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Diagnosis and Treatment of Peptic Ulcer Disease in Children

With advances in diagnostic technology, specifically upper gastrointestinal tract endoscopy, peptic ulcer disease in infants and children should no longer be considered rare. Whereas secondary ulcers are usually gastric and are often multiple, primary ulcers occur with almost equal frequency in the duodenum or stomach and tend to be solitary. In spite of intensive scientific investigation, the etiology of peptic ulcer disease remains unclear. Genetic factors appear to play a role and a polygenic mode of inheritance has been proposed. Emotional factors also seem to be important. Children with peptic ulcer disease tend to be of above-average intelligence, are often overachievers who have trouble dealing with frustation, and tend to internalize their feelings. Hydrochloric acid has traditionally been implicated in the pathogenesis of peptic ulcer and most therapies are directed at either "neutralizing" acid or blocking its secretion. Recently, local factors such as gastric mucus, alkaline secretion by the gastric mucosal cells, gastric blood flow, and prostaglandins have been shown to be important in local tissue resistance to acid and to digestive enzymes. The diagnosis of peptic ulcer disease depends on a high index of suspicion. Although pain is the most common symptom, there is no typical or characteristic pattern. Nausea and vomiting may also occur in conjunction with the pain. The finding of occult blood in the stool definitely warrants a diagnostic evaluation. An upper gastrointestinal tract radiographic series with small bowel follow-through should be done first. If this is nondiagnostic in a child with persistent pain or in a child with blood in the stool, upper gastrointestinal tract endoscopy is indicated. When performed by a skilled pediatric gastroenterologist, this procedure can usually be done under local sedation with minimal discomfort, either psychologic or physical, to the patient. Antacids have been the cornerstone of therapy for peptic ulcer disease and are recommended for the patient younger than 3 years of age. Cimetidine, an H2-receptor blocker, although not officially approved for use in children, is recommended for patients 3 to 12 years of age. Ranitidine, another H2 blocker, is useful in patients older than 12 years of age because of its less frequent (twice daily) dosage schedule. Sulcrafate, a coating agent, is an effective alternative to the above for the treatment of duodenal ulcer. Therapy should continue for 6 to 8 weeks. Repeat gastrointestinal series or endoscopy is only necessary if symptoms persist during therapy or return following cessation of therapy. With earlier diagnosis and newer therapeutic modalities, the long range outlook for complete recovery is good.