Paediatric Peptic Ulcer Disease (PUD)
Lesson Objectives
By the end of this lesson, learners should be able to:
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Define peptic ulcer disease and explain its pathophysiology.
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Identify the common anatomical sites of ulcers in children.
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Recognize age-specific clinical presentations.
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Describe appropriate diagnostic investigations, including endoscopy.
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Outline treatment strategies, including H. pylori eradication and acid suppression.
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Interpret triple therapy regimens and dosing for paediatric patients.
Description
Peptic ulcer disease (PUD) results from mucosal injury due to imbalance between cytoprotective and cytotoxic factors in the stomach and duodenum. Acid and pepsin overwhelm the mucosal defenses, causing gastritis or frank ulceration. Gastric ulcers are usually located along the lesser curvature, while 90% of duodenal ulcers are in the duodenal bulb.
Common causes: H. pylori infection, NSAID or other medication use, and stress-related mucosal injury. Less common causes include corrosive ingestion, Zollinger-Ellison syndrome, systemic mastocytosis, IBD, chronic renal failure, and hyperparathyroidism.
Clinical Features
| Age Group | Symptoms |
|---|---|
| Infants / Young children | Feeding difficulty, vomiting, crying episodes, hematemesis, melena |
| School-aged children | Epigastric pain, nausea, dyspepsia |
| Adolescents / Older children | Epigastric abdominal pain or fullness, dyspepsia |
| Neonates | Gastric perforation may be the first presentation |
| All ages | Hematemesis or melena in up to 50% of cases |
Investigations
| Investigation | Utility / Findings |
|---|---|
| Esophagogastroduodenoscopy (EGD) | Gold standard; allows visualization and hemostasis; biopsy for histology, culture, or rapid urease testing for H. pylori |
| Fecal H. pylori antigen test / urea breath test | Non-invasive; confirmatory for H. pylori infection |
| Blood H. pylori antigen / abdominal ultrasound | Less reliable; should not be solely used for diagnosis |
⚠️ Endoscopy is essential for both diagnosis and therapeutic intervention in children with suspected PUD.
Treatment
Key principles:
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Eradicate H. pylori.
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Suppress gastric acid.
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Provide supportive care (diet, hydration).
Triple therapy regimens for H. pylori eradication:
| Medication | Dosage | Duration |
|---|---|---|
| Omeprazole | 1 mg/kg/day in 2 divided doses | 1 month |
| Amoxicillin | 50 mg/kg/day in 2 divided doses | 14 days |
| Clarithromycin | 15 mg/kg/day in 2 divided doses | 14 days |
| Omeprazole | 1 mg/kg/day in 2 divided doses | 1 month |
| Tinidazole | 50 mg/kg/day (max 2 g) | 14 days |
| Clarithromycin | 15 mg/kg/day in 2 divided doses | 14 days |
| Omeprazole | 1 mg/kg/day in 2 divided doses | 1 month |
| Metronidazole | 20 mg/kg/day in 2 divided doses | 14 days |
| Clarithromycin | 15 mg/kg/day in 2 divided doses | 14 days |
⚠️ Triple therapy choice depends on drug availability, resistance patterns, and patient tolerance.
Key Summary
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PUD results from an imbalance between acid/pepsin and mucosal defenses.
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Most ulcers occur in the lesser curvature (stomach) or duodenal bulb.
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Clinical presentation varies by age: vomiting and feeding difficulty in infants, epigastric pain in older children, and hematemesis/melena in many patients.
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Endoscopy is the diagnostic and therapeutic gold standard.
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H. pylori eradication with triple therapy plus acid suppression is the mainstay of treatment.
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Supportive care, monitoring for complications, and adherence to therapy are essential for cure.