Peptic ulcers are classified as either primary, when they occur in the absence of an underlying systemic disease, or secondary, when they are caused by medications or other diseases. Acute secondary (stress ulcers), which represent the majority of PUD during infancy and early childhood, occur in association with shock, burns, surgery, sepsis, or intracranial hypertension (Cushing's ulcers).62 Chronic PUD secondary to diseases which produce an increase of gastric acid secretion (Table 6.2) are rare at any age.
Since its discovery, many clinical pictures have been attributed to H. pylori infection. Table 6.4 shows the main conditions associated with H. pylori according to evidence-based criteria. By comparison of the results from different studies, it appears that there are two main populations of children with PUD: the first, predominantly constituted by females younger than 8 years of age, usually has a gastric localization of the ulcer,6,7 which is not associated with H. pylori and rarely proceeds to relapse; the second, more similar to the adult PUD, is mainly found in males older than 8-10 years and shows an H. pylori-associated, highly relapsing, bulbar ulcer.
Symptoms depend strictly on the age of the subjects.6,62,63 In infancy and in early childhood, PUD is characterized by vomiting and/or digestive bleeding. Children with ulcer may be referred for abdominal pain and/or vomiting. Epigastric localization, nocturnal pain, and meal or antacid relief of pain, are typical of so-called 'ulcer-like' dyspepsia, and might frequently be reported by older subjects. Hematemesis, weight loss and other alarm signs should alert the physician and strongly suggest further evaluation.62
Table 6.4 Human digestive diseases associated with Helicobacter pylori infection
Acute gastritis Chronic gastritis Duodenal ulcer Gastric ulcer Gastric carcinoma B-Lymphoma (MALToma)
Children with H. pylori-associated gastritis without ulcer are asymptomatic in the majority of cases10 or, rarely, they may suffer from the same dyspeptic symptoms as patients with ulcer. No clinical picture has been found to be specific for H. pylori-associated gastritis.
The clinical picture of recurrent abdominal pain (RAP) was first described over four decades ago by Apley and Naish.64 They found RAP, defined as at least three bouts of abdominal pain, severe enough to affect the child's activity, over a period of not less than 3 months, in 10.8% of 1000 school-age children.64 The etiology, based on patient history and clinical grounds, was attributed to social and familial environment stress rather than to an organic disease. This generic definition served pediatricians for many years, but the development of new techniques (ultrasound, endoscopy, motil-ity probes) and new acquisitions (identification of H. pylori, the role of motility disorders, etc.) ultimately proved that RAP is a description and not a single, homogeneous diagnosis65 (see also Chapter 7).
Is H. pylori gastritis a cause of RAP? In a very large pediatric series, abdominal pain occurred in 90% of 110 cases of duodenal ulceration, and it was the main presenting feature in 88% of them.63 Since 1986, when H. pylori infection was first described in pediatric patients,66 many endoscopic series supported the association between the infection and gastroduodenal pathology in children.67-69 However, abdominal pain was not more frequent in H. pylori-positive than in H. pylori-negative children submitted to endoscopy.70-72 In addition, eradication did not resolve symptoms in all cases,
being very effective only in those rare cases with ulcer.73
Moreover, population-based studies failed to show any association between RAP and H. pylori infection in both school-aged and pre-school-aged populations.10,74,75 Nevertheless, it is evident that discordant results may also be dependent on the heterogeneity of the clinical populations studied (endoscopic series vs. school populations), and the differences in the inclusion criteria (age, duration of the pain, etc.)30
A recent report from the Committee on Childhood Functional Gastrointestinal Disorders76 states that 'it seemed more appropriate to apply the most specific diagnostic category to a symptomatic child', defining clinical criteria of functional dyspepsia as in adults. Gastroenterologists working on adults with upper gastrointestinal symptoms prefer to aggregate more symptoms in the complex picture of ulcer-like and dysmotility-like forms of dyspepsia. Recent studies have shown that a relationship between dyspeptic symptoms and some pathogenic factors (mainly H. pylori infection and motility disturbances) is apparent.77 However, a large intervention study on adults failed to demonstrate that symptoms are dependent on H. pylori infection and, by extrapolation, on gastritis.78 In the eradication trials, the summary odds ratio for improvement in dyspeptic symptoms in patients with non-ulcer dyspepsia in whom H. pylori was eradicated was 1.9 (1.3-2.6).
The presence of severe epigastric pain, associated with nocturnal pain, fasting pain and relief of pain after meal intake, characterizing the picture of ulcer-like dyspepsia in subjects aged over 10 years,10 could be the clinical picture more suggestive of gastroduodenitis, suggesting the need for further evaluation.
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Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.