifests itself with symptoms similar to peptic ulcer disease. It is characterized by pronounced intragastric hypersecretion, hypertrophy of the gastric mucosa, and rigidity to conventional therapy. The screening test is the detection of an increase in the fasting concentration of gastrin in the blood serum.

Secondary ulcers can be:

• hepatogenic - with a decrease in the inactivation of gastrin and histamine in the liver;
• pancreatogenic - with a decrease in the production of bicarbonates and an increase in the production of kinins;
• hypoxic - with pulmonary heart failure;

• in diffuse diseases of connective tissue - as a result of microcirculation disorders;
• in chronic renal failure - due to a decrease in the destruction of gastrin in the kidneys and a disruption of the protective barrier of the stomach.

Treatment peptic ulcer disease in a child

The goal of treating peptic ulcer disease is to relieve clinical symptoms of the disease and heal the ulcer defect, and subsequently to carry out rehabilitation measures aimed at restoring structural and functional disorders of the gastroduodenal zone and preventing relapses of the ulcer process.

An important task is to decide on the place of treatment of peptic ulcer disease in children. It is generally recognized that when peptic ulcer disease is first detected, inpatient examination and treatment are mandatory, adjusted taking into account the anamnesis, the characteristics of the child's mental state and the psychological climate in the family, school or kindergarten.

Antisecretory drugs used in peptic ulcer disease include H2 receptor antagonists and proton pump inhibitors (PPIs). PPIs have largely replaced H2 receptor blockers due to their superior healing and effectiveness. PPIs block the production of acid in the stomach, relieving symptoms and promoting healing. Treatment may include calcium supplements, as long-term use of PPIs may increase the risk of bone fractures.

NSAID-induced ulcers can be treated by stopping the NSAID or switching to a lower dose. Corticosteroids, bisphosphonates, and anticoagulants should also be stopped if possible. Prostaglandin analogues (misoprostol) are sometimes used as a preventive measure for NSAID-induced peptic ulcers.

First-line treatment for H. pylori-induced PUD is a triple regimen of two antibiotics and a proton pump inhibitor.[ 23 ] The antibiotics and PPIs work synergistically to eradicate H. pylori.[ 24 ] The antibiotic chosen should take into account the presence of antibiotic resistance in the environment. If first-line therapy fails, quadruple therapy with bismuth and various antibiotics is used.

Read more in this article: How is gastric ulcer treated in children?

Prevention

Primary prevention of peptic ulcer disease includes monitoring the condition of the upper gastrointestinal tract (especially in children with a family history of peptic ulcer disease), epidemiological measures aimed at preventing infection with H. pylori, monitoring compliance with an age-appropriate diet and quality of nutrition, promoting a healthy lifestyle, as well as timely eradication treatment when H. pylori infection is detected, and correction of autonomic dysfunctions.

Forecast

Early detection of peptic ulcer disease in children, adequate therapeutic treatment, regular dispensary observation and prevention of relapses make it possible to achieve stable clinical and endoscopic remission of the disease for many years, which significantly improves the quality of life of patients.

Prevention of peptic ulcer disease along with the exclusion of external factors of its formation involves timely detection and treatment of pre-ulcer condition. The presence of hereditary morphofunctional features of the stomach and duodenum in a child, capable of transforming into peptic ulcer disease under certain conditions, is considered as a pre-ulcer condition. Criteria have been established, with the combination of which the formation of peptic ulcer disease is very likely:

1. a burdened heredity for peptic ulcer disease, especially cases of peptic ulcer disease among first-degree relatives;
2. increased acid-peptic, especially basal, aggression of the stomach;
3. increased levels of pepsinogen I in the blood and urine;
4. dominance of the Pg3 fraction in the pepsinogen phenotype;
5. decrease in mucin and bicarbonates in duodenal juice.

Belonging to blood group I (ABO) and signs of vagotonia are also important.

Since the realization of hereditary predisposition in peptic ulcer disease occurs through HP-associated gastroduodenitis, the latter should also be considered an important criterion of the pre-ulcer condition.

Preulcerative condition requires the same diagnostic, therapeutic and dispensary approaches as peptic ulcer disease.

Outpatient observation is carried out for life, in the first year after exacerbation of peptic ulcer disease it is carried out 4 times a year, from the second year - 2 times a year. The main method of dynamic observation, in addition to questioning and examination, is endoscopic. It is also necessary to evaluate HP infection in dynamics and achieve eradication.