Peptic Ulcer Disease in Chil

den

Gastroenterology Department
MingFang Sun
2020.7.7
 Contents

Epidemiology

Etiology and pathogenesis

Clinical manifestation and Diagnosis

Treatmment
 Epidemiology

Definition
It is the end result of inflammation caused by an imbalance between
cytoprotective and cytotoxic factors in the stomach and duodenum, manifests
with varying degrees of gastritis or frank ulceration

Location
gastric ulcers are generally located on the lesser curvature of the stomach
duodenal ulcers are found in the duodenal bulb(>90%)
duodenal > gastic ulcer
Larger than 2cm in diameter is called a giant ulcer

Age: school-age children male>female

 Etiology and pathogenesis

Common cause:
positive for Helicobacter pylori infection
Drug (NSAID)-induced,Acid hypersecretory state (Zollinger-Ellison syndrome)
Anastomosis ulcer after subtotal gastric resection
Rare specific causes
Crohn disease of the stomach or duodenum
Eosinophilic gastroduodenitis
Systemic mastocytosis
Radiation damage
Viral infections (cytomegalovirus or herpes simplex infection,
particularly in immunocompromised patients)
Colonization of stomach with Helicobacter heilmannii
Severe systemic disease
Cameron ulcer (gastric ulcer where a hiatal hernia passes through
the diaphragmatic hiatus)
 Etiology and pathogenesis

Acid Secretion abnormal

 By 3-4Y, gastric acid secretion approximates adult values

 Excessive acid secretion is associated with a large parietal cell mass,

hypersecretion by antral G cells, and increased vagal tone, resulting in increased

or sustained acid secretion in response to meals and increased secretion during

the night
 Etiology and pathogenesis

Mucosal Defense

 It depends on mucosal blood flow, regeneration of

epithelial cells, mucus secretion and complete mucosal

barrier

 If mucus-bicarbonate barrier damage, it will appear

mucosal ischemia necrosis and induce ulcer

 Etiology and pathogenesis

HP infection

The interaction between bacterial and host factors determines the outcome of H

pylori infection. The ability of H pylori strains to produce different proteins has

been linked to their virulence and to the host immune response. H. pylori causes

an inflammatory response with neutrophils, lymphocytes, plasma cells, and

macrophages within the mucosal layer and causes epithelial cell degeneration and

injury. If mucus-bicarbonate barrier damage, it will appear Mucosal ischemia

necrosis,and induce ulcer.

 Etiology and pathogenesis

Defense
Damage factor capability
 Clinical manifestation

Different age

 Infants and younger children: feeding difficulty, vomiting, crying episodes, hematemesis

 School-age and adolescents: epigastric pain and nausea

Different position

 GU:  antrum more often, 0.5-1.5h after dinner

 DU ： duodenal bulb, pain onset before dinner ， relief after eating

 Complication

Norepinephrine spraying/PPI/somatostatin （ eg. Stilamin ）

 Hemorrhage

 Perforation

 Pylorochesis

 Canceration
 Dignosis

Symptoms +auxiliary examination

 Gastroscopy is the most important examination,it allows the direct visualization of

esophagus, stomach, and duodenum, identifying the specific lesions

 screen for the presence of H. pylori infection

1. 13C-urea breath tests(UBT) and stool antigen tests(SAT) are also noninvasive

methods of detecting H. pylori infection

2.RUT and HP culture from Pathological specimen of gastroscopy

(nitice:patient need to stop medication before examination,PPI for 2 week,antibiotics and

bismuth for 4 week)

 Treatment

Ulcer therapy has 2 goals: 1.ulcer healing and elimination of the primary cause

2.relief of symptoms and prevention of complications

 Treatment

Acid-inhibitory drug----the first-line drug

 The first-line drugs for the treatment of gastritis and peptic ulcer disease in children are PPIs and H2

receptor antagonists .

 H2-receptor antagonists (cimetidine, ranitidine, famotidine, nizatidine) competitively inhibit the binding of

histamine at the H2 subtype receptor of the gastric parietal cell.

 PPIs block the gastric parietal cell H+/K+–adenosine triphosphatase pump in a dose-dependent,fashion,

reducing basal and stimulated gastric acid secretion.

5 PPIs are available in children : omeprazole, lansoprazole,pantoprazole, esomeprazole, rabeprazole.

 Treatment

Mucous membrane protector

 Sucralfate: Covering the surface of the ulcer, Prevent acid and pepsin invasion of the ulcer

 Bismuth salts ： same as above,and also kill HP

 Hydrotalcite tablets: Gastric acid and bile are neutralized by precipitation and adsorption
 Treatment

Eradication of Helicobacter pylori

In the presence of H. pylori-associated peptic ulcer disease (PUD), eradication of the microorganism is

recommended

 Triple therapy: PPI + 2 antibiotics

 Bismuth-containing triple therapy: PPI + 2 antibiotics(Amoxicillin and metronidazole)

 The sequential treatment : PPI and amoxicillin administered for 5 days,then

PPI+clarithromycin+metronidazole for the remaining 5 days.

 Duration of therapy: 10-14d

Triple therapy: PPI + 2 antibiotics
HP eradication judgement: one of three

 UBT(negative)

 SAT(negative)

 RUT(from the antrum and the gastric body –negative ）

 Treatment

The indications for surgery

 uncontrolled bleeding

 perforation

 Obstruction(Scar)
 Case 1

Male ,3 years old, Accidentally swallowed button battery for 6 hours

Gastroscopy

Treatment
PPI
nasogastric tube
enteral nutrition 
 Case 2
Female,5Y,abdominal pain for 1 month
Present history:1month ago, this children begin to complain of abdominal
pain without any inducing factors. It’s intermittent pain in midsection,not
serious ,and can spontaneous remission,so her family didn’t take her to see
doctor.while it becomes more frequent for a week,so come to our hospital Peptic ulcer
now. HP infection
Familly history: her mother has been diagnosed HP infection
PE:W 20kg ,T 37℃, P 95/min, R 20/min, BP 89/50mmHg. Tenderness in the
upper abdomen , no muscle tension and rebound pain. Negative for heart,
lung,and nervous system.

Treatment ： PPI+Clarithromycin+ Amoxicillin clavulanate potassium for 2

weeks
Thank you!