Duodenal ulcers dominate acute upper gastrointestinal tract bleeding in childhood: a 10-year experience from Hong Kong

The trends of pediatric duodenal ulcer and predictors of recurrence

BACKGROUND

Duodenal ulcer (DU) causes various symptoms in children. The prevalence of Helicobacter pylori (Hp)-associated DU has been reducing in some regions, yet the updated trend in Taiwan is unknown. Risk factors of DU recurrence have not been comprehensively investigated in children.

METHODS

This retrospective study included children diagnosed with DU to evaluate the demographics, symptoms, diagnostics, treatment, and outcomes. Specific populations (infant, surgery required) were sorted for subgroup analysis. Predictors of DU recurrence was analyzed in patients who received endoscopic follow-ups.

RESULTS

A total of 488 children were included. Most patients were male (72.5%), school-aged (11.3 ± 4.8 years old), and with varied underlying diseases in one-fifth. The annual incidences were around 3-5%, with a declining trend of case numbers and the Hp-positive proportion. Hp infection, concurrent gastric ulcer, perforation, and mortality were noted in 32.7%, 16%, 1.6%, and 1% of patients. Patients with or without Hp infection showed different clinical features but similar outcomes. The characteristics of subpopulations were depicted respectively. Male sex, lower Hb level, and perforation were independent risk factors associated with recurrence.

CONCLUSION

Hp-positive DU seems to wane. Patients with male sex, lower Hb level, or perforation at diagnosis carried a higher risk of recurrence, which may warrant active surveillance and endoscopic follow-up.

Gastrointestinal Bleeding in Children: The Role of Endoscopy and the Sheffield Scoring System in a Resource-Limited Setting

Objective

To document the clinical presentation, endoscopic diagnosis, and Sheffield scores of children with gastrointestinal (GI) bleeding who were referred for endoscopy at the Lagos University Teaching Hospital. The participants who needed endoscopy based on clinical criteria and according to the Sheffield scores were also documented.

Methods

This study analyzed the records of 111 children with GI bleeding retrospectively from January 2013 to January 2021, while 9 children were recruited prospectively from February 2021 to March 2022. Receiver operating curves and area under the curve were generated to test the ability of the Sheffield scores to predict rebleeds, mortality, and the need for endoscopic intervention for upper GI bleeds.

Results

One hundred and twenty participants were recruited. Ninety-one (75.8%) presented with upper GI bleeding (UGIB), while 29 (24.2%) had lower GI bleeding (LGIB). Only 70 (58.3%) (53 UGIB and 17 LGIB) had endoscopy performed. For UGIB, 5 (9.4%) had no source of the bleeding identified at endoscopy, 12 (22.6%) had variceal bleeding, and 36 (67.9%) had nonvariceal bleeding. Colonoscopy revealed juvenile polyps in 5 (29.4%), indeterminate colitis in 5 (29.4%), ulcerative colitis in 4 (23.5%), Crohn's disease in 1 (5.9%), and hemorrhoids in 2 (11.8%) participants, respectively. The Sheffield score was ≥8 in 42 (46.1%) of the participants who presented only with UGIB (hematemesis and melena). The scores were significantly related to the type of bleeds, rebleeds, and deaths (P = 0.00).

Conclusion

The clinical and endoscopic findings in this study are similar to those reported previously. The Sheffield scoring was useful in assessing Nigerian children. However, due to limited access and other restraints, endoscopy was not performed on all the study participants even when the scoring system was suggestive. The availability, and therefore, utility of GI endoscopy in this setting are still suboptimal. The need for the provision of adequate equipment and resources and the training of personnel is thus recommended.

Changing trend in the spectrum of upper gastrointestinal bleeding in children-A multicentre experience

In children, upper gastrointestinal bleeding (UGIB) is an uncommon, but potentially serious, condition with diverse etiologies. A prospective study had been undertaken to find out any changing trend in the etiology and outcome of pediatric UGIB in Eastern India. This retrospective analysis of case records of children, presenting in outpatient or emergency with hematemesis and/or melena from 2 tertiary GI centers of Kolkata, was undertaken to find out the etiologies of bleed and the outcome of management. A total of 180 children were evaluated including 30 (16.7%) infants. The predominant cause of GGIB was gastroduodenal ulcer and erosions (60%) followed by variceal bleeding (19.4%). Vascular lesions were detected in 4 (2%). Hyperplastic antral polyp was an unusual etiology in 3 (1.7%) infants. Various endotherapies were needed in 28% of cases. No mortality was noted. Melena, hemoglobin below 8 gm%, the need for volume replacement, and packed red blood cells transfusion on admission were associated with significant endoscopic lesions, which needed endotherapies. This study, comprising the largest cohort among Indian published series, found an etiology of pediatric upper GI bleed, different from the one, previously depicted. This may be a reflection either of regional variations or a changing trend over time.

Analysis of risk factors and development of scoring system to predict severity of upper gastrointestinal bleeding in children

BACKGROUND AND AIM

Upper gastrointestinal bleeding is a rare and potentially life-threatening condition in children. Herein, clinical features and risk factors in children with upper gastrointestinal bleeding were analyzed, and a clinical scoring system was constructed to assess severity.

METHODS

This retrospective cohort study involved 224 children hospitalized with upper gastrointestinal bleeding between January 2012 and April 2018. Demographic data, clinical information, and laboratory test results on admission were statistically examined.

RESULTS

Out of 224 upper gastrointestinal bleeding cases, 76 were diagnosed as severe and 148 as mild cases according to the rate of blood loss and severity. Severe group was significantly different from mild group in 23 items including age, number of patients aged more than 7 years, and so forth (P < 0.01 or P < 0.05). Positive detection rate of bleeding etiology was gradually decreased (P < 0.01) in relation to delay in timing of endoscopy. Analysis of logistic regression evinced five independent risk factors for severe cases to be associated with poor consciousness, hemoglobin < 80 g/L, hemoglobin drop of > 20 g/L, hematochezia, and anemic appearance (P < 0.01 or P < 0.05). Using these five parameters, a number of scoring models were tested. The most predictive resulted in a scoring system constructed with a total of 16 and a cutoff for intervention of 8.

CONCLUSIONS

Amalgamation of risk factors with the scoring system plays an important role in assessing upper gastrointestinal bleeding severity in children.

Pediatric gastrointestinal bleeding: Perspectives from the Italian Society of Pediatric Gastroenterology

There are many causes of gastrointestinal bleeding (GIB) in children, and this condition is not rare, having a reported incidence of 6.4%. Causes vary with age, but show considerable overlap; moreover, while many of the causes in the pediatric population are similar to those in adults, some lesions are unique to children. The diagnostic approach for pediatric GIB includes definition of the etiology, localization of the bleeding site and determination of the severity of bleeding; timely and accurate diagnosis is necessary to reduce morbidity and mortality. To assist medical care providers in the evaluation and management of children with GIB, the "Gastro-Ped Bleed Team" of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) carried out a systematic search on MEDLINE via PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) to identify all articles published in English from January 1990 to 2016; the following key words were used to conduct the electronic search: "upper GIB" and "pediatric" [all fields]; "lower GIB" and "pediatric" [all fields]; "obscure GIB" and "pediatric" [all fields]; "GIB" and "endoscopy" [all fields]; "GIB" and "therapy" [all fields]. The identified publications included articles describing randomized controlled trials, reviews, case reports, cohort studies, case-control studies and observational studies. References from the pertinent articles were also reviewed. This paper expresses a position statement of SIGENP that can have an immediate impact on clinical practice and for which sufficient evidence is not available in literature. The experts participating in this effort were selected according to their expertise and professional qualifications.

Upper Gastrointestinal Bleeding in Chinese Children: A Multicenter 10-Year Retrospective Study

Objective This study aims to analyze the clinical and endoscopic presentations of upper gastrointestinal bleeding (UGIB) in the Chinese children. Methods A 10-year retrospective study was made on children with UGIB and undertaken esophagogastroduodenoscopy (EGD) from 4 tertiary referral centers in China. Results Of the 1218 children studied, the bleeding source was found in 76.4%. Erosive gastritis was the most common endoscopic finding (33.5%), followed by duodenal ulcer (23.2%). The proportion of erosive gastritis decreased with age (correlation coefficient = -0.787), and duodenal ulcer increased with age (correlation coefficient = 0.958). The bleeding source was more likely to be determined in children having EGDs within 48 hours (80.6% vs 67.9%). Conclusions In Chinese children with UGIB, erosive gastritis and duodenal ulcer were the leading causes, and their proportions varied with age. EGDs performed within 48 hours may improve the possibility of finding the source of bleeding.

Emergent transcatheter arterial embolization for norovirus-associated life-threatening ulcer bleeding to achieve successful hemostasis in 2-year-old boy

Case

We report a 2-year-old boy with duodenal ulcer with active bleeding that occurred as a result of norovirus gastroenteritis. On admission, the patient presented with shock accompanied with vomiting and melena. Abdominal contrast enhanced computed tomography scan showed signs of duodenal bleeding.

Outcome

He was successfully treated with emergent transcatheter arterial embolization. After the treatment, endoscopic examination revealed duodenal ulcer and the stool norovirus antigen test was found to be positive. The patient recovered completely without any sequelae.

Conclusion

Life-threatening duodenal ulcer bleeding in children can be caused by viral gastroenteritis. When endoscopic therapy is unsuccessful or difficult, in cases of small children, angiographic intervention can be a safe alternative treatment option of gastrointestinal bleeding.

Antral gastritis caused by Helicobacter pylori infection in the pediatric age group is associated with increased mesenteric lymph node dimension observed by ultrasonography

BACKGROUND

To find out if transabdominal ultrasonography (US) may have a predictive role for detection of antral gastritis and Helicobacter pylori (HP) infection in the antrum of pediatric age group.

METHODS

A total of 91 (63.6%) patients and 52 (36.4%) controls were allocated into two groups as follows: Group 1 (n=91): patients with complaints and endoscopic findings consistent with gastritis and documented HP infection; Group 2 (n=52): patients with complaints and endoscopic findings consistent with gastritis in the absence of documented HP infection. These two groups were compared in terms of demographics and biggest mesenteric lymph node detected, muscularis mucosa thickness, submucosal thickness, muscularis propria thickness, and total gastric wall thickness.

RESULTS

The two groups exhibited no statistically significant difference with respect to age (P=0.747), and presenting symptoms (P=0.982). However, the mesenteric lymph node dimension was significantly increased in Group 1 (P=0.039). Median mesenteric lymph node dimension was 12.9 (±15.4) mm in Group 1, while 11.0 (±12.8) mm in Group 2. No significant difference was observed between groups in terms of muscularis mucosa thickness (P=0.243), submucosal thickness (P=0.174), muscularis propria thickness (P=0.356), and total gastric wall thickness (P=0.223).

CONCLUSIONS

Antral gastritis caused by HP infection in the pediatric age group is associated with increased mesenteric lymph node dimension observed by US.

Surviving Sengstaken

AIM OF THE STUDY

To report the outcomes of children who underwent Sengstaken-Blakemore tube (SBT) insertion for life-threatening haemetemesis.

METHODS

Single institution retrospective review (1997-2012) of children managed with SBT insertion. Patient demographics, diagnosis and outcomes were noted. Data are expressed as median (range).

MAIN RESULTS

19 children [10 male, age 1 (0.4-16) yr] were identified; 18 had gastro-oesophageal varices and 1 aorto-oesophageal fistula. Varices were secondary to: biliary atresia (n=8), portal vein thrombosis (n=5), alpha-1-anti-trypsin deficiency (n=1), cystic fibrosis (n=1), intrahepatic cholestasis (n=1), sclerosing cholangitis (n=1) and nodular hyperplasia with arterio-portal shunt (n=1). Three children deteriorated rapidly and did not survive to have post-SBT endoscopy. The child with an aortooesophageal fistula underwent aortic stent insertion and subsequently oesophageal replacement. Complications included gastric mucosal ulceration (n=3, 16%), pressure necrosis at lips and cheeks (n=6, 31%) and SBT dislodgment (n=1, 6%). Six (31%) children died. The remaining 13 have been followed up for 62 (2-165) months; five required liver transplantation, two underwent a mesocaval shunt procedure and 6 have completed endoscopic variceal obliteration and are under surveillance.

CONCLUSIONS

SBT can be an effective, albeit temporary, life-saving manoeuvre in children with catastrophic haematemesis.

Helicobacter pylori Infection in European children with gastro-duodenal ulcers and erosions

BACKGROUND

To analyze risk factors associated with gastro-duodenal ulcers and erosions in children.

METHODS

Open, prospective, multicenter, case-control study carried out in 11 European countries in patients with gastric or duodenal ulcers/erosions and 2 age-matched controls each. Possible risk factors were recorded. Logistic regression models were performed with adjustment for centers and age groups.

RESULTS

Seven-hundred thirty-two patients (244 cases, 153 with erosions only and 91 with ulcers, and 488 controls) were recruited. Children receiving antimicrobials or acid suppressive drugs before endoscopy were excluded (202 cases/390 controls remained for risk factor analysis). Helicobacter pylori was detected more frequently in cases than controls but only in 32.0% versus 20.1% in controls (P = 0.001). Independent exposure factors for gastric ulcers were male gender (P = 0.001), chronic neurologic disease (P = 0.015), chronic renal disease (P < 0.001) and nonsteroidal anti-inflammatory drug consumption (P = 0.035). Exposure factors for duodenal ulcers were H. pylori infection (P < 0.001) and steroid consumption (P = 0.031). Chronic renal disease was the only independent factor associated with gastric erosions (P = 0.026), those associated with duodenal erosions being H. pylori infection (P = 0.023), active smoking (P = 0.006) and chronic arthritis (P = 0.008). No risk factor was identified in 97/202 (48.0%) cases.

CONCLUSIONS

H. pylori remains a risk factor for duodenal, but not for gastric lesions in children in countries with low prevalence of infection. No risk factor could be identified in half of the children with gastro-duodenal ulcers/erosions.

Clinical practice: Helicobacter pylori infection in childhood

Helicobacter pylori infection is recognised as a cause of gastritis and peptic ulcer disease (PUD) and usually acquired during the first years of life. While there is a decline in the prevalence of H. pylori infection in northern and western European countries, the infection is still common in southern and eastern parts of Europe and Asia. Symptoms of H. pylori-related PUD are nonspecific in children and may include epigastric pain, nausea and/or vomiting, anorexia, iron deficiency anaemia and hematemesis. Besides, only a small proportion of children develop symptoms and clinically relevant gastrointestinal disease. H. pylori infection can be diagnosed either by invasive tests requiring endoscopy and biopsy or non-invasive tests including the (13)C-urea breath test, detection of H. pylori antigen in stool and detection of antibodies in serum, urine and saliva. The aim of treatment is at least 90 % eradication rate of the bacteria, and a combination of two antibiotics plus a proton pump inhibitor has been recommended as first-line treatment. However, frequent use of antibiotics during childhood is associated with a decline in eradication rates and the search for new treatment strategies as well. This is an overview of the latest knowledge and evidence-based guidelines regarding clinical presentation, diagnosis and treatment of H. pylori infection in childhood.

Diagnostic endoscopy and clinical characteristics of gastrointestinal bleeding in children: a 10-year retrospective study

BACKGROUND

Upper gastrointestinal (UGI) endoscopy is a tool used frequently in the evaluation of patients presented with hematemesis.

OBJECTIVES

The purpose of this study was to evaluate clinical presentations and features of UGI bleeding (UGIB) in children.

METHODS/PATIENTS AND MATERIALS

A descriptive retrospective analysis was carried out on the medical records of the patients. Children and adolescents aging 0 - 18 years who were presented with UGIB were recruited in the survey over a period of 10 years (2000 to 2010) in Children's Hospital, Tabriz, Iran.

RESULTS

There were 447 patients included in this study and they were all evaluated by upper endoscopy. Clinical manifestations included hematemesis (120 cases, 26.85%), melena (60 cases, 13.42%), and hematochezia (11 cases, 2.46%). Age-related analysis showed that erosive esophagities was a more common cause of hematemesis in the younger age group (under 1 year of age) with a prevalence of 37% when compared with elder children and adolescents (40%). Peptic ulcer disease was seen in only 7.4% of infants under the age of one. Overall, Esophagitis and erosive esophagitis was the most common endoscopic finding (179, 40%) .

CONCLUSIONS

There were 80 (17.90%) patients receiving endoscopic hemostatic therapy. In children with UGIB, upper endoscopy is a diagnostic procedure for the categorization of underlying causes of upper gastrointestinal bleeding in children and various endoscopic lesions may be found in a patient with the impression of UGIB.

Upper gastrointestinal bleeding in children: an 11-year retrospective endoscopic investigation

BACKGROUND

Upper gastrointestinal bleeding (UGIB) may present as hematemesis, coffee-ground emesis, or melena requiring esophagogastroduodenoscopy (EGD) for diagnosis and/or therapy. Worldwide, differences exist for the etiology of UGIB reflecting geographical differences in common disease states. In the past 25 years, there have been improvements in endoscopic optics. This study was undertaken to determine: 1) if identifying a bleeding source in UGIB have improved with better endoscopic optics, 2) geographic differences in causes of UGIB, 3) differences in severity of UGIB based on clinical factors, and 4) the likelihood of finding a bleeding source based on symptom duration and time to endoscopy.

METHODS

A retrospective chart review was made on children having EGD for evaluation of UGIB. Data collected included type, etiology, and degree of bleeding.

RESULTS

Of 2569 diagnostic procedures, 167 (6.5%) were performed for UGIB. The most common presentation was hematemesis (73.4%). Melena was associated with lower hemoglobin levels and higher transfusion rates. A source of UGIB was found in 57.0%, no cause in 11.4% and a questionable cause in 29.7%. A source was found less commonly in children with a history of UGIB less than one month and in those undergoing endoscopy over 48 hours after a bleeding episode.

CONCLUSIONS

Improved endoscopic optics has not changed diagnostic ability for UGIB. Etiologic differences for UGIB in children from varying geographic areas are related to indication for endoscopy, patient selection, and co-morbid conditions. Duration of bleeding and time to endoscopy after a bleeding episode may help predict when endoscopy should be performed to determine a bleeding source.

Has H. pylori prevalence in bleeding peptic ulcer been underestimated? A meta-regression

OBJECTIVES

It has been suggested that prevalence of Helicobacter pylori (Hp) in peptic ulcer bleeding (PUB) is lower than that in non-complicated ulcers. As Hp infection is elusive in PUB, we hypothesized that this low prevalence could be related to an insufficiently intensive search for the bacteria. The aim of the study was to evaluate whether the prevalence of Hp in PUB depends on the diagnostic methods used in a given study.

METHODS

A systematic review was performed of studies assessing the prevalence of Hp infection in patients with PUB. Data were extracted in duplicate. Univariate and multivariate random-effects meta-regression analyses were performed to determine the factors that explained the differences in Hp prevalence between studies.

RESULTS

The review retrieved 71 articles, including 8,496 patients. The mean prevalence of Hp infection in PUB was 72%. The meta-regression analysis showed that the most significant variables associated with a high prevalence of Hp infection were the use of a diagnostic test delayed until at least 4 weeks after the PUB episode-odds ratio: 2.08, 95% confidence interval: 1.10-3.93, P=0.024-and a lower mean age of patients-odds ratio: 0.95 per additional year, 95% confidence interval: 0.92-0.99, P=0.008.

CONCLUSIONS

Studies that performed a delayed test and those including younger patients found a higher prevalence of Hp, approaching that recorded in cases of non-bleeding ulcers. These results suggest that the low prevalence of Hp infection described in PUB may be related to the methodology of the studies and to patients' characteristics, and that the true prevalence of Hp in PUB is still to be determined. Our data also support the recent recommendations of the International Consensus on Non-Variceal Upper Gastrointestinal Bleeding regarding the performance of a delayed diagnostic test when Hp tests carried out during the acute PUB episode are negative.

Helicobacter pylori infection in pediatrics

his review summarizes the articles published on Helicobacter pylori infection in children between April 2008 and March 2009. Recent evidence highlights the decreasing prevalence trend of H. pylori infection and supports both intrafamilial and extrafamilial transmission. The association with various symptoms is still being debated. Interestingly, H. pylori infection seems inversely associated with allergic diseases. Monoclonal stool antigen tests are widely used and accurate for the diagnosis of H. pylori infection, but less accurate in young children. The new biprobe real-time PCR assay applied to stools showed a poor sensitivity in children. Using the urea hydrolysis rate next to the delta over baseline values, the (13)C-urea breath test provides excellent results for all age children, even for young children. Treatment of H. pylori infection remains a challenge, considering suboptimal efficacy of current therapy. Among emerging alternatives, sequential treatment appears promising. The adjunction of probiotics to conventional regimens, although eliciting great interest, has shown limited therapeutic benefit.

Differences in peptic ulcer between the East and the West

PUD affects both the East and the West. The magnitude of the problem, however, varies within these regions. The study of peptic ulcer epidemiology is impeded by the paucity of general population-based data, invasiveness of diagnostic tests, and variable access to testing facilities. As such, direct comparisons of PUD epidemiology between the East and the West are difficult. The prevalence rates of H pylori are highly variable and depend greatly on the local sanitation conditions. The use of NSAIDs and aspirin is ubiquitous and increasing especially for the antiplatelet activity of aspirin in the prophylaxis of cardiovascular events. There is evidence that pharmacogenetics play a role in susceptibility to the ulcerogenic properties of NSAIDs. The prevalence of PUD parallels the risk factors, but emerging in both the East and the West is idiopathic PUD, now a substantial proportion of ulcers in areas of declining H pylori infection. Genetic polymorphisms affect the efficacy of treatment using PPIs. Local H pylori resistance rates also influence the eradication success rates.