Stomach and Duodenal Ulcers in Children - A Complete Guide

Introduction:

Ulcers are wide open sores caused due to epithelial lining breakdown. This break in the epithelium occurs in the lining of the stomach and duodenum (first and upper portion of small intestine) to cause stomach and duodenal ulcers respectively. These ulcers together constitute the peptic ulcer. Such breach in the epithelium is very commonly seen in adults. However, children are not an exception to such ulcers.

What Causes Stomach and Duodenal Ulcers in Children?

The incidence of peptic ulcers (stomach and duodenal ulcers) is about four percent in the pediatric population. The causes of such ulcers are divided into primary and secondary ones.

The primary causes of peptic ulcers in children are:

• Infection by Helicobacter pylori. The colonization of this bacterial species locally in the stomach areas causes inflammation. When there is continued inflammation, there can be a disruption in the epithelial integrity due to excessive action of the released acid and pepsin from the stomach, leading to ulcer formation.

• Children who have parents with peptic ulcers tend to have an increased incidence. This is because of genetic predisposition and the associated response to H. pylori infection.

The secondary causes of ulcers in children are also considered to be major risk factors for the incidence and progression of peptic ulcers. This includes:

• Medications are given to children for pain relief purposes. They mostly contain non-steroidal anti-inflammatory agents that irritate the gastric mucosa to cause epithelial break.

• Children who are ill for a prolonged period or exposed to stressful situations for a long time have a higher incidence of peptic ulcers. Stressful situations, in this case, do not relate to emotional stress. This includes physical forms of stress like severe burns or other traumatic injuries.

• Certain medical conditions can predispose children to get peptic ulcers. This includes cystic fibrosis (genetic disorder affecting the consistency of mucus secretion), Crohn's disease (disease with inflamed gut tissues), or Zollinger-Ellison syndrome (excessive gastrin and acid secretion secondary to pancreatic and duodenal tumors).

• Adolescents who indulge in smoking habits tend to have an increased incidence of ulcers, and in such cases, the formed ulcers also take a long time to heal.

What Are the Symptoms of Stomach and Duodenal Ulcers in Children?

• Abdominal pain that is burning or gnawing in nature is the most common and first presentation of peptic ulcers in children. This pain will generally be localized. However, in very young children, the pain may be diffuse, and children will not be able to locate a particular location of pain. Children complain of intense pain in the early mornings or just before a meal.

• Nausea.

• Vomiting.

• Loss of appetite.

• Weight loss is secondary to reduced appetite.

• Vomiting blood commonly called as haematemesis.

• In severe cases, there may be perforation of the lining, leading to bleeding within the intestine. This causes the child to pass black tarry stool (a condition called melena).

• Bloating and belching.

• Weakness due to nutritional deficit.

How to Diagnose Stomach and Duodenal Ulcers in Children?

• Symptoms explained by the child, along with a general physical examination, is the first step to diagnose peptic ulcers in children. A medical history of prolonged NSAID intake by the child can help in elucidating the etiological factor.

• Laboratory investigations are necessary to have an insight into H. pylori infection in the gut. Common tests done are urea breath test and blood antibody test. In rare cases where diagnosing the condition remains uncertain, invasive procedures like endoscopic biopsy with rapid urease testing are advised.

• When chronic blood loss is suspected due to ulcer, hematological investigations will be performed to have an overview of the anemic status of the child. Liver function tests and pancreatic enzyme tests will also be done to differentiate the reason behind abdominal pain.

• A breach in the epithelial lining can be best visualized with the help of a camera inserted into the stomach or duodenal areas. This is achieved through gastrointestinal endoscopy (this procedure is also considered the best way to diagnose peptic ulcers). During this procedure, a sample of the ulcerated tissue can also be obtained, and Helicobacter pylori infection can be looked for.

• In rare cases, a barium swallow radiograph will also be done to check for ulcers that cannot be captured and visualized through routine endoscopy.

How to Treat Stomach and Duodenal Ulcers in Children?

The underlying etiological factors should be identified precisely and removed for managing stomach and duodenal ulcers in children.

• If Helicobacter pylori is identified as the culprit for the causation of ulcers in growing children and adolescents, it should be completely eradicated with antibiotics. Generally, a combination of antibiotics containing Metronidazole and Amoxicillin will be given. A proton pump inhibitor will be given in this treatment regimen to curb the secretion of acid and allow time for the stomach to heal completely. The regimen (triple therapy) period will range from 10 to 14 days.

• If prolonged painkiller intake is the etiology, stopping the intake of such drugs and switching to other pain management modalities will be employed. This will always be supplemented with a drug regimen comprising a medicine that blocks proton pump (proton pump inhibitor) or histamine-2 receptor antagonist just to aid in the healing process of the affected stomach and duodenal tissues and prevent any new recurrences of the ulcer.

• For critically ill children, treating the primary reason is the management strategy. The use of proton pump inhibitors in such cases will help in protecting the tissues of the gut from the acidic environment.

• Surgery is rarely needed in children with peptic ulcers. However, it may be needed for children with complications such as perforation, obstruction, or refractory ulcers (non-healing ulcers) that do not respond to other kinds of medical treatment even after eight to 12 weeks.

What Are the Complications of Stomach and Duodenal Ulcers in Children?

Untreated peptic ulcers in children for a prolonged period can cause the ulcer to remain in the intestinal lining and irritate the mucosa. This can subsequently cause:

• Bleeding from the gastrointestinal tract.

• Perforation of the gut wall. This will cause all gastrointestinal contents to spill over to the abdominal cavity and result in peritonitis (inflammation).

• Scarring and narrowing of the intestinal lining occur with chronic ulcers. This leads to obstruction of the tract.

Conclusion:

Children with stomach and duodenal ulcers have a good prognosis if the condition is looked at and treated on time. The focus for the best prognosis should be on eradicating H.pylori completely from the gut and eliminating associated secondary or risk factors. Overall, protecting the gut health of children without the burden of ulcers is achievable with timely diagnosis and treatment.