Peptic Ulcer Disease & Gastritis

Question 1

Define peptic ulcer disease

Answer 1

Break in the superficial epithelial lining of either stomach (gastric) or duodenum (more common)

Break = >5mm in diameter with depth to submucosa
Erosions = <5mm

Question 2

What are the primary causes of peptic ulcer disease and what is the epidemiology

Answer 2

H. Pylori infection of the stomach
Zollinger-Ellison syndrome (gastrin-secreting neuro-endocrine tumour →↑ gastric acid)
G-cell hyperplasia
Systemic mastocytosis
Short bowel syndrome
Hyperparathyroidism

More common in children >10 yo
Usually chronic
Often in the duodenum

Question 3

What are the secondary causes of peptic ulcer disease and what is the epidemiology

Answer 3

Drugs - NSAIDs, corticosteroids, sodium valproate, thiophylline, bisphosphonates, aspirin
Physiological stress/systemic illness:
- Sepsis
- Head trauma
- Burns
- Sickle cell disease
- T1DM
- Systemic lupus erythematosus
- ICU stays (>48hrs ventilation)
- Infection e.g. CMV in HIV patients, TB
- Crohn’s disease

More common in younger children - in neonates/infants the vast majority are secondary and in the stomach
Usually acute
Occurs in the stomach or duodenum

Question 4

What are the symptoms of peptic ulcer disease

Answer 4

Abdominal pain (epigastric, associated with eating, nocturnal, radiates to the back)
Dyspepsia
Nausea and vomiting
Anorexia and weight loss
Early satiety
Poor growth

Rupture: Melaena, Coffee-ground vomit

Question 5

What investigations should be done for peptic ulcer disease

Answer 5

Bedside:
- H. pylori [13C] breath testing (not indicated in children for diagnosis)
- Stool antigen test
- ECG

Bloods: FBC, LFTs, CRP, U&Es, fasting serum gastrin level
Other:
- Endoscopy (OGD) + biopsy: Ulcerating or exophytic mucosal lesions that may narrow the lumen, Mucosal break of ≥5mm covered with fibrin
- CXR, AXR

Question 6

What is the management for peptic ulcer disease

Answer 6

Lifestyle management i.e. avoid spicy food, alcohol, late meals, big meals, stop smoking

H. pylori +ve: Triple therapy (1x PPI, 2x Abx) for 7 days
- Omeprazole/lansoprazole/pantoprazole (30mins before breakfast and 30mins before the evening meal)
- Clarithromycin/metronidazole + amoxicillin
+ re-test after erradication with C-13 urrea breath test

H. pylori -ve: PPI or H2RA (Ranitidine) 4-8 weeks

Question 7

What is the management for peptic ulcers identified on endoscopy

Answer 7

1. Can inject adrenaline (epinephrine) to actively bleeding ulcers
2. Eradication therapy + 4-8 weeks PPI/H2RA
3. 6-8 weeks Urea breath test and repeat endoscopy
4. Non-healed - exclude:
   - Malignancy
   - Crohn’s
   - Drugs, Zollinger-Ellison syndrome, GIST (gastrointestinal stromal tumours)

Question 8

What are the complications of peptic ulcer disease

Answer 8

Pancreatitis
Haematemesis
SOB and syncope
Massive GI bleed, shock and syncope (Ulcer erodes into wall of blood vessel)
Peritonitis (ulcer perforation → erosion through stomach wall)
Pyloric stenosis/gastric outlet obstruction (Ulcer → inflammation/scarring → blocked outflow → stomach full of gastric acid juice + food → vomiting without pain)
Malignancy

Question 9

What is the prognosis for peptic ulcer disease

Answer 9

<1/3 of children become free of symptoms for a prolonged period of time without recourse to surgery
Nearly half continued with pain treatment despite H2 antagonist management
Low mortality rates in older children