Peptic Ulcer Disease

PUD: Intro & Epidemiology - Tiny Tummy Ailments

• Definition: Mucosal defect > 5mm in stomach/duodenum; depth through muscularis mucosae into submucosa.
• Types:
  • Gastric Ulcer (GU): Less common in peds vs DU.
  • Duodenal Ulcer (DU): More frequent, esp. proximal.
• Pediatric Epidemiology:
  • Overall rare vs adults; DU > GU, particularly >10 years.
  • Neonates: Acute stress ulcers (Cushing - CNS; Curling - burns).
  • Older children: Helicobacter pylori infection is a primary etiological factor.
  • NSAID use: An increasingly recognized risk factor.
  • India: High H. pylori prevalence; pediatric PUD data limited, varies regionally.

⭐ Duodenal ulcers are significantly more common than gastric ulcers in the pediatric population, frequently associated with H. pylori.

PUD: Etiopathogenesis - Ulcer Bugaboos

• Core Imbalance: Aggressive factors overwhelm mucosal defenses.
  • Aggressive: Gastric acid, pepsin, H. pylori, NSAIDs.
  • Defensive: Mucus-bicarbonate barrier, prostaglandins, mucosal blood flow, epithelial regeneration.
• Key Etiologies & Mechanisms:
  • Helicobacter pylori:
    • Most common (DU > GU).
    • Virulence: Urease, Toxins (📌 CagA, VacA); causes inflammation, ↑acid.
  • NSAIDs:
    • Inhibit prostaglandins (COX-1/2) → ↓defense.
    • Direct mucosal injury.
  • Stress Ulcers (SRMD):
    • Critically ill: Burns (Curling's), Head injury (Cushing's).
    • Patho: Splanchnic hypoperfusion → ischemia.
  • Zollinger-Ellison Syndrome (ZES):
    • Gastrinoma → massive acid hypersecretion.
    • Clues: Multiple, refractory, atypical ulcers.

⭐ H. pylori: childhood infection, Class I carcinogen (gastric adenocarcinoma), MALT lymphoma risk.

PUD: Clinical Features - Bellyache Clues

• Infants & Toddlers (< 2 years):

  • Poor feeding, vomiting (may be heme-positive)
  • Irritability, crying spells (especially post-prandial)
  • Failure to thrive
  • Melena (less common)

• Preschool & School-Age Children (2-12 years):

  • Periumbilical or epigastric pain (often nocturnal)
  • Nausea, vomiting (may be coffee-ground)
  • Anemia (iron deficiency)
  • Dyspepsia

• Adolescents (> 12 years):

  • Epigastric pain (classic gnawing/burning)
  • Pain relieved by food/antacids (duodenal ulcer) or worsened by food (gastric ulcer)
  • Nocturnal pain waking from sleep
  • Weight loss

• Alarm Signs (⚠️ Red Flags):

  • Persistent vomiting (especially bilious/projectile)
  • Hematemesis, melena
  • Severe abdominal pain, guarding
  • Unexplained weight loss, dysphagia
  • Family history of PUD, GI cancer

⭐ Nighttime pain awakening a child is a classic symptom highly suggestive of peptic ulcer disease, particularly duodenal ulcers.

📌 Mnemonic (Alarm signs): "Abdominal pain (severe), Loss of weight, Anemia, Recurrent vomiting, Melena/hematemesis, Swallowing difficulty" (ALARM-S).

PUD: Diagnosis & Management - Scope, Soothe, Solve

Diagnosis (Scope):

• Gold Standard: Upper GI Endoscopy + Biopsy (histology, Rapid Urease Test - RUT).
• H. pylori Testing:
  • Invasive: RUT, histology, culture.
  • Non-invasive: Urea Breath Test (UBT), Stool Antigen Test (SAT). Serology (IgG) indicates exposure.
• Scope Indications: Alarm symptoms (weight loss, bleeding, dysphagia), age >55 yrs, persistent NSAID use, failure of empiric therapy.

Management (Soothe & Solve):

• Acid Suppression (Soothe):
  • PPIs (e.g., Omeprazole) for 4-8 wks.
  • H2RAs: less potent.
• H. pylori Eradication (Solve):
  • Triple Therapy (📌 OAC: Omeprazole + Amoxicillin + Clarithromycin) for 14 days.
  • Bismuth Quadruple (📌 PBMT: PPI + Bismuth + Metronidazole + Tetracycline) for 10-14 days (if resistance/failure).
• Lifestyle: Stop NSAIDs, smoking, alcohol.
• Complications: Bleeding (endoscopy, IV PPI), Perforation (surgery), Obstruction (NGT, dilation).

⭐ Urea Breath Test (UBT) or Stool Antigen Test (SAT) are preferred non-invasive tests for confirming H. pylori eradication, performed ≥4 weeks post-therapy & 1-2 weeks off PPIs.

High‑Yield Points - ⚡ Biggest Takeaways

• H. pylori is the primary cause of duodenal ulcers in children; NSAIDs are more linked to gastric ulcers.
• Key symptom: Epigastric pain, often worse at night or with fasting; may present as recurrent abdominal pain.
• Upper GI endoscopy with biopsy (for H. pylori testing like CLO test/histology) is the diagnostic gold standard.
• Triple therapy (PPI + two antibiotics, e.g., amoxicillin and clarithromycin) is first-line for H. pylori eradication.
• Consider Zollinger-Ellison syndrome (gastrinoma) with multiple, refractory, or unusually located ulcers.
• Major complications include GI bleeding (melena, hematemesis), perforation, and gastric outlet obstruction.
• Stress ulcers (Cushing's - CNS injury; Curling's - burns) can occur in critically ill children.