| disease | Pediatric Peptic Ulcer |
| alias | Stomach Ulcer, Duodenal Ulcer |
Peptic ulcers are uncommon in early childhood and are more frequently seen in adolescence. In recent years, with the widespread clinical use of endoscopy, the incidence rate has shown an increasing trend. Peptic ulcers can occur in children of all age groups, with a higher prevalence in newborns and older children. Gastric ulcers often occur in infants, mostly as stress ulcers, while duodenal ulcers are more common in older children. The average incidence rate of duodenal ulcers in children is about 3 to 5 times higher than that of gastric ulcers. Boys are more affected than girls, with a general statistical ratio of about 2:1. It is reported that 21-50% of adult cases begin in childhood, and 1.6% start before the age of 4.
bubble_chart Etiology
In childhood, acute peptic ulcers are more common than chronic ulcers, and secondary ulcers are more common than primary ones. They often occur secondary to severe hypoxia or severe infections (sepsis, pneumonia, gastroenteritis, meningitis), grade III malnutrition, prolonged use of large doses of adrenal corticosteroids, extensive burns (Curling's ulcer), and neurological injuries (cranial injuries, encephalitis, brain tumors involving the thalamus, especially in the advanced stages of the disease, which can complicate into Rokitansky-Cushing's ulcer). In primary cases, excessive gastric acid secretion is often the main cause. Normal newborns reach peak gastric acid secretion within 48 hours, maintain high levels within the first year, slightly lower from 1 to 4 years, and increase again after 4 years. Psychological factors also play a role, with 85% of cases occurring in older children who are studious and emotionally volatile, often triggered by mental stress or trauma. The role of genetics is still inconclusive, but one-third of cases have a family history, showing autosomal dominant inheritance characteristics. Blood type O is more susceptible. Recently, a spiral bacterium called Helicobacter pylori (abbreviated as CP) has been found in the gastric antrum mucosa of children with peptic ulcers, which may be a cause of the disease. This can be confirmed by silver staining, electron scanning microscopy, and culture, and it also plays an important role in recurrence.
bubble_chart Pathological ChangesNewborn infants often suffer from acute ulcers, with hemorrhagic erosions and small bleeding spots on the mucous membrane, accompanied by epidermal detachment. These ulcers are usually multiple, prone to healing but also prone to perforation, which can penetrate the stomach or duodenal wall and cause peritonitis. Older children are more likely to have chronic ulcers, which are usually single and deeper. Gastric ulcers mostly occur on the anterior wall of the lesser curvature of the stomach near the pylorus, and rarely on the greater curvature. Duodenal ulcers are mostly located on the posterior wall of the first segment of the duodenum. Due to the strong regenerative capacity during childhood, the lesions generally heal relatively quickly.
bubble_chart Clinical Manifestations
It is generally believed that cases over the age of 10 exhibit obvious symptoms, while those under 10 have non-specific clinical manifestations.
Ulcers in newborns and infants are acute, with a rapid onset, making diagnosis difficult. They often present with perforation or bleeding, and are easily masked by primary diseases, usually lacking specific symptoms. Early signs include crying, refusal to eat, followed quickly by vomiting, hematemesis, and hematochezia. Mild cases may resolve quickly, while severe cases can worsen, with the most common complication being perforation, leading to peritonitis symptoms, abdominal pain, significant abdominal distension and fullness, and abdominal muscle rigidity, often accompanied by shock.
The main symptoms in young children are recurrent periumbilical pain, occurring at irregular times, reluctance to eat, often worsening after meals, and easily misdiagnosed. Or, they may present primarily with recurrent vomiting, often accompanied by poor appetite, developmental delays, or weight loss.
The diagnosis of peptic ulcers in children is much more challenging than in adults, primarily due to atypical symptoms. For instance, recurrent epigastric pain and tenderness accompanied by vomiting during fasting may suggest an ulcer. Gastric juice analysis is of limited significance in children, as gastric acid levels do not show significant changes, with only a few cases showing an increase. X-ray examinations can sometimes aid in diagnosis. However, typical ulcer craters are rarely found in children, as the duodenal bulb is deep and fixed, and ulcers are often located on the posterior wall of the bulb, making them difficult to visualize in standard and lateral views. Additionally, ulcers in children are often shallow and small, and they heal easily. Most cases present with increased gastric retention, enhanced gastric peristalsis, pyloric spasm obstruction, poor filling of the duodenal bulb, rough and disordered mucosa, and local tenderness as indirect signs. In infants, an upright abdominal X-ray showing free gas in the abdominal cavity suggests perforation of the stomach or duodenum. Both domestically and internationally, fiberoptic endoscopy has been widely used in children to directly detect ulcers, offering a higher and more reliable diagnostic rate compared to X-ray barium meal examinations, especially for gastric ulcers, where the endoscopic detection rate is 97.5%, compared to only 50% for X-rays. However, endoscopy is contraindicated in cases of suspected perforation. For children with upper gastrointestinal bleeding, emergency endoscopy should be performed as soon as possible within 24 to 48 hours. Most lesions can be identified within a week, with the vast majority caused by duodenal bulb ulcers.
For infants with acute ulcers complicated by bleeding, blood transfusion and close observation are recommended. In cases complicated by perforation, immediate surgical suturing is required. Older children are suitable for conservative medical treatment. For mild cases, dietary methods are adopted, focusing on soft or easily digestible foods, with small, frequent meals, and avoiding acidic and irritating foods. Between meals, mucosal protective agents such as sucralfate (0.5-1.0g each time) or Marzulene (0.3g each time) are given. For those with severe pain, anticholinergic drugs such as belladonna, propantheline, or atropine are taken before meals and at night. For severe cases, H2 receptor blockers with strong antacid effects and fewer side effects, such as cimetidine (6mg/kg each time, twice daily, with a double dose at night) or ranitidine, omeprazole, etc., can be added. The treatment course is 4-6 weeks, with significant efficacy. A maintenance dose is taken once nightly for 6 months to 1 year. The disease is related to Campylobacter, and anti-infective drugs such as gentamicin oral tablets (40,000 units each time, three times daily) should be given for 2-3 weeks. Alternatively, fluoroquinolone drugs can be used. For bleeding symptoms, a small amount of sedative can be given. Generally, fasting is not required as it may cause hunger, anxiety, and increased gastrointestinal motility. Infants should be given a milk diet, and older children should be given soft foods; otherwise, bleeding may worsen. For massive bleeding, hemostatic agents such as hemostatic powder or Yunnan Baiyao can be given orally. Absolute rest and temporary fasting are required, with fluids supplemented parenterally, such as saline and 10% glucose solution, and blood transfusion if necessary. If bleeding persists or recurs multiple times, surgery should be considered. Complications such as pyloric obstruction, frequent episodes unresponsive to medical treatment, or ulcer perforation should be treated surgically. Postoperative growth and development in children are not affected. Chinese medicinals for treating ulcers include Minor Center-Fortifying Decoction, Bupleurum and Cinnamon Twig Decoction, etc., combined with acupuncture, which can often relieve pain. Acupuncture points include Weishu, Zusanli, Neiguan, Qimen, Pishu, Danshu, triple energizer Shu, Zhongwan, etc. For ear acupuncture, points such as stomach, small intestine, and subcortical areas can be used.
Infants often suffer from acute ulcers, frequently presenting with complications such as bleeding and perforation, leading to medical consultation. The incidence rate is approximately 15%, with severity increasing with younger age, particularly being most dangerous during the neonatal period. If perforation occurs, the mortality rate is relatively high. Due to the strong regenerative capacity in children, ulcer conditions generally progress more mildly compared to adults. Many patients can achieve rapid recovery with medical treatment within 3 to 4 weeks. However, about 50% of cases may recur, and approximately 25% can lead to local cicatricial stenosis, causing pyloric obstruction and necessitating surgical intervention.
1. Differential Diagnosis of Hematemesis: Apart from gastric and duodenal ulcers, hematemesis in infancy can be seen in neonatal hemorrhagic disease, scurvy, and hiatal hernia. Hematemesis in childhood can be observed in purpura, hemophilia, grade III anemia, cirrhosis (gastric and esophageal varices), chronic congestive splenomegaly, and splenic vein thrombosis. Sometimes, swallowing foreign objects can cause gastric injury and bleeding, or nasopharyngeal bleeding may be swallowed and then vomited from the stomach.
2. Differential Diagnosis of Hematochezia: Bleeding from gastric and duodenal ulcers is often tarry stool, while red blood stool is seen in cases of massive bleeding. It should mainly be differentiated from intussusception, intestinal duplication malformation, bleeding from distal ileum diverticulum, intestinal tumors, intestinal cold-damage disease, allergic purpura, and other blood diseases.
3. Differential Diagnosis of Abdominal Pain: Abdominal pain similar to that of ulcers can be caused by intestinal spasms, intestinal Chinese Taxillus Herb infestation, biliary spasms, and biliary ascariasis. For those with long-term, regular epigastric pain, a barium meal examination may be considered to assist in diagnosis. A rare hereditary disease, Zollinger-Ellison syndrome, characterized by intermittent abdominal pain, hematemesis, hematochezia, diarrhea, and steatorrhea, with significantly increased gastric acid and the presence of non-beta islet cell tumors, should be differentiated from ulcer disease. Children with this syndrome have extremely high levels of gastrin in their blood, which can aid in diagnosis.
