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The Turkish Journal of Gastroenterology
2012, Volume 23, No 6, Pages 666-669
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Peptic ulcer disease in children: An uncommon disorder with subtle symptomatology
Çiğdem Ömür ECEVİT, Funda ÖZGENÇ, Hasan Ali YÜKSEKKAYA, Fatih ÜNAL, Çiğdem ARIKAN, Raflit Vural YAĞCI
Department of Pediatric Gastroenterology, Ege University School of Medicine, İzmir
Keywords: Peptic ulcer, children, endoscopy, Peptik ülser, çocuk, endoskop.
Summary
Background/aims:Data concerning peptic and infectious ulcers in children are limited. The aim of the study was to investigate the prevalence, presenting symptoms and significance of symptomatology in ulcer diagnosis in the pediatric age group. Materials and Methods: Between January 2000 and 2009, upper gastrointestinal endoscopy charts were examined retrospectively. All children in whom a diagnosis of ulcer was established were included in the study. Demographic, clinical, endoscopic, and histopathologic data were obtained from the patients’ records. Peptic ulcer disease prevalence, presenting symptoms and symptomatology were evaluated. Results:Ulcer disease was observed in 31 (3.4%) of 902 patients. The mean age was 10.85±4.25 (range: 2-17 years), and the male to female ratio was 2:1. The most common symptom was chronic abdominal pain (68%), hematemesis and melena (55%) and vomiting (39%). Helicobacter pylori was identified in 19 patients (61%) with ulcer. In the Helicobacter pylori-positive group, upper intestinal bleeding and pain were the major symptoms. Symptom frequency was not different between Helicobacter pylori-positive and -negative patients (p>0.05). Conclusions: Ulcer disease is an uncommon disorder in children with nonspecific clinical symptoms. Unlike the adult population, symptoms fail to diagnose peptic ulcer disease before gastrointestinal bleeding occurs
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  • Materials And Methods
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  • Introduction
    Peptic ulcer disease (PUD) is an uncommon entity in children. However, with the use of endoscopy, the diagnosis of pediatric PUD has been reported more frequently (1). In one study, the diagnosis of PUD increased three-fold after the introduction of endoscopy (2). Helicobacter pylori (H. pylori)has been identified as the primary etiologic agent of PUD in children, whereas PUD due to H. pyloriinfection occurs at a rate of approximately 3-25% of infected patients (3). Despite the new diagnostic tools, studies are difficult to perform due to the low prevalence of the disease. In this study, we aimed to investigate retrospectively the prevalence, presenting symptoms and significance of symptomatology in ulcer diagnosis in the pediatric age group.
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  • Materials And Methods
  • Results
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  • Materials And Methods

    In this study, a total of 902 cases aged 2-17 years who underwent upper gastrointestinal endoscopy over a period of nine years between January 2000 and January 2009 were evaluated retrospectively. These children were admitted to the Pediatric Gastroenterology, Hepatology and Nutrition Department of Ege University. Data retrieved from the records included age, gender, clinical presentation, endoscopy, H. pyloristatus, and histopathology reports.

    Peptic ulcer disease (PUD) was defined as the presence of a clear-cut ulcer in both the stomach and duodenum. Ulcer was defined as a >5 mm mucosal
    break. A standard forward-viewing 9 mm endoscope was used in the xamination. Children were examined under sedation using intravenous midazolam while lying in the left lateral position. In older patients, pharyngeal anesthesia with lidocaine spray was used.

    Biopsies were taken for routine histology and identification of H. pylori. Every patient who underwent upper endoscopy had at least two duodenal,
    three antral and two esophageal biopsies that were stained with hematoxylin and eosin and Giemsa
    stains. Children were considered H. pylori-infected
    if histology was positive. Informed consent was obtained from the patients’ parents in all cases.

    The Statistical Package for the Social Sciences (SPSS) 15.0 was used for the statistical analysis. Group parametric (mean) comparisons were tested by the  chi-squared or two sample ttest. Values of p<0.05 were considered as significant

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  • Materials And Methods
  • Results
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  • Results
    From 1 January 2000 to 1 January 2009, a total of 31 children (3.4%) of 902 presented with upper gastrointestinal symptoms, and primary peptic ulcers were diagnosed. Ages ranged from 2 to 17 years, with a mean age of 10.85±4.25 years. There were 21 boys and 10 girls (2/1). Twenty-two gastric and 9 duodenal ulcers were diagnosed. The median age of children with duodenal ulcer was 11.1±4.4 and with gastric ulcer was 10.1±3.8. Three patients (9.7%) were under 4 years of age. Since it is not very reliable to express abdominal pain in younger cases, recurrent abdominal pain was evaluated in patients older than 4 years of age according to the Rome III criteria obtained by parents’ review. The major presentation was gastrointestinal chronic abdominal pain in 21/31 (68%) of the children followed by bleeding and vomiting. No significant difference was found regarding clinical manifestations between children with ulcer and non-ulcer disease (Table 1). Helicobacter infestation was identified in 19 of 31 gastric biopsies performed in children with PUD. Twenty-two had gastric ulcers (70%); 14 were H. pylori-positive, and 8 (37%) were H. pylori-negative. Nine had duodenal ulcers (30%); 5 (55%) were H. pylori-positive and 4 were H. pylori-negative. The H. pylori-positive children were younger than the H. pylori-negative children (p=0.08) (Table 2). The most common histological finding in the H. pylori-positive group was gastritis and in the H. pylori-negative group was esophagitis (Figures 1, 2).
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  • Discussion
    The prevalence of PUD is very low, such that it is not possible to comment regarding the frequency of the disease in the pediatric age group. There are only a few studies regarding primary PUD. Roma et al. (4) found PUD in 2% of children. In different studies, the ratios were 5.3% and 5% (5,6). In our study, peptic ulcer was diagnosed in 3.4% of children who underwent upper gastrointestinal endoscopy for various reasons, and these data support the fact that PUD is very rare in the pediatric population as well as the male dominancy in this disease (9). The clinical presentations of PUD differ in children and adults. In the adult population, complications such as bleeding and perforation are the major symptoms, whereas in children, chronic abdominal pain is the usual presentation (10). Nord et al. (7) and El Mouzan et al. (6) found that chronic abdominal pain was the commonest presentation. In our study, abdominal pain, followed by bleeding and vomiting, was the major symptom in both the ulcer and non-ulcer groups. The difference between the two groups was not significant (p>0.05). We therefore may suggest that the presenting feature is not specific for ulcer disease. Peptic ulcers can be classified as primary or secondary. In children, primary peptic ulcers are usually duodenal, while secondary peptic ulcers are gastric (11). Roma et al. (4) reported their experience of 42 duodenal ulcers in 52 children with PUD. Kato et al. (12) found higher numbers of duodenal ulcers than gastric ulcers. Interestingly, we found more gastric ulcers than duodenal ulcers in our series. Egbaria et al.’s (8) results were similar to ours. The reasons for this difference is unclear but may be related to differences in the ethnic background of the population. H. pyloriinfection is the commonest cause of the PUD in children (15). A strong association between H. pyloriinfection and PUD has been reported in many studies (13,14). In a meta-analysis, the prevalence of H. pyloriinfection in children with duodenal ulcer was reported as 92% (range: 30-100) (16). In our study, more than half of the children were infected with H. pyloriin both the gastric ulcer and duodenal ulcer group. In H. pylori-infected children, gastritis is the major histological finding. In H. pylori-negative children, duodenitis and esophagitis were found more commonly. In this study, H. pylorigastritis was present in 18 patients (95%). This result was similar to other studies (17,18). In conclusion, PUD is an uncommon disorder in childhood. Children with ulcer may have more atypical symptoms compared to adults. PUD occurs more commonly in boys and is associated with H. pyloriantral gastritis. Therefore, an efficient antibacterial eradication regimen will improve the response to treatment and reduce the recurrences.
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  • References
    1. Goggin N, Rowland M, Imrie C, et al. Effect of Helicobacter pylorieradication on the natural history of duodenal ulcer disease. Arch Dis Child 1998; 79: 502-5. 2. Tam PKH, Saing H, Lau TK. Diagnosis of peptic ulcer in children: the past and the present. J Pediatr Surg 1986; 21: 15-6. 3. Suerbaum S, Michetti P. Helicobacter pyloriinfection. N Engl J Med 2002; 347: 1175-86. 4. Roma E, Kafritsa Y, Panayiotou J, et al. Is peptic ulcer a common cause of upper gastrointestinal symptoms? Eur J Pediatr 2001; 160: 497-500. 5. Mitchell HM, Bohane TD, Tobias V, et al. Helicobacter pyloriinfection in children: potential clues to pathogenesis. J Pediatr Gastroenterol Nutr 1993; 16: 120-5. 6. El Mouzan MI, Abdullah AM. Peptic ulcer disease in children and adolescents. J Trop Pediatr 2004; 50: 328-30. 7. Nord KS. Peptic ulcer disease in the pediatric population. Pediatr Clin North Am 1988; 35: 117-40. 8. Egbaria R, Levine A, Tamir A, Shaoul R. Peptic ulcers and erosions are common in Israeli children undergoing upper endoscopy. Helicobacter 2008; 13: 62-8. 9. Chan KL, Tam PK, Saing H. Long-term follow-up of childhood duodenal ulcers. J Pediatr Surg 1997; 32: 1609-11. 10. Chiang B, Chang M, Lin M, et al. Chronic duodenal ulcer in children: clinical observation and response to treatment. J Pediatr Gastroenterol Nutr 1989; 8: 161-5. 11. Dohil R, Hassall E. Peptic ulcer disease in children. Baillieres Best Pract Res Clin Gastroenterol 2000; 14: 53-73. 12. Kato S, Nishino Y, Ozawa K, et al. The prevalence of Helicobacter pyloriin Japanese children with gastritis or peptic ulcer disease. J Gastroenterol 2004; 39: 734-8. 13. Yeung CK, Yuen KY, Fu KH, et al. Rapid endoscopy room diagnosis of Campylobacter pyloriassociated gastritis in children. J Pediatr Gastroenterol Nutr 1990; 10: 357-60. 14. Wong BPY, Chao NSY, Leung MWY, et al. Complications of peptic ulcer disease in children and adolescents: minimally invasive treatments offer feasible surgical options. J Pediatr Surg 2006; 41: 2073-5. 15. Rowland M, Rumm B. Helicobacter pyloriinfection and peptic ulcer disease in children. Curr Opin Pediatr 1995; 7: 553-9. 16. Macarthur C, Saunders N, Feldman W. Helicobacter pylori,gastroduodenal disease, and recurrent abdominal pain in children. JAMA 1995; 273: 729-34. 17. Blecker U, Gold BD. Gastritis and peptic ulcer disease in childhood. Eur J Pediatr 1999; 158: 541-6. 18. Sherman PM. Peptic ulcer disease in children. Diagnosis, treatment, and the implication of Helicobacter pylori.Gastroenterol Clin North Am 1994; 23: 707-25.
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  • Introduction
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  • Results
  • Discussion
  • References
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