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374 Peptic Ulcer Disease in Children

vasoconstrictive agents. This is rarely available in resource-poor settings. corrected. In some instances, the nasogastric decompression and
Rebleeding is reported to occur in 10–30% of cases and usually treatment with antiulcer drugs will allow oedema to subside enough
occurs within the first week after primary therapeutic endoscopy. for gradual introduction of oral feeds. Definitive therapy consists of
Endoscopic treatment can be repeated for rebleeding. bilateral truncal vagotomy with pyloroplasty or in the presence of
Indications for surgery in bleeding PUD include: severe fibrosis gastrojejunostomy.
1. failed endoscopic treatment; Prognosis and Outcomes
2. identified arterial bleeding; Peptic ulcer is usually a benign disease without a high mortality if
3. identified vessels at the base of the ulcer; diagnosed and treated early. With modern therapy and eradication of H.
pylori, the cure rate is more than 90%. Mortality rates remain highest
4. rebleeding; and
in neonates as well as in infants and children with systemic illness or
5. loss of more than 50% of the patient’s estimated blood volume in a injury who present with acute bleeding or perforation.
short period (i.e., 8–24 hours).
Choice of Surgery Prevention
Simple plication or oversewing of the bleeding source is usually all Prevention involves the avoidance of predisposing factors, such as
that is needed for peptic ulcers. A more definitive procedure, such as ingestion of NSAIDs, coffee, smoking, and alcohol in older children
vagotomy and pyloroplasty, may be added if the patient is stable and fit. and adolescents. Secondary peptic ulceration in severely stressed and
In patients with stress ulcers related to brain injury or burns, the proce- traumatized patients can be prevented by prophylactic antacids and
dure of choice may be vagotomy and antrectomy. Total gastrectomy is H -receptor blockers or PPIs. Early recognition and evaluation of
2
rarely performed to treat multiple gastric ulcers in paediatric patients. abdominal pain will prevent the development of complications of PUD.
Perforated Peptic Ulcer Disease in the Child Evidence-Based Research
When perforation occurs, it is usually on the anterior wall of the first Table 60.2 presents a retrospective study of 45 years of data on surgical
part of the duodenum, resulting in both chemical and bacterial peritoni- treatment of peptic ulcer disease in children.
tis. Perforation is accompanied by the sudden onset of abdominal pain, Table 60.2: Evidence-based research.
vomiting, and generalised abdominal distention. Shoulder pain may be
present due to diaphragmatic irritation. Examination of the acutely ill Title A 45-year experience with surgical treatment of peptic
ulcer disease in children
child reveals evidence of peritonitis with board-like rigidity and dimin-
ished bowel activity. In the infant, perforation may occur in the absence Authors Azarow K, Kim P, Shandling B, Ein S
of any recognizable stress. Institution Division of General Surgery, The Hospital for Sick Children
A plain abdominal x-ray may be helpful, as it may reveal pneumo- and University of Toronto, Toronto, Ontario, Canada
peritoneum. Reference J Pediatr Surg 1996; 31(6):750–753
Late presentations are not uncommon in developing countries Problem The role of the proton pump inhibitor on the incidence
because of a lack of suspicion and poor access to health care. Late- of surgery for complications of PUD and the outcome of
presenting patients may be severely toxic and dehydrated, requiring surgical treatment in complicated PUD in children was
investigated.
urgent fluid resuscitation and correction of electrolytes and acid-base Comparison/ This is a retrospective study of all patients who required
disorder. An NGT and urinary catheter should be inserted. The child control operations for PUD between 1949 and 1994 (n = 43). The
should be started on broad-spectrum antibiotics. Surgery is performed (quality of patients were classified into three groups: A (n = 38): pre–
as soon as the child is stabilized. evidence) H receptor blocker era (1949–1975); B (n = 3): pre–proton
2
Operative repair of perforated ulcers may be performed by pump inhibitor era (1976–1988); and C (n = 2): proton
pump inhibitor era (1989–1994). The incidence of surgery
using a simple closure or oversewing. Where available, this may be for complicated PUD in children and the outcome of
accomplished laparoscopically. An omental patch (Graham patch) surgical intervention were compared across the three eras.
may be used to cover the area of perforation. This treatment should be Outcome/ The authors concluded that although the incidence of
followed by medical therapy. In a stable patient with chronic ulcer, a effect surgery for PUD has declined, the incidence of surgery for
selective vagotomy or a bilateral truncal vagotomy with pyloroplasty obstruction secondary to PUD has not. The obstruction
probably is related to scarring from long-standing disease.
may be added. H. pylori may be a risk factor in the development of
Gastric Outlet Obstruction obstruction. Lesser procedures, such as vagotomy and
pyloroplasty for bleeding PUD, simple oversewing of a
Gastric outlet obstruction occurs following chronic inflammation with perforation, and vagotomy plus a drainage procedure for
fibrosis at the pylorus. This is often accompanied by acute inflam- gastric outlet obstruction, may be sufficient with appropriate
mation and mucosal oedema, leading to luminal obstruction. Gastric ulcer medical treatment postoperatively, especially in those
who did not have definitive ulcer surgery.
outlet obstruction is an uncommon complication of PUD in children. Historical This study provides indirect evidence that medical
It is characterized by recurrent episodic vomiting. The vomitus usually significance/ treatment has significantly reduced the incidence of
contains food residues eaten over the previous few days. The vomiting comments complications of PUD, especially bleeding in children.
is characteristically projectile in nature. Weight loss is not uncommon, In Africa and developing countries with a low index of
and in late presentation the child is severely dehydrated and pale. suspicion and poor access to health care facilities, this
may not be the case. In an environment where late
Serum electrolytes characteristically show hypochloremic alkalosis presentation may be the case, the clinical state should
with hyponatraemia and hypokalaemia. Blood gas analysis shows a determine the surgical approach to those presenting with
base excess of more than +3. There may be hypoproteinaemia as a complicated PUD; extensive surgery may not be indicated
and simple surgery as practiced in this study may suffice
result of the malnutrition.
Diagnosis is usually confirmed by upper gastrointestinal series or
endoscopic gastroduodenoscopy. A dilated stomach with narrowing of
the pylorus and deformity of the duodenal bulb is typically demonstrated.
Treatment consists of aggressive resuscitation with crystalloid,
ensuring adequate urinary output. Nasogastric decompression and
lavage is necessary while the hypoproteinaemia and anaemia are