Peptic Ulcer Disease

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Description

Peptic ulcer disease (PUD), the end result of inflammation caused by an imbalance between cytoprotective and cytotoxic factors in the stomach and duodenum, manifests with varying degrees of gastritis or frank ulceration. 

The pathogenesis of peptic ulcer disease is multifactorial, but the final common pathway for the development of ulcers is the action of acid and pepsin-laden contents of the stomach on the gastric and duodenal mucosa and the inability of mucosal defense mechanisms to allay those effects.

Gastric ulcers are generally located on the lesser curvature of the stomach, and 90% of duodenal ulcers are found in the duodenal bulb.

The common causes of peptic ulcers include H pylori, medication use, and stress-related gastric injury. Less common causes include ingestion of corrosive substances, hypersecretory states (Zollinger-Ellison syndrome), IBD, systemic mastocytosis, chronic renal failure, and hyperparathyroidism.

Signs and Symptoms

• Vary with the age of the patient.
• Hematemesis or melena is reported in up to half of the patients with peptic ulcer disease.
• Epigastric pain and nausea, especially in school going children.
• Dyspepsia, epigastric abdominal pain or fullness is seen in older children.
• Infants and younger children usually present with feeding difficulty, vomiting, crying episodes,
  hematemesis, or melena.
• In the neonatal period, gastric perforation can be the initial presentation.

Investigations

• Esophagogastroduodenoscopy is the method of choice.
• Safely performed in all ages by experienced paediatric gastroenterologists. Endoscopy allows the direct visualization of esophagus, stomach, and duodenum.
• Biopsy specimens may be obtained from the stomach for histopathology, culture or rapid urease testing for H. pylori.
• Endoscopy also provides the opportunity for hemostatic therapy including injection and the use of a heater probe or electrocoagulation if necessary.
• Other investigations include faecal-H. pylori antigen test and urea breath test.

*Blood-H. pylori antigen test and abdominal ultrasound are less informative hence a diagnosis should not be based solely on these.

Treatment

PUD treatment includes eradication of H. pylori and gastric acid suppression using triple therapy comprising of 2 antibiotics and a proton pump inhibitor (PPI). Examples of triple therapy regimens are shown in the table below.

Medication	Dosage	Duration
Omeprazole	1mg/Kg/day in 2 divided doses	1 month
Amoxicillin	50mg/Kg/day in 2 divided doses	14 days
Clarithromycin	15mg/Kg/day in 2 divided doses	14 days
Omeprazole	1mg/Kg/day in 2 divided doses	1 month
Tinidazole	50mg/Kg/day (max 2g)	14 days
Clarithromycin	15mg/Kg/day in 2 divided doses	14 days
Omeprazole	1mg/Kg/day in 2 divided doses	1 month
Metronidazole	20mg/Kg/day in 2 divided doses	14 days
Clarithromycin	15mg/Kg/day in 2 divided doses	14 days