Pediatric Primary Care (86 page)

A.  Erosion or ulceration of gastroduodenal mucosa.

B.  Etiology.

1.  Imbalance between cytotoxic and cytoprotective factors.

a.  Cytotoxic: acid, pepsin, medications, infection.

b.  Cytoprotective: Gastric mucous layer provides mechanical barrier.

2.  Primary PUD: mainly caused by
Helicobacter pylori
infection in adults.

a.  Route of transmission unknown, may be fecal-oral, acquired early in life.

b.  Can cause gastritis positive/negative peptic ulcer, usually in older than 10 years of age.

3.  Secondary PUD: physiologic stress (burns, trauma), medications (NSAIDs, aspirin, corticosteroids), caustic ingestion (including alcohol), viral infections, Zollinger-Ellison syndrome, eosinophilic gastroenteritis (allergic inflammation), Crohn's disease.

C.  Occurrence.

1.
H. pylori.

a.  Increased risk for acquiring infection in developing countries, poor socioeconomic conditions, overcrowding.

b.  Possible ethnic/genetic predisposition: higher rate among Asians, African Americans, Hispanics.

c.  Less common in children, but may acquire infection in childhood that is asymptomatic until later.

d.  Among most common bacterial infections in humans.

D.  Clinical manifestations.

1.  Neonates (up to 1 month): usually present with GI hemorrhage/perforation.

2.  Infants to 2 years: vomiting, irritability, poor growth, GI hemorrhage.

3.  Preschool: periumbilical pain, often postprandial, vomiting, GI hemorrhage.

4.  School age and older: epigastric abdominal pain that may awaken child from sleep. Acute/chronic GI blood loss (hematemesis, hematochezia, melena) may occur along with iron-deficiency anemia.

5.  Family history of PUD.

6.  Difficult to distinguish from other GI disorders such as GERD.

7.  Obtain full diet and medication history.

8.  Location, frequency, quality, duration, timing of pain. Does it wake child from sleep?

9.  Any regurgitation or vomiting? Hematemesis, coffee ground-like emesis?

10.  Frequency, consistency of stools. Any melena or hematochezia?

E.  Physical findings.

1.  Height, weight: Plot on growth curve and compare with previous.

2.  Temperature, vital signs.

3.  Full physical exam with attention to following:

a.  HEENT: Assess for dental caries, enamel erosion.

b.  Abdomen: Assess for tenderness, masses, hepatosplenomegaly.

c.  Rectal: Perform digital exam. Assess for fissures.

F.  Diagnostic tests.

1.  Physical exam: CBC (anemia); comprehensive metabolic panel, amylase, lipase; urinalysis and urine culture.

2.  Test stool for occult blood.

3.  Upper GI series: to assess anatomy in child with vomiting. Little value in diagnosing ulcers or gastritis in children.

4.  
H. pylori
serology: unreliable in children, not recommended.
H. pylori
stool antigen: fairly reliable for diagnosis of current infection.

5.  Endoscopy with biopsies (test of choice) to diagnose
H. pylori
and PUD.

G.  Differential diagnosis.

1.  
H. pylori
infections: reliable diagnosis in children by upper endoscopy.

2.  Secondary PUD:

a.  Medication: history of NSAID, aspirin, corticosteroid use, and others.

b.  Trauma/stress PUD: history of burns, trauma, surgery.

c.  Caustic ingestion/ETOH.

d.  Crohn's disease: History may include growth problems, diarrhea, blood in stool.

H.  Treatment.

1.  
H. pylori:
14 days of amoxicillin and Biaxin (Clarithromycin) and at least 1 month of proton pump inhibitor (e.g., Prevacid [Lansoprazole]).

2.  Secondary PUD.

a.  Discontinue offending medication/caustic substance. If on corticosteroids to treat another disease, may wean or give acid-reducing medicine until therapy complete.

b.  Gastritis/PUD can be treated first with H2 blocker (Zantac [Rantadine], Pepcid [Famotidine]). If no response in 7-14 days, can increase therapy to PPI.

c.  History of upper GI bleed, melena, hematochezia requires referral to tertiary care facility/consultation of MD before therapy.

d.  Treat iron-deficiency anemia.

I.  Follow up.

1.  
H. pylori:
follow-up testing (repeat endoscopy) for patients symptomatic after treatment. Other methods can be unreliable or not approved for children.

2.  Return to clinic 1 month after treatment started for nonspecific/suspected PUD.

3.  Immediate return for any worsening symptoms.

J.  Complications.

1.  
H. pylori
(chronic colonization carries theoretical risk of developing gastric cancer).

2.  Massive GI bleed/perforation.

3.  Chronic iron-deficiency anemia.

K.  Education.

1.  
H. pylori
not common in children, communicability low. Increased risk among household contacts of others with this infection.

2.  Explain that because differentiating between GERD and PUD is difficult, if no response to treatment with acid-reducing medication, possible endoscopy may be necessary.

3.  Employ conservative management for symptoms, such as dietary restrictions.

XIV. PINWORMS (ENTEROBIASIS)

A.  Etiology.

1.  Humans only known hosts for this obligate parasite; ingest embryonated eggs, which hatch in stomach. Larvae migrate to cecum area where mature into adult worms.

2.  Adult worms are about 1 cm in length. Females migrate by night to perianal region to deposit eggs.

3.  Ova mature after approximately 6 hours. Larvae viable for about 20 days.

4.  Eggs carried under fingernails, transmitted directly to another human or deposited in environment (dust, bed clothes) where others come in contact. Autoinfection/reinfection common; highly communicable.

B.  Occurrence.

1.  Highest prevalence in children 5-14 years of age.

2.  Increased incidence in crowded living conditions, among family members of infected patients, in institutions.

C.  Clinical manifestations.

1.  Anal pruritus, especially nocturnal (most likely from female pinworm depositing eggs).

2.  Sleeplessness.

3.  Perianal irritation/erythema may occur (most likely from scratching).

D.  Physical findings.

1.  Child should appear well. Physical exam normal or nonspecific perianal irritation.

E.  Diagnostic tests.

1.  Cellophane tape test.

a.  Adult worms sometimes visualized in evening around anus using flashlight: white, thread-like moving worm.

b.  Essentially diagnostic, specimen rarely required.

F.  Differential diagnosis.

1.  Perianal streptococcal infection: anal erythema, pain. No pruritus.

G.  Treatment.

1.  Vermox: children older than 2 years, adults: 100 mg (chew, crush, swallow). Repeat in 2 weeks.

2.  Consider simultaneous treatment for household contacts (except pregnant women and children younger than 2 years).

H.  Follow up.

1.  As needed, not usually necessary.

2.  Consult with MD for patients younger than 2 years.

I.  Complications.

Perianal irritation, 569.49

1.  Perianal irritation/discomfort; secondary bacterial infection from scratching.