Treatment of Campylobacter pylori-associated antral gastritis in children with bismuth subsalicylate and ampicillin

Changes in the Treatment Strategies for Helicobacter pylori Infection in Children and Adolescents in Korea

The policies developed for the treatment of Helicobacter pylori infection in adults may not be the most suitable ones to treat children and adolescents. Methods used to treat children and adolescents in Europe and North America may not be appropriate for treating children and adolescents in Korea due to differences in epidemiological characteristics of H. pylori between regions. Moreover, the agreed standard guidelines for the treatment of H. pylori infection in children and adolescents in Korea have not been established yet. In this study, the optimal treatment strategy for H. pylori infection control in children and adolescents in Korea is discussed based on these guidelines, and recent progress on the use and misuse of antimicrobial agents is elaborated. Non-invasive as well as invasive diagnostic test and treatment strategy for H. pylori infection are not recommendable in children aged less than ten years or children with body weight under 35 kg, except in cases of clinically suspected or endoscopically identified peptic ulcers. The uncertainty, whether enough antimicrobial concentrations to eradicate H. pylori can be maintained when administered according to body weight-based dosing, and the costs and adverse effects outweighing the anticipated benefits of treatment make it difficult to decide to eradicate H. pylori in a positive non-invasive diagnostic test in this age group. However, adolescents over ten years of age or with a bodyweight of more than 35 kg can be managed aggressively as adults, because they can tolerate the adult doses of anti-H. pylori therapy. In adolescents, the prevention of future peptic ulcers and gastric cancers is expected after the eradication of H. pylori. Bismuth-based quadruple therapy (bismuth-proton pump inhibitor-amoxicillin/tetracycline-metronidazole) with maximal tolerable doses and optimal dose intervals of 14 days is recommended, because in Korea, the antibiotic susceptibility test for H. pylori is not performed at the initial diagnostic evaluation. If the first-line treatment fails, concomitant therapy plus bismuth can be attempted for 14 days as an empirical rescue therapy. Finally, the salvage therapy, if needed, must be administered after the H. pylori antibiotic susceptibility test.

Helicobacter pylori antimicrobial resistance in a pediatric population

BACKGROUND

The increasing prevalence of Helicobacter pylori (H. pylori) antimicrobial resistance, primarily for clarithromycin decreases the success of treatment. The aim of this study is to determine the local pattern of first-line antimicrobials resistance and the eradication rate.

MATERIAL AND METHODS

Prospective cohort study of H. pylori infected patients (positive histological or cultural exams) treated at Centro Materno-Infantil do Norte from January of 2013 to October of 2017. Susceptibility to 4 antibiotics: amoxicilin, metronidazole, clarithromycin, and levofloxacin were analyzed by E-test (phenotypic resistance). The E-test was chosen because it is simple and cost-effective for routine susceptibility testing. Point mutations that confer clarithromycin resistance were surveyed (genotypic resistance). Eradication of H. pylori infection was defined by a negative urea breath test or fecal antigen 6-8 weeks after the end of treatment.

RESULTS

Of a total of 74 H. pylori infected patients, 16 were excluded because they had previous H. pylori treatment or severe systemic disease. Median age of infection cases was 15 years (3-17 years). Eradication regimen used in all patients combined the use of 3 antibiotics (amoxicillin and metronidazole or clarithromycin) and proton pump inibhitor for 14 days and was tailored according antimicrobial susceptibility. 79.5% of the patients completed the treatment. The resistance rate for metronidazole and clarithromycin was 3.3% and 23.3%, respectively. There was no resistance for amoxicilin and levofloxacin. The rate of genotypic resistance to clarithromycin was 37.2%. The eradication rate was 97.8%.

CONCLUSIONS

The authors found a high resistance rate of H. pylori for clarithromycin in this northern portuguese pediatric center. This factor should determine a change in local current treatment, contraindicating the use of clarithromycin as a first-line treatment for H. pylori infection in children. The high eradication rate maybe explained for the eradication treatment tailored according antimicrobial susceptibility.

What do we know about benefits of H. pylori treatment in childhood?

Policy analysis shows that H. pylori test and treat strategies targeting adults at moderate to high risk of H. pylori-induced disease is likely to be cost-effective for preventing digestive diseases responsible for a large global disease burden. Little is known, however, about health benefits to children from eliminating this infection. We conducted a systematic review of the evidence regarding health benefits to children from treatment to eliminate H. pylori infection.   We systematically searched Ovid MEDLINE for pertinent review articles published through 2012. We excluded reviews focused on treatment efficacy and scrutinized reference lists of selected reviews to identify additional eligible reviews. Fifteen reviews met specified inclusion criteria. Overall, they show that few reported studies investigating pediatric health effects of treatment for H. pylori infection were well designed with adequate statistical power. Thus, there is insufficient evidence for drawing conclusions about health benefits to children from treatment to eliminate H. pylori infection.

Review article: bismuth-based therapy for Helicobacter pylori eradication in children

BACKGROUND

Because of the decrease in the Helicobacter pylori eradication rate after standard triple therapy with a proton pump inhibitor and two antibiotics, bismuth-based therapy has recently been recommended as alternate first-line regimen in children.

AIM

To comprehensively review the clinical, pharmacologic and microbiologic properties of bismuth salts, and to summarise the evidence for the therapeutic efficacy of bismuth-based therapy for H. pylori eradication in children.

METHODS

Bibliographical searches were performed in MEDLINE. Results on the efficacy of bismuth-containing regimens on H. pylori eradication were combined using the inverse variance method.

RESULTS

Bismuth monotherapy showed a very low efficacy. Overall, the mean eradication rate with bismuth-based dual therapy was 68% (95% CI, 60-76%) (intention-to-treat analysis-ITT) and 73% (95% CI, 64-81%) (per protocol-PP). In case series, the overall percentages of children with successful eradication for triple therapy containing bismuth were 82% (95% CI, 76-88%) and 86% (95% CI, 80-92%) according to ITT and PP respectively. In comparative studies, H. pylori eradication rates ranged between 69% and 85% according to ITT and between 74% and 96% PP. Side effects included dark stools, urine discoloration, black tongue, burning tongue, and marked darkness of the gums.

CONCLUSIONS

The evidence in favour of bismuth compounds for treating infected children is still not clear. Well-designed, randomised, multi-centre studies of H. pylori eradication trials in children comparing bismuth-based triple therapy with the best available recommended first-line therapies are needed. The evidence obtained from audited case series that produce an eradication rate of >95% on PP analysis should also be considered.

In French children, primary gastritis is more frequent than Helicobacter pylori gastritis

The aim of this study was to analyze the histological characteristics according to the updated Sydney classification (intensity of gastritis, degree of activity, gastric atrophy, intestinal metaplasia, and Helicobacter pylori) in symptomatic children referred for upper gastrointestinal endoscopy. A 4-year retrospective descriptive study was carried out in 619 children (282 females and 337 males), median age 3.75 years (15 days to 17.3 years) referred for endoscopy. Six gastric biopsies were done (three antrum and three corpus) for histological analysis (n = 4), direct examination and H. pylori culture (n = 2). H. pylori status was considered positive if at least two out of three tests were positive and negative if all three tests were negative. The results showed that only 66 children (10.66%) were H. pylori positive. Histological antral and corpus gastritis was detected in, respectively, 53.95% and 59.12% of all cases, most of them of mild grade 1. Antral and corpus activity was grade 1 in 18.57% and 20.03% of cases. H. pylori-positive versus H. pylori-negative children did differ in terms of moderate and marked histological gastritis and grade 2 or 3 activities. One girl had moderate gastric atrophy and another one moderate intestinal metaplasia, both being H. pylori negative. The findings indicate that primary antrum and corpus gastritis is 5.3 and 6.9 times, respectively, more frequent than H. pylori gastritis in French children, with usually mild histological gastritis and activity. Gastric atrophy and intestinal metaplasia are rare.

Meta-analysis: Helicobacter pylori eradication treatment efficacy in children

BACKGROUND

Several meta-analyses assessing the efficacy of anti-Helicobacter pylori treatment in adults have been published but a comparable meta-analysis in children is lacking.

AIMS

To summarize the efficacy of treatments aimed at eradicating H. pylori in children and to identify sources of variation in treatment efficacy across studies.

METHODS

We searched Medline, reference lists from published study reports, and conference proceedings for anti-H. pylori treatment trials in children. Weighted meta-regression models were used to find sources of variation in efficacy.

RESULTS

Eighty studies (127 treatment arms) with 4436 children were included. Overall, methodological quality of these studies was poor with small sample sizes and few randomized-controlled trials. The efficacy of therapies varied across treatment arms, treatment duration, method of post-treatment assessment and geographic location. Among the regimens tested, 2-6 weeks of nitroimidazole and amoxicillin, 1-2 weeks of clarithromycin, amoxicillin and a proton pump inhibitor, and 2 weeks of a macrolide, a nitroimidazole and a proton pump inhibitor or bismuth, amoxicillin and metronidazole were the most efficacious in developed countries.

CONCLUSIONS

Before worldwide treatment recommendations are given for eradication of H. pylori, additional well-designed randomized placebo-controlled paediatric trials are needed, especially in developing countries where both drug resistance and disease burden is high.

The Nobel Prize in 2005 for the discovery of Helicobacter pylori: implications for child health

The Nobel Prize in Physiology or Medicine in 2005 has been awarded to B. Marshall and R. Warren for their discovery that peptic ulcer disease is caused by an infection with Helicobacter pylori. This infection, which affects about half of the world's population and is already extremely prevalent in adolescents in developing countries, starts as an asymptomatic gastritis which, under certain conditions, is followed by gastric or duodenal ulcer disease.

CONCLUSION

No proven benefit has yet been found by treating H. pylori-infected children with gastritis unless they have a peptic ulcer. Vaccination against H. pylori infection during early childhood is considered a means of preventing peptic ulcer disease and also possibly adenocarcinoma.

Helicobacter pylori infection and recurrent abdominal pain in Turkish children

BACKGROUND

Helicobacter pylori infection is primarily acquired in childhood. However, the association between H. pylori infection and recurrent abdominal pain (RAP) remains unclear.

MATERIALS AND METHODS

One hundred and forty-one children with and 21 without RAP underwent upper gastrointestinal endoscopy. At least five antral gastric biopsies were obtained from each patient and the presence of H. pylori infection was accepted when at least two out of four tests (histology, direct antral smear, culture, and rapid urease test) were positive. Patients with H. pylori infection underwent triple therapy with omeprazole, clarithromycin, and metronidazole.

RESULTS

Eighty-five out of 141 (60.3%) patients with RAP were H. pylori positive whereas 5 out of 21 (20.8%) patients without RAP were (p =.0037). Symptoms were disappeared in 87% of children whose H. pylori infection was eradicated compared with 41% of those in whom the infection was not eradicated (p =.0035).

CONCLUSIONS

It was concluded that children with RAP and H. pylori infection appear to benefit from eradication therapy in Turkey.

A systematic review of Helicobacter pylori eradication treatment schedules in children

METHODS

We systematically reviewed all available data in the paediatric literature on treatment for Helicobacter pylori infection to determine overall efficacy of different schedules. A comprehensive search of all published articles and letters from 1987, and of abstracts presented at three main meetings on this topic between 1997 and 1999, was carried out. Results from all English and French papers, letters and abstracts were extracted and analysed.

RESULTS

Only 30 full articles and 16 abstracts were found, with results on eradication of H. pylori in 870 and 1552 children, respectively. Monotherapy or dual therapy with an antisecretory drug plus one antibiotic showed a very low efficacy. Dual therapies with bismuth plus one antibiotic (either amoxycillin or a nitro- imidazole) or two antibiotics when administered for 2 or more weeks were as effective as either bismuth-based or proton pump inhibitor-based triple therapies. Triple therapies were less effective than in adults, and while bismuth-based triple therapies were more effective when given for 2 weeks than for one week, proton pump inhibitor-based triple therapies have a similar efficacy irrespective of the duration.

CONCLUSION

In children dual therapies seemed as effective as triple therapies, and longer courses of proton pump inhibitor-base triple therapies are not better than shorter ones.

Helicobacter pylori infection and eradication in paediatric patients

Helicobacter pylori is now recognised to be typically acquired during childhood. Studies also indicate that the infection is frequently lost in childhood; however, it is still unclear whether this is related to the use of antibacterials, the natural history of the infection, or both. H. pylori colonises gastric mucosa and is causally related to chronic gastritis and peptic ulcer disease in both children and adults. Successful eradication of H. pylori has resulted in the healing of duodenal ulcers and the lowering of the ulcer relapse rate in children. Therapy to cure the infection should be started in all children with peptic (duodenal or gastric) ulcer who are still infected. The ideal anti-H. pylori regimen should be safe, cheap, easy to comply with, well tolerated by children and able to achieve a high cure rate. Although US data are lacking, it is anticipated that the treatment regimen for children should be similar to that in adults (a triple therapy regimen that combines a proton pump inhibitor with 2 antimicrobial agents for 14 days). It is inappropriate to prescribe anti-H. pylori therapy without a firm diagnosis. The use of multiple antibacterials in a paediatric patient with an ulcer but without H. pylori infection cannot provide any benefit to the patient or the community. Such an approach only provides the possibility for adverse effects, for example development of antibacterial resistance among bystander bacteria. It is very important to confirm the diagnosis of H. pylori infection. The [13C]urea breath test is the noninvasive method of choice to determine H. pylori status in children and the ideal test for post-therapy testing. There is a need for post-therapy confirmation because of the likelihood of poor outcome for some treatment regimens, which is why post-therapy testing should be the standard of care. There is weak and inconsistent evidence of an association between H. pylori infection and recurrent abdominal pain (RAP) in children, in part because of the unclear definition of RAP in the literature. Therefore, there is still considerable debate regarding the treatment of infected children with RAP.

Helicobacter pylori eradication in patients with non-ulcer dyspepsia

Epidemiological and pathophysiological studies, as well as clinical trials, attempting to identify a relationship between Helicobacter pylori infection and non-ulcer dyspepsia (NUD), or a subset of NUD, have produced inconsistent and confusing results. While it is possible that H. pylori eradication may be beneficial for symptom relief in a small proportion of patients, routine H. pylori testing and treatment in documented NUD is not currently widely accepted. Despite the lack of convincing evidence, the European Helicobacter pylori Study Group, an Asian Pacific Consensus Meeting, the American Digestive Health Foundation and the American Gastroenterology Association have all recommended considering H. pylori eradication in patients with NUD on a patient-by-patient basis. Recently, large prospective, randomised, double-blind, controlled clinical trials applying highly effective antimicrobial therapy have been conducted with 12 months follow-up. Although these well-designed studies have reached differing conclusions, the results have been largely negative. H. pylori eradication therapy in NUD will fail to relieve symptoms in most patients in the long term.

Dual versus triple therapy of Helicobacter pylori infection: results of a multicentre trial

OBJECTIVE

To compare dual therapy (omeprazole and amoxicillin) with triple therapy (omeprazole, amoxicillin, and clarithromycin) in the treatment of Helicobacter pylori infection. The efficacy of 1 mg/kg/day omeprazole was randomly compared with 2 mg/kg/day.

STUDY DESIGN

252 patients (median age, 11.0 years; range, 3-18) presenting with chronic abdominal pain underwent endoscopy and a 13C-urea breath test. Gastric biopsy specimens were taken for histological examination and for the rapid urease test. Patients were treated for two weeks: group A (n = 63) received amoxicillin (50 mg/kg; maximum, 2 g/day), group B (n = 73) received amoxicillin and clarithromycin (20 mg/kg; maximum, 1 g/day). Both groups were randomly treated with either 1 or 2 mg/kg omeprazole (maximum, 80 mg/day). Diagnostic procedures were repeated four weeks after the end of treatment.

RESULTS

11 patients were excluded; 136 patients were H pylori positive (56%), 105 of whom were re-examined after treatment. Helicobacter pylori was eradicated in 52% of group A and 83% of group B. The dose of omeprazole had no influence on the eradication rate. Specificity and sensitivity of the rapid urease test were 94% and 93%, respectively. Specificity and sensitivity of the 13C-urea breath test were 93% and 95%, respectively.

CONCLUSIONS

Dual therapy can no longer be recommended. Triple therapy is more effective than dual therapy in the eradication of H pylori infection. The lower dose of 1 mg/kg omeprazole was as effective as 2 mg/kg.

Helicobacter pylori gastritis in children: efficacy of 2 weeks of treatment with clarithromycin, amoxicillin and omeprazole

Thirty-eight children with Helicobacter pylori gastritis diagnosed by histopathology, and/or bacteriological culture were treated with omeprazole, amoxicillin and clarithromycin. Follow-up endoscopy was performed in 34 children. Outcome was measured by negative histology and culture for H. pylori. Six patients were excluded. Of the 32 remaining children eradication was achieved in 75% (95% confidence interval 60-90%).

Dyspepsia in infants and children

Pathological processes and diseases of the upper gastrointestinal tract have become increasingly recognized over recent years as childhood entities responsible for a variety of upper gastrointestinal symptoms previously labelled as functional or non-organic. The term 'dyspepsia' is an adult one whose definition requires clarification before use in the paediatric context, but it encompasses age-dependent symptoms such as feed-associated irritability in the infant, peri-umbilical pain in the younger child, and heart-burn, nausea, and indigestion in the older child as in adults. The possible organic conditions giving rise to such symptoms are multiple and multiorgan and include: gastro-oesophageal reflux; peptic ulcer disease; upper gastrointestinal Crohn's disease; antroduodenal motility disorders; pancreatitis; cholecystitis; cholelithiasis; biliary dyskinesia; and abdominal migraine. However, Munchausen syndrome by proxy must not be forgotten. Non-ulcer dyspepsia, it is now clear, has a basis in altered gastroduodenal motility and may be amenable to propulsion agents. In many individuals the dyspeptic symptoms of recurrent abdominal pain may be altered by psychotherapeutic intervention. Indeed there remains a proportion of children who undoubtedly have a behavioural or psychological base to their complaint. Nevertheless, with the recent increase in diagnostic yield from improved technical investigative aids available to paediatrics in the last 5-10 years, it is clear that the responsibility of the paediatrician to the child to find a cause of their symptoms is paramount. The variety of presenting features, possible causes of these symptoms, and appropriate investigation and treatment will be discussed, and management algorithms based on published literature and personal practice will be offered.

One-week triple therapy with omeprazole, clarithromycin, and nitroimidazole for Helicobacter pylori infection in children and adolescents

BACKGROUND

Resolution of Helicobacter pylori infection is important in the management of peptic ulcer disease and reduces peptic ulcer recurrence in both adults and children. Various anti-H pylori treatment regimens have been proposed, reflecting the incomplete clinical success of each. A combination of omeprazole, clarithromycin, and tinidazole, given for 1 week, has been shown to be highly tolerable and effective, achieving a success rate of >90% in the adult population.

OBJECTIVE

The aim of this study was to evaluate this short-term regimen in pediatric and adolescent populations.

METHODS

The study group consisted of 35 children referred for evaluation of dyspeptic symptoms. They all underwent upper gastrointestinal endoscopy, in which H pylori infection was confirmed by rapid urease test and/or histologic staining. They were given omeprazole (20 mg twice daily), clarithromycin (250 mg twice daily), and tinidazole or metronidazole (500 mg twice daily) for 1 week. The patients were divided into two groups: those who received the first course of anti-H pylori therapy during this study (group 1) and those who had previously received standard metronidazole and bismuth combination therapies that failed to eradicate H pylori (group 2). Therapeutic efficacy was assessed by a 13C-urea breath test performed 4 weeks after completion of treatment. Results. The 35 study patients had a mean age of 15.9 years (range, 10 to 19) and included 19 males and 16 females, of whom 22 were born in Israel and 13 were immigrants from the former USSR. There were 27 patients (77. 1%) in group 1 and 8 patients (22.9%) in group 2. Endoscopic findings were nodular gastritis (14), gastritis (11), gastric ulcer (1), duodenal ulcer (5), and duodenitis (4). H pylori resolution was significantly higher in group 1 patients (24/27, 88.9%) than in group 2 patients (1/8, 12.5%). There was no difference between patients with nodular gastritis and those with nonnodular gastritis, and between Israeli-born patients and patients born in the former USSR. Compliance in both groups was equally good, and no major side effects were recorded.

CONCLUSIONS

One-week omeprazole/clarithromycin/tinidazole triple therapy is highly tolerable and effective for treating H pylori in the pediatric age group, but previous treatment failure diminishes the likelihood of success with this regimen.

High risk of Helicobacter pylori infection associated with cow's milk antibodies in young diabetics

Antibody titres (IgA and IgG) for Helicobacter pylori were assayed in 69 insulin-dependent diabetes mellitus patients (42 males, age 1-20 years) and 310 healthy controls (171 males, age 1-20 years). A positive antibody titre for Helicobacter pylori was found in 18/69 diabetic subjects compared to 17/310 controls (p < 0.001). There was no difference between Helicobacter pylori positive and negative diabetic subjects as regards age, sex, duration of diabetes, diabetic control, insulin dose and SDS for weight and height. Gastroduodenoscopy revealed presence of Helicobacter pylori and evidence of gastric inflammation in 7/8 symptomatic diabetic children. There was a significant association in the diabetic subjects between positivity for anti-cow's milk protein and anti-Helicobacter antibodies, compared to the control group. Seven of the 17 diabetics studied within 3 months of the onset of diabetes had positive antibody titres for Helicobacter. Of these seven patients, five were positive for anti-cow's milk protein antibodies. In our study the prevalence of Helicobacter pylori infection was significantly higher in diabetic subjects than in controls, but the infection was asymptomatic and there was no correlation with diabetes control. In diabetic subjects Helicobacter pylori infection was associated with a humoral response to cow's milk proteins and was often present from the onset of diabetes.

Omeprazole-based dual and triple regimens for Helicobacter pylori eradication in children

OBJECTIVE

To evaluate the efficacy and safety of omeprazole-based dual and triple regimens for the treatment of children with Helicobacter pylori infection.

METHODS

Twenty-two patients (3 with gastric ulcer, 12 with duodenal ulcer, and 7 with nodular gastritis alone) were studied. Twelve ulcer patients also had nodular gastritis. The dual regimen included a 2-week course of omeprazole (0.6 mg/kg twice a day) and amoxicillin (30 mg/kg twice a day) (n = 10), and the triple regimen included the dual regimen plus clarithromycin (15 mg/kg twice a day) (n = 12). In patients with active ulcers, omeprazole once daily was administered for another 4 weeks. Endoscopic biopsies were taken before therapy and 4 weeks after completion of a 2-week course of therapy, and patients were followed for 6 months. The gastritis score (grade 0 to 3) and serum anti-H pylori IgG antibody titers were also determined.

RESULTS

The regimens were tolerated by all patients. Eradication rates for the dual and triple regimens were 70% and 92%, respectively. Active ulcers completely healed within 6 weeks. Patients with nodular gastritis alone showed different clinical responses to therapy. Pretreatment histology showed chronic gastritis in all patients. Successful H pylori eradication significantly reduced the mean gastritis score from 2.9 to 1.3, but unsuccessful eradication did not reduce it. The disappearance of antral nodularity often coincided with the success of eradication. Successful eradication significantly decreased pretreatment serum anti-H pylori IgG antibody titers by 29% at 1 month, by 52% at 3 months, and by 67% at 6 months. Side effects were mild and were reported in 23% of patients.

CONCLUSION

An omeprazole-based regimen is safe and may be a better option for eradication of H pylori in children. Antral nodularity is a macroscopic marker of H pylori infection.

One week treatment for Helicobacter pylori infection

Helicobacter pylori is associated with primary antral gastritis, duodenal ulceration, and gastric cancer. Current regimens for treating infection in children using bismuth and antibiotics for two to six weeks are cumbersome. The aim of this study was to evaluate a one week course of treatment. All children undergoing endoscopy were assessed for the presence of H pylori by culture, histology, rapid urease test, and 13C urea breath test. Infected children received a one week course of colloidal bismuth subcitrate 480 mg/1.73 m2/day (maximum 120 mg four times a day), combined with metronidazole 20 mg/kg/day (maximum 200 mg three times a day), and clarithromycin 15 mg/kg/day (maximum 250 mg twice a day). To optimise compliance, drugs were dispensed in a 'Redidose' box containing a compartment for each day, and subcompartments marked 'breakfast', 'lunch', 'dinner', and 'bedtime'. Compliance and side effects were assessed immediately after treatment. A urea breath test was performed at least one month after treatment. Twenty two children infected with H pylori were entered into the study; 20 of these took all doses; two children suffered significant side effects (diarrhoea and vomiting). H pylori was eradicated in 21 of the 22 children (95.45%; 95% confidence interval 77% to 100%). This study shows that H pylori infection in children can be cleared by a one week course of treatment.

Symptomatology of Helicobacter pylori infection in children

In a retrospective evaluation we reviewed the symptomatology of 143 children (age 2-15 years, mean 8.9 years) who were referred to us for upper gastrointestinal endoscopy because of recurrent abdominal pain with a duration of 6 weeks or longer. Helicobacter pylori infection was diagnosed in 36 out of 143 patients (25.2%). No statistically significant differences could be detected between the symptoms experienced by the 36 H. pylori-infected children and those experienced by the remaining 107 H. pylori-negative pediatric patients (p = 0.18-0.60). We conclude that no specific symptoms are associated with H. pylori gastritis in children. Our observations suggest that the recurrent abdominal complaints found in children with H. pylori infection seem to be caused by the secondary gastroduodenal pathology, rather than by H. pylori infection itself.

Presentation and management of Helicobacter pylori infection in childhood

Helicobacter pylori is responsible for one of the most frequently encountered infectious diseases worldwide. Helicobacter pylori infection can lead to the development of gastritis and peptic ulcer disease. The presence of Helicobacter pylori in the human stomach also represents an increased risk of gastric cancer and gastric lymphoma. Epidemiological data obtained in adults suggest that the actual colonization with Helicobacter pylori is in fact determined by childhood factors. Therefore, the pediatric age group represents the ideal target population for studies concerning the pathogenesis and epidemiology of Helicobacter pylori infection. The present work reflects our experience with regard to the diagnosis, epidemiology and pathogenesis of Helicobacter pylori infection in childhood.

Infectious gastroenterocolitides in children: an update on emerging pathogens

The recognition that bacterial infections induce signal transduction responses in infected epithelial cells also provides new avenues to consider as novel forms of therapy. For example, the chemokine interleukin-8, which attracts neutrophils to sites of mucosal infection, is produced by epithelial cells of gastric and intestinal origin in response to bacterial infection. Inhibitors of chemokine production or inhibition of the biologic effects of neutrophil chemoattractants have the potential to reduce both mucosal inflammatory responses and the attendant clinical sequelae. Eukaryotic cells also respond to infection with elevations in cytosolic second messengers, including inositol triphosphate (IP3) and calcium ([Ca2+]i). In intestinal epithelium, these second messengers can mediate the diarrheal response to infection. Calcium/calmodulin inhibitors may have a beneficial effect in treating those gastrointestinal infections mediated through changes in the level of cytosolic free calcium. DuPont and colleagues showed, for example, that oral therapy with zaldaride maleate relieves symptoms of disease and shortens the duration of diarrhea in travelers with ETEC-induced diarrhea. Evaluation of additional signal transduction responses to microbial infections should provide both new insights into the pathogenesis of gastrointestinal infectious diseases and novel approaches to consider for the prevention and therapy for these human illnesses.

Helicobacter pylori disease in childhood

Helicobacter pylori (H. pylori) is responsible for one of the most frequently encountered infectious diseases worldwide. H. pylori infection can lead to the development of gastritis and peptic ulcer disease. The presence of H. pylori in the human stomach also represents an increased risk for gastric cancer and gastric lymphoma. Epidemiologic data obtained in adults suggest that the actual colonization with H. pylori is in fact determined by childhood factors. Therefore, the pediatric age group represents the ideal target population for studies concerning the pathogenesis and epidemiology of H. pylori infection.

Helicobacter pylori and peptic disease in the pediatric patient

The data accumulated on Helicobacter pylori infection in children suggests an important causative role of the organism in gastritis and peptic ulcer disease in this age group. The importance of eradication of H pylori in asymptomatic children in relation to its role in peptic disease and cancer in adults is debatable. This article describes the current data on bacteriologic features, pathologic spectrum, clinical significance, epidemiology, methods of diagnosis, and treatment of H pylori infection in children. Further studies will provide the information on the pathogenicity, mode of transfer, and optimal treatment of H pylori infection.

What are the specific features of Helicobacter pylori gastritis in children?

Children with recurrent abdominal pain and dyspeptic symptoms often present histological gastritis and Helicobacter pylori infection. No specific symptomatology has been found, however, to discriminate H. pylori positive from negative subjects. Certain differences exist in gastritis in paediatric age groups, in comparison with adults. In terms of treatment, children also form a special entity because of the long exposure time of H. pylori infection. This article describes the typical findings of H. pylori gastritis in children and discusses their significance from a clinical point of view.

[Helicobacter pylori infection in children]

Helicobacter pylori (Hp) is a pathogen of human gastric mucosa and is considered as the major cause of chronic gastritis and duodenal ulcer disease recurrence. The prevalence rate of Hp infection increases with age and is related to low socioeconomic status in childhood. Childhood appears to be a high-risk period for Hp infection. Clinical and histological features of Hp infection are variable and often moderate in children. This is probably due to both genetic and environmental factors. Abdominal pain is the most frequent symptom and is usually associated with a mild chronic gastritis. Serology, 13C-urea breath test, bacterial culture and histological examination of biopsy specimen can be used for the diagnosis of Hp infection. Eradication of Hp infection is difficult and indications and modalities of treatment need to be specified in children. A better knowledge of epidemiology and natural history of Hp infection in childhood should permit to answer these questions.

[Helicobacter pylori gastritis in children]

BACKGROUND

The role of Helicobacter pylori in chronic gastric and duodenal ulcer disease has now been proven in adults as well as in children.

MATERIAL AND METHODS

H pylori has been looked for during endoscopy in 130 children suffering from recurrent abdominal pain (78 patients) or other symptoms (52 patients). Biopsy samples were taken from the antrum and the fundus, and were examined for histology and bacteriology (Gram staining, urease test, culture).

RESULTS

H pylori was found in 30 cases (H pylori+ group, medium age: 12 years) and was absent in the 100 other cases (H pylori- group, medium age: 6 years). H pylori was present in 27% of children suffering from recurrent abdominal pain and 17% of children with other symptoms. Epigastric location of the pain and vomiting were equally frequent in both groups. Endoscopic gastritis, often nodular, was noted in 60% of the cases in the H pylori+ group and in 46% in the H pylori- group (NS). Chronic gastritis was noted in 90% of the cases in the H pylori+ group, and in 32% of the cases in the H pylori- group (p < 0.01). Culture was positive in 27 out of 28 cases (97%) in the H pylori+ group, including 3 cases with negative histologic examination. Twenty-two children in the H pylori+ group were treated with amoxicillin and metronidazole. Endoscopy performed about 2 months later showed eradication of H pylori in 63% of the cases, associated with disappearance of histologic lesions in 6 out of 14 cases and of symptoms in 5 out of 7 cases.

CONCLUSIONS

H pylori is associated with some pediatric cases of antral gastritis. Further studies are needed to determine the influence of its eradication on symptoms and the interest to search this pathology (by serology) in children suffering from chronic abdominal pain.

Treatment and long-term follow-up of Helicobacter pylori-associated duodenal ulcer disease in children

In a 7-year period, 33 children had endoscopically documented duodenal ulcer disease. Of the 33 children, 29 had Helicobacter pylori antral gastritis. All children with H. pylori-associated duodenal ulcer disease were treated with antibiotics but no H2-receptor blocking agents. For the first 3 years of the study, initial treatment was with bismuth subsalicylate or amoxicillin for 6 weeks. For the latter 4 years, therapy with both bismuth subsalicylate and amoxicillin for 6 weeks was used initially; those in whom treatment failed received bismuth subsalicylate and amoxicillin for 6 weeks, and metronidazole for 4 weeks. Follow-up with endoscopic biopsies was performed immediately after each treatment course and at a mean of 6.5 months after clearance of H. pylori from antral biopsy specimens. Data for noncompliant patients and those receiving nonsteroidal antiinflammatory drugs were analyzed separately. For compliant patients, the rates of H. pylori clearance from antral biopsy specimens immediately after each treatment were as follows: bismuth subsalicylate, 6 of 12 children; amoxicillin, 1 of 5 children; double therapy, 9 of 9 children; and triple therapy, 3 of 3 children. At long-term follow-up, the number of children with no H. pylori in antral biopsy specimens were as follows: monotherapy, 1 of 5; double therapy, 4 of 4; and triple therapy, 3 of 3. Of the noncompliant patients, only 1 of 5 had H. pylori eradication with combination therapy and none had H. pylori eradication with monotherapy. Duodenal ulcer disease had healed in all children with H. pylori-negative antral biopsy specimens at follow-up; duodenal ulcers recurred in all children with persistent or recurrent H. pylori infection. We conclude that therapy with two drugs for 6 weeks is the treatment of choice for endoscopically proved duodenal ulcer and histologically proved H. pylori antral gastritis, and that poor patient compliance reduces the rate of success. Our data strongly support a causal relationship between H. pylori and duodenal ulcer disease.

Omeprazole therapy for Helicobacter pylori infection

To determine whether omeprazole eradicates Helicobacter pylori infection of the gastric antrum, six adolescents and one adult with H. pylori colonization of the antrum were entered into a clinical, open trial of medical therapy. Histologic evidence of antral gastritis and three complementary methods to document H. pylori colonization of the stomach (silver stain, urease testing, and culture of antrum) were obtained before and after an 8-week course of omeprazole. In vitro susceptibility to omeprazole and restriction endonuclease analysis were performed on H. pylori isolates obtained from patients before and after omeprazole therapy. Each of the seven patients treated with omeprazole had continued active inflammation in the antrum and one or more features indicative of persisting H. pylori colonization. Minimum inhibitory concentrations and DNA fingerprints of H. pylori isolated after therapy were identical to those of the pre-treatment bacterial isolates in each of the four subjects examined. We conclude that omeprazole therapy alone did not eradicate H. pylori infection of the human antrum. Continued bacterial colonization was not related to either acquired bacterial resistance to the drug or reinfection of the stomach with a different H. pylori strain.

Management and response to treatment of Helicobacter pylori gastritis

Gastritis associated with Helicobacter pylori was present in gastric biopsies from 24/95 (25%) children and adolescents undergoing endoscopy for recurrent abdominal pain and upper gastrointestinal symptoms. H pylori associated gastritis occurred mainly in older children (8-16 years) and was significantly associated with low socioeconomic class and a family history of peptic ulcer disease. Antral nodularity was a common endoscopic finding in H pylori positive children. Eighteen children, all over 5 years of age, were treated with tripotassium dicitratobismuthate (De-Nol) for two months and ampicillin for two weeks. In 12 children follow up gastric biopsies were obtained six weeks after completion of treatment. In 9/12 (75%) children H pylori was eradicated, and gastritis improved.

Peptic ulcer disease in children

Primary duodenal ulcer disease occurs in children of all ages, but is most often seen in those over 10 years. As in the adult, it often pursues a chronic course. Primary gastric ulcer is seen in children under 6 years, is more unusual, and does not tend to recur. Stress ulcers are seen most often in infants and in critically ill children and are asymptomatic until the complications of hemorrhage or perforation appear. Drug-related ulcers are being seen more frequently as the use of nonsteroidal anti-inflammatory agents increases. With the use of new therapeutic agents, management has been simplified and surgical intervention has become a rarity. Helicobacter pylori is now a recognized cause of antral gastritis and ulceration in the child.

Syncopes leading to the diagnosis of a Helicobacter pylori positive chronic active haemorrhagic gastritis

A 15-year-old girl was admitted after 1 week of increasing fatigue and pallor. She had no gastro-intestinal complaints. The patient had suffered from four episodes of syncope during the last 3 days prior to admission. Besides pallor and a discrete cardiac murmur, the physical examination was normal. A further thorough investigation revealed an iron deficiency anaemia related to a Helicobacter pylori positive chronic active haemorrhagic gastritis. Treatment consisted of amoxycillin and colloidal bismuth subcitrate (500 mg and 120 mg orally respectively, 3 times daily) during a period of 6 weeks. Iron supplements were not administered. Together with the clearance of H. pylori and healing of the haemorrhagic gastritis, as demonstrated by histology, haemoglobin values returned to normal and the symptoms disappeared. An eradication of the micro-organism was obtained. She has since had no further similar complaints.

Bismuth therapy in gastrointestinal diseases

Bismuth therapy has shown efficacy against two major gastrointestinal disorders: peptic ulcer disease and diarrhea. In peptic ulcer disease it is as effective as the H2-receptor antagonists, costs considerably less, and offers a lower rate of relapse. When Helicobacter pylori is implicated, bismuth acts as an antimicrobial agent, suppressing the organism but not eliminating it. In recent studies, bismuth compounds have been used with conventional antibiotics, producing elimination of the organism, histological improvement, and amelioration of symptoms for periods longer than one year. Bismuth subsalicylate has shown modest efficacy in treating traveler's diarrhea and acute and chronic diarrhea in children, and it is effective prophylactically for traveler's diarrhea. An epidemic of neurological toxicity was reported in France in the 1970's with prolonged bismuth treatment, usually bismuth subgallate and subnitrate. Such toxicity has been rare with bismuth subsalicylate and colloidal bismuth subcitrate. However, recent studies have demonstrated intestinal absorption of bismuth (about 0.2% of the ingested dose) and sequestration of this heavy metal in multiple tissue sites, even occurring with conventional dosing over a 6-week period. These findings have inspired recommendations that treatment periods with any bismuth-containing compound should last no longer than 6-8 weeks, followed by 8-week bismuth-free intervals.

Eradication of Helicobacter mustelae from the ferret stomach: an animal model of Helicobacter (Campylobacter) pylori chemotherapy

Colonization of the ferret stomach by Helicobacter mustelae has been suggested as a possible animal model for Helicobacter pylori-associated gastroduodenal disease of humans. Our study was designed to determine whether antimicrobial chemotherapy could eradicate H. mustelae from ferrets. Triple antimicrobial therapy combining amoxicillin, metronidazole, and bismuth subsalicylate was successful in eradicating the organism from 5 of 7 (71%) adult ferrets. Despite apparent in vitro susceptibility, neither chloramphenicol monotherapy nor a polytherapeutic regimen combining tetracycline, metronidazole, and bismuth subsalicylate proved effective in the eradication of H. mustelae. Several strains isolated after unsuccessful polytherapy showed markedly increased resistance to metronidazole. These preliminary findings are similar to results of H. pylori treatment trials with humans and suggest that the ferret may be a useful model for evaluating and comparing potential antimicrobial modalities for the eradication of H. pylori.

Intrafamilial clustering of Helicobacter pylori infection

Colonization of the gastric antrum by Helicobacter pylori (formerly Campylobacter pylori) has been associated with primary gastritis. We determined the frequency of colonization by H. pylori in gastric-antrum biopsy specimens from 93 children undergoing gastroscopy for the evaluation of upper gastrointestinal symptoms. We also determined H. pylori IgG antibody levels by enzyme-linked immunosorbent assay in coded serum samples from these children, family members, and control subjects of comparable ages. Among 27 children with primary, or unexplained, gastritis, H. pylori was identified by silver staining in 24 biopsy specimens and by culture in 22; specific antibodies were present in 23 children (96 percent). Three children with unexplained gastritis had no evidence of H. pylori in the antrum, nor did any of 13 children with secondary gastritis or any of 53 children with normal antral histologic features; specific antibodies were present in only 1 of these 69 children. H. pylori antibody was detected in 25 of 34 parents of colonized children, but in only 8 of 33 parents of noncolonized children (P less than 0.001). Of 22 siblings of children colonized by H. pylori, 18 had specific antibodies, as compared with only 5 of 37 controls (P less than 0.001). We conclude that H. pylori-specific IgG antibodies are associated with bacterial colonization of the gastric antrum by this organism. The intrafamilial clustering of H. pylori infection suggests that there may be person-to-person spread of these bacteria.