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Peptic Ulcer Disease in Children 373

the ulcers are usually acute, often perforate, and only rarely bleed or Sucralfate, which is an aluminum salt of sulfated sucrose, may also be
become chronic. In children older than 11 years of age, the behavior of used. In the presence of acidic pH, sucralfate forms a complex, paste-
the ulcers approximates that seen in adults. like substance that adheres to the damaged mucosal area. This forms a
Physical Examination protective coating that acts as a barrier between the lining and gastric
A general physical examination in uncomplicated cases is usually not acid, pepsin, and bile salts.
informative. Pallor may suggest blood loss. A combination of chronic Recommended Eradication Therapies for H.
epigastric or periumbilical pain and anaemia should raise a suspicion pylori Disease in Children
of PUD in a child. Careful inspection, auscultation, and palpation of First-line therapy is the use of one PPI and two antibiotics for 10 to 14
the abdomen, including rectal examination, are important, although days. This can be either:
findings may be normal. Haemorrhage accompanies PUD in 15–20% of
patients and may be severe enough to require blood replacement. Shock • omeprazole + amoxicillin + clarithromycin; or
may result from haemorrhage. • omeprazole + amoxicillin + metronidazole; or
Peritonitis resulting from perforation of the GIT occurs in about 5%
of children with PUD. • omeprazole + clarithromycin + metronidazole.
Investigations Second-line therapy is employed when there is no response to first-
line therapy. It consists of either
Due to the cost and lack of availability of resources, investigating a
• omeprazole + bismuth subsalicylate + metronidazole + amoxicillin
child with abdominal pain should be focused and targeted. The follow-
or tetracycline for 14 days; or
ing investigations may be indicated:
• The haemoglobin level is used to diagnose anaemia and determine • ranitidine + bismuth citrate + clarithromycin + metronidazole for
its severity. A blood film appearance may show hypochromic, 14 days.
microcytic cells suggestive of iron deficiency anaemia. Sophisticated Other drug combinations and durations of treatment are currently
laboratory tests to diagnose iron deficiency anaemia in chronic cases being evaluated.
may not be available in the developing world settings. For children in the developing world, cost may be a significant
• Oesophagogastroduodenoscopy (EGD) is the procedure of choice consideration in the treatment options available.
for detecting PUD in children and adolescents but is often unavail- Management of Complications of PUD in
able in most African hospitals. An endoscopy can be performed
safely in all paediatric age groups. It allows for direct visualisation Children
of the ulcers; the location and the number can be determined and Surgical intervention is required in a small percentage of infants and in
biopsy can be taken where necessary. In children with severely children with complications of PUD that include perforation, obstruc-
deformed duodenum or pylorus, there may be some difficulty in tion, intractable pain, and bleeding unresponsive to medical or endo-
visualisation of the duodenum. Urease activity can also be assessed scopic therapy.
by EGD. Therapeutically, EGD allows for control of bleeding Bleeding Peptic Ulcer Disease
ulcers by using vasoconstricting agents such as epinephrine or by Bleeding is the most common complication of PUD in children.
using a heater probe to coagulate the bleeding vessels. Monitoring Most cases are self-limiting and subside with conservative treat-
of response and efficacy of medical treatment can also be done via ment. However, in an acute bleed, the most important clinical step
endoscopy. For peptic ulcer disease in children, a definitive endo- is resuscitation and the restoration of blood volume. The following
scopic and microbiological diagnosis is advisable. steps are critical:
• An upper GI series is an alternative to EGD where such facilities 1. Two large-bore intravenous catheters are inserted.
are not available, but it has a high false positive rate of up to 30%. 2. A bolus fluid of 20 ml/kg of crystalloid is infused rapidly to combat
Diagnosis is based on the demonstration of an ulcer crater and shock, and is repeated as necessary pending availability of cross-
deformity of the duodenal cap.
matched blood.
• Serum gastrin estimation may be useful in cases of suspected 3. An appropriately sized urethral catheter is inserted to monitor
Zollinger-Ellison syndrome. urinary output. The urinary output, which may be all that is available
Diagnosis of Helicobacter pylori Infection in most centres in Africa, gives an estimation of organ perfusion
as a response to the fluid resuscitation. An output of 1–2 ml/kg is
Invasive and noninvasive tests are available for diagnosing H. pylori considered satisfactory but should be used in concert with other
infection. Invasive tests require endoscopy and include rapid urease test clinical parameters. A central venous pressure monitor can be
(RUT), histopathology, and culture of gastric biopsy. The noninvasive inserted where available. Complete blood counts and chemistry
tests, such as urea breath test and stool antigen detection, are used to values are also determined.
determine eradication of infection following treatment, whereas serolo-
4. A nasogastric tube (NGT) is placed as a way of performing lavage,
gy is used for epidemiological studies but may be unreliable in children.
preventing aspiration, and monitoring ongoing haemorrhage.
Medical Care With these initial measures (steps 1–4), most bleeding peptic ulcers
The initial treatment of PUD in children is medical. The treatment of will subside.
PUD, as in adults, encompasses eradication of H. pylori. This is accom- 5. Perform an endoscopy, if available, as soon as the patient is stable,
plished by a combination of medications to reduce acid production and/ usually within 24 hours of admission. Endoscopy confirms the
or improve the mucosal defense in combination with antibiotics. The diagnosis and may be therapeutic. Vasoconstrictive agents, such as
success of histamine-2 receptor blockers and proton pump inhibitors epinephrine, 1 in 10,000 dilution, can be injected, and use of a heater
(PPIs), and the eradication of H. pylori, has virtually eliminated the probe, electrocoagulation, or photocoagulation can also be employed.
need for elective ulcer surgery. Although colonisation by H. pylori 6. Angiography may be necessary in patients with a massive GI
may be high, there is no evidence that eradication in an asymptom- bleed in whom endoscopy cannot be performed. Angiography can
atic patient is warranted. PPIs have been found to be safe in children.
depict the source of the bleeding, and allow for the direct injection of