Acid peptic disease (APD) , a conditions characterized by the overproduction of gastric acid, leading to injury and inflammation of the gastrointestinal tract. Common APDs in children include gastroesophageal reflux disease (GERD), gastritis, and peptic ulcer disease (PUD).
History and examination
| Symptoms | Signs |
| Pain abdomen (Epigastric or periumbilical region) Nausea and vomiting Early satiety Passage of loose stool (foul smelling, semi digested) Poor appetite | Pallor Tenderness over epigastric or periumbilical region Failure of growth (in chronic cases) |
Differential diagnosis (D/D) & Complication
D/D:
- Functional Abdominal pain (chronic abdominal without any obvious cause; common in school going children due to stress and anxiety)
- Mesentric adenitis
- Urinary Tract infection (Fever, crying during micturation, itching over genital region)
- Constipation
- Pancreatitis (severe upper abdominal pain, elevated serum amylase and lipase levels)
- Gastroenteritis (Diarrhea, fever, acute onset)
Complications:
- Anemia
- Malnutrition
- Esophagitis
- Stricture formation
- Perforation
- Gastric outlet obstruction
Investigation
- CBC (To rule out anemia if pallor present)
- USG abdomen and pelvis to rule out mesenteric adenitis
- LFT, Serum amylase and lipase (To rule out pancreatitis)
- Fecal Occult Blood Test if baby is anemic
- URME if UTI is supected
- Helicobacter pylori test
- Upper GI endoscopy (to visualize the esophagus, stomach, and duodenum) (Criteria for endoscopy)
When to send H. Pylori Test?
- Persistent symptoms such as epigastric pain, nocturnal pain, postprandial,water brash, vomiting, weight loss, fecal occult blood, and hematemesis.
- Family history of peptic ulcer disease
- Refractory Iron Deficiency Anemia
- Tests:
| Stool Antigen Test | High sensitivity and specificity | Recommended for diagnosis and confirmation of eradication |
| Urea Breath Test | High sensitivity and specificity | Recommended for diagnosis |
| Serology | Low sensitivity and specificity | Not recommended |
Criteria for doing Endoscopy in children with APD
- Family history of peptic ulcer disease
- History of H. Pylori infection
- Age >10 years
- Symptom persisting more than 6 months and severe enough to affect daily acitivities
- Upper gastrointestinal bleeding
Admission criteria
- Admission may be necessary for severe pain, significant weight loss, dehydration, complications (e.g., perforation, obstruction), or failure of outpatient management
Management
Medical
Rx:
- Syp or Tab Ranitidine PO BD x 7 days
- Syp Antacid PO TDS x 7 days
- Prokinetic agents (e.g., Metoclopramide or Domperidone ) for GERD-associated delayed gastric emptying (only when GERD features present)
- Antibiotics for Helicobacter pylori eradication
- Deworming if it is not done
Note:
- Proton Pump Inhibitors (PPIs) can be used in children when other treatment is not available or not suitable. It is safe to use H2 receptor blocker as PPIs have been associated with increased risks of gastrointestinal and respiratory tract infection, vitamin B12 deficiency, hypomagnesemia, bone fractures, and rebound hyperacidity after discontinuation. Also, PPIs can increase the risk of long-term kidney damage.
- Triple Therapy for H. Pylori Treatment for 10-14 Days.
Triple Therapy
| Body Weight (kg) | PPI Dose (mg) | AMOXICILLIN Dose (mg) | High Dose AMOXICILLIN (mg) | CLARITHROMYCIN Dose (mg) | METRONDIAZOLE Dose (mg) |
|---|---|---|---|---|---|
| 15–24 | 20/20 | 500/500 | 750/750 | 250/250 | 250/250 |
| 25–34 | 30/30 | 750/750 | 1000/1000 | 500/250 | 500/250 or 375/375 |
| >35 | 40/40 | 1000/1000 | 1500/1500 | 500/500 | 500/500 |
* PPI s ( Omeprazole, Lansoprazole, Pantoprazole) or Use Ranitidine
* Use Metronidazole in case of penicillin allergy
* If symptom did not improve use Quadurple or Sequential Therapy of H. Pylori eradication
Lifestyle modifications
- Small, frequent meals
- Avoidance of spicy, fatty, or acidic foods
- Elevation of the head of the bed (for GERD)
- Avoidance of lying down or sleeping within 2-3 hours after eating
- Drink plenty of water
Referral
- Refer to a pediatric gastroenterologist for further evaluation and management of persistent or recurrent APD
Follow up
- Follow up within 2 weeks after initiation of treatment to assess response
- Long-term follow-up for patients with chronic APD or complications