Duodenal ulcer in childhood. A study of predisposing factors

ABO blood group, hypercoagulability, and cardiovascular and cancer risk

The antigens of the ABO system (A, B, and H determinants, respectively) consist of complex carbohydrate molecules. It has been known for nearly half a century that the ABO blood group exerts a major influence on plasma levels of the von Willebrand factor (VWF)-factor VIII (FVIII) complex and that normal group O individuals have significantly lower levels of VWF and FVIII than do non-O individuals. As a consequence, several investigators have studied the association between ABO blood group and the risk of developing bleeding or thrombotic events. A number of epidemiological studies have also analyzed the biologic relevance of this interaction by assessing whether the ABO blood group could influence human longevity through the regulation of VWF-FVIII plasma levels. In this review, the molecular mechanisms by which the ABO blood group determines plasma VWF and consequently, FVIII levels, the possible clinical implications, and the current knowledge on the association between the ABO blood group and the risk of developing certain cancers will be reviewed.

The relationship of ABO blood group, age, gender, smoking, and Helicobacter pylori infection

It is well known that blood group antigens are related to the development of peptic ulcer and gastric carcinoma. This study sought to determine the relationship between H. pylori and ABO/Rhesus blood groups, age, gender, and smoking. Patients (335 women and 205 men; mean age, 51.68 +/- 15.0 years; range, 18-85 years) who attended our outpatient clinic were enrolled in the study. All patients were randomly selected in each age group. Demographic data recorded for each patient included age, gender, and tobacco use. Blood samples were tested for H. pylori antibodies, and ABO/Rhesus blood group antigen typing was performed. Serum antibodies were tested against H. pylori infection. Prevalences of all blood groups were O (29.2%), A (38.2%), B (17.8%), and AB (14.8%). As expected from previous studies, we found that seropositivity for H. pylori increased with age. H. pylori Ig G antibody positivity was detected in 185 of 335 women (60.6%), compared with 88 of 205 men (42.9%), a statistically significant difference (P < 0.05). H. pylori Ig G antibody positivity was detected in 206 of 379 nonsmokers (54.3%) compared with 67 of 161 smokers (41.6%), a statistically significant difference (P < 0.05). Patients in blood groups A and O were more prone to H. pylori infection than were patients in other blood groups (P < 0.05), and patients in the AB blood group were less prone to H. pylori infection compared with patients in other blood groups (P < 0.05). The results of this study demonstrate that H. pylori infection can be related to ABO blood group, age, gender, and smoking.

Helicobacter pylori infection, serum gastrin, and gastric acid secretion in teen-age subjects with duodenal ulcer, gastritis, or normal mucosa

BACKGROUND

Many studies have confirmed the close association of Helicobacter pylori with duodenal ulcer (DU) in adults. However, in the subtype of DU known as 'childhood' or 'early onset DU' genetic factors seem to play a prominent role in the pathogenesis. The aim of this study was to investigate the prevalence of H. pylori in teen-age subjects with DU, gastritis, and normal mucosa and to examine the relationship of H. pylori to serum gastrin levels and gastric acid secretion.

METHODS

Sixty-one teen-age subjects (24 with DU, 14 with gastritis, and 23 normal subjects) were investigated for the presence of H. pylori, antral histology, gastrin levels, basal acid output (BAO), and maximal acid output (MAO).

RESULTS

All 24 patients with DU and 8 of 14 with gastritis were infected with H. pylori; none of the normal subjects were infected. Mean gastritis scores and fasting serum gastrin levels were significantly higher in patients with DU or H. pylori-positive gastritis than in subjects with H. pylori-negative gastritis or normal mucosa (p < 0.05). The difference in serum gastrin levels was also significant when patients with DU were compared with those with H. pylori-positive gastritis (p < 0.05). BAO and MAO were significantly higher in patients with DU than in subjects with H. pylori-positive gastritis or normal mucosa (p < 0.05), but there was no difference between subjects with H. pylori-positive gastritis and those with normal mucosa.

CONCLUSION

H. pylori infection is associated closely with teen-age DU and gastritis and with hypergastrinemia but does not affect BAO and MAO in most infected teen-age subjects.

Epidemiology and genetics of peptic ulcer

At the turn of the century, duodenal ulcer rose from rarity to affect 10% of males in their life time, subsequently declining in some countries such as UK, levelling off in others such as Germany, and continuing to increase in still others such as Hong Kong. The annual incidence per 1000 population varies from about 1 in Japan to 1.5 in Norway, 1.8 in USA and 2.7 in Scotland, and the frequency also varies within many individual countries, such as Australia, China and India, and among races such as a higher prevalence among whites than blacks in USA and among Chinese than Javanese in Indonesia. Ulcer frequency is higher in winter months, and this appears universal, being true in cold as well as in warm countries. Most places report a rise of ulcer rates among the elderly in recent decades. The male to female ratio also varies geographically, for example from 1:1 in USA to 18:1 in India, and with time such as moving from 2:1 to 1:1 in the last two decades in USA, and the duodenal ulcer to gastric ulcer ratio varies widely from place to place, for example from 0.8 in Japan to 19:1 in Africa and 32:1 in India. Placebo healing rates also differ geographically, ranging from 5% in Philippines to 78% in Mexico. These epidemiological data can only be explained by the presence of multiple aetiological factors, including analgesics, society stress, cigarette smoking, Helicobacter pylori, dietary factors, and genetic factors. Three lines of evidence support a genetic role: family studies, twin studies and blood group studies. Family aggregation occurs more commonly in patients with early-onset (< 30 yr) of symptoms. Blood group O prevalence is more associated with late-onset of symptoms. Other genetic markers include nonsecretor status, HLA antigens, phenylthiocarbamide taste sensitivity, and alpha-1-antitrypsin. Genetic syndromes such as MEN I also support a genetic role and give insight into pathogenetic mechanisms. The best physiological marker is still hyperpepsinogenemia I, which is transmitted by autosomal dominance, despite recent report of lower serum pepsinogen 1 after healing of Helicobacter pylori associated gastritis.

Characteristics of teen-age patients with juvenile duodenal ulcer. Relation between inherited hyperpepsinogenemia I and duodenal ulcer

We analyzed environmental factors, family history of peptic ulcer, gastric acid secretion, and serum levels of pepsinogen I (PG I) and gastrin in 56 juvenile patients with duodenal ulcer and 39 normal teenage subjects. Basal acid output and maximal acid output were significantly higher in our duodenal ulcer patients than in controls without ulcer (both, p < 0.01), and patients with duodenal ulcer showed significantly higher serum levels of PG I and gastrin than the controls (both, p < 0.001). There were no significant differences in any environmental factor between the patients and controls. Fifteen of the 17 patients who had one or both parents with hyperpepsinogenemia I had high serum PG I levels. Over half of the duodenal ulcer patients had high serum gastrin levels, irrespective of family history of hypergastrinemia. Our findings suggest that hyperpepsinogenemia I and hypergastrinemia are important characteristics and that genetic background, particularly the inheritance of a gastric mucosal trait expressed as hyperpepsinogenemia I, is frequently involved in the pathogenesis of juvenile duodenal ulcer.

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.

Acute duodenal ulcer

A series of 31 infants and children with acute duodenal ulcer verified by endoscopy was studied over an eight year period. Eighteen (58%) of them were under 2 years of age. The most common symptom was upper gastrointestinal bleeding (n = 27, 87%). Twenty nine patients (94%) had a preceding illness characterised by diarrhoea, upper respiratory tract infection, or fever, which was not necessarily treated with antipyretic drugs. Initial endoscopy showed that ulcer lesions were solitary in 14 patients and present on the anterior wall (n = 11), posterior wall (n = 2), or both (n = 1). Multiple ulcers were found in 17 patients, and present in the bulb with (n = 6) or without (n = 11) extension into the second part of duodenum. The most conspicuous finding was the irregularly shaped ulcers seen in eight young children with similar clinical and endoscopic features. Sixteen patients were re-endoscoped one to two weeks after the initial examination; the ulcers had entirely disappeared in 13, and there were only small residual ulcers in three. Thirty patients were treated medically and only one (with uncontrollable haemorrhage) required operation. Most patients were symptom free two to six years after the initial diagnosis. Our results suggest that young children may develop acute duodenal ulcers after viral illnesses whether or not they are treated with drugs, mainly antipyretics. This kind of acute duodenal ulcer usually heals quickly irrespective of the morphology, site, and number of ulcers.

Peptic ulcer disease in the pediatric population

Peptic ulcer disease occurs in infants, children, and adolescents. Primary and stress ulcers pose a challenge to the pediatrician, who needs to arrange for appropriate diagnostic and therapeutic services. Highlights of our understanding of the pathophysiology, genetics, natural history, diagnosis, and therapy of peptic ulcer disease are presented.

Duodenal ulceration: review of 110 cases

This paper describes 110 cases of childhood duodenal ulcer, which were diagnosed over 26 years: 63 were diagnosed by barium meal examination; 47 by upper gastrointestinal endoscopy. The mean age at diagnosis was 11.2 years, with symptoms reported in 46% before 10 years and in 15% before 6 years of age. There was often a considerable delay in diagnosis, particularly in the younger age group. Nocturnal pain (61%) and a close family history of duodenal ulcer disease (62%) were the most valuable pointers to the diagnosis. Fifteen children had required surgery for persistent symptoms. Thirty four had received treatment with an H2 receptor antagonist, and all but four had had a satisfactory initial response. Seventy per cent relapsed within six months of discontinuing treatment, and long term maintenance treatment may therefore be necessary.

Diagnosis of peptic ulcer in children: the past and present

The problem of diagnosis of peptic ulcer in children was analysed in a series of 50 consecutive cases. Atypical symptomatology occurred frequently and resulted in errors in diagnosis in six instances: perforated ulcer was misdiagnosed as appendicitis in five and bleeding ulcer was misdiagnosed as Meckel's diverticulitis in one. Barium meal was the investigation employed in earlier years but had proven unsatisfactory, being incorrect in four out of 22 examinations. Fiberoptic endoscopy was introduced in recent years and having achieved correct diagnosis in 20 patients with no errors, has established itself as the choice of investigation.

Duodenal ulceration presenting in childhood longterm follow-up

Forty-one children diagnosed as suffering from duodenal ulceration by endoscopy and barium studies have been reviewed 5 to 15 years (mean 8.6 years) later. Mean age at diagnosis was 8.6 years. All were managed medically as children. Fifty-one percent are now asymptomatic, off all treatment; the rest have chronic symptoms typical of duodenal ulcer. Six patients (15%) required surgery, four as emergencies for complications and two for failure of medical management.

Cimetidine in primary duodenal ulcer in children

Of 16 children with primary duodenal ulcer, 11 had complete relief of symptoms with initial full dose cimetidine therapy. After stopping cimetidine two of these 11 relapsed, six are in remission and three occasionally complain of abdominal pain requiring antacids. The remaining five children showed no improvement at all. Only one out of the 16 children showed side-effects due to cimetidine. Although there was wide variation in dosage of cimetidine and duration of therapy, no significant difference was noted in the dosage regimen of responders and non-responders to cimetidine. We suggest, full dose cimetidine 20 to 40 mg/Kg/day for 4 to 8 weeks, followed by 8 mg/Kg nocte daily for another 4 to 8 weeks.

Duodenal ulcer in South Indian children

Twenty-nine children with duodenal ulcer received treatment during an 18 year period. Twenty-five were followed over a period that ranged from 3 to 18 years; 53.8 percent of the patients who received medical treatment either had recurrence or persistence of ulcer symptoms during adolescence or adulthood. Two patients with acute bleeding ulcers have remained well after vagotomy and drainage procedures. Pyloric stenosis was the most common indication for surgical intervention and in all such cases the patients underwent truncal vagotomy and drainage procedures and continue to live without any symptoms, except one in whom anastomotic ulcer due to incomplete vagotomy has developed.

Peptic ulceration in adolescence

The fate of 22 adolescents (mean age 14 years) with proved peptic ulceration is reported. Five presened as an emergency with performation of haemorrhage, whilst the remining 17 had typical ulcer dyspepsia. Despite intensive medical measures 17 patients required difinitive surgery. Ten patients were under 18 years of age at the time of operation and all were opearted on at under 25 years of age. the results were excellent in 14 out of 17 patients at 5-year followup, suggesting that surgery should not be withheld on the grounds of age alone. The role of histamine H2 receptor antagonists needs to be assessed in this type of patient.

Gastro-cutaneous syndrome: peptic ulcer/hiatal hernia, multiple lentigines/café-au-lait spots, hypertelorism, and myopia

We report the familial occurrence in a French Canadian family of peptic ulcer/hiatal hernia, multiple lentigines/café-au-lait spots, apparent hypertelorism, and myopia caused by a pleiotropic autosomal dominant gene with high penetrance and variable expressivity. Other probable but rarer components of the syndrome include ischemic heart disease, congenital heart disease, and maturity onset diabetes. Symptoms of peptic ulcer/hiatal hernia usually started in the second or third decade and were associated, as least in some examined individuals, with relatively increased acid secretion and abnormal dermatoglyphics.

Relationship of postprandial serum gastrin response to sex, body weight, blood group status, familial dyspepsia, duration, and age of onset of ulcer symptoms in duodenal ulcer

Integrated postprandial serum gastrin levels were studied in a prospective series of 144 Chinese patients with duodenal ulcer in relation to sex, total body weight, age of onset and duration of ulcer symptoms, blood group status, and positivity for familial dyspepsia. Postprandial gastrin was unrelated to sex, total body weight, duration of symptoms, and blood group status. Patients whose onset age was in the first two decades (early onset group) had significantly higher postprandial gastrin than those with onset age in the 4th and 6th decades (P less than 0.01). This was found to be associated with the presence in the early onset group (n = 35) of a high proportion of patients with positive family history of ulcer dyspepsia (n = 24), in whom postprandial gastrin was significantly higher than those without such history (P less than 0.01). These results suggest that early onset patients who are positive for family history of ulcer dyspepsia segregate to form one subgroup of duodenal ulcer. They also offer a clue that familial hypergastrinaemia may be one marker for familial duodenal ulcer.

Duodenal ulcer disease in chidren

Eleven cases of chronic duodenal ulcer in children were subjected to surgical treatment in a period of 7 years. The diagnosis was based on typical peptic ulcer symptoms, hyperchlorhydria, and barium meal x-ray studies delineating a duodenal bulb deformity with an ulcer crater in 8 patients. Three cases of duodenal ulcer perforation in infants were diagnosed at aparotomy for peritonitis with pneumoperitoneum. All the patients hailed from the rgion of Assam, India, where peptic ulcer is prevalent. A positive family history of peptic ulcer in 5 patients, blood group O in 7 patients, and the regional diet were considered to be predisposing factors. Medical treatment consisting of a bland diet, sedatives, antispasmodics, and a brief hospital stay failed to provide permanent relief of symptoms. Truncal vagotomy with a drainage procedure was done in 8 patients with no deaths. However, simple closure of the perforation in the 3 infants resulted in fatalities due to fulminant septicemia. The patients were followed up for 1-8 years. Six patients had permanent relief of symptoms. Two patients occasionally complained of epigastric fullness and eructation. They showed normal growth, gain in weight and hemoglobin levels, and had no recurrence. We believe that operative treatment is preferable to medical management of chronic duodenal ulcer in children.

Duodenal ulcer in childhood: a continuing disease in adult life

Thirty-one of the 37 children with duodenal ulcers were available for follow-up. Of the 28 patients treated medically, 22 had persistence of symptoms over periods up to 18 yr after the time of the initial diagnosis. Five patients required surgery elsewhere for complications, thirteen showed ulcer crater or duodenal deformity on a follow-up barium meal studies. Earlier surgery is recommended in chronic ulcer disease.

Primary peptic ulcer in childhood. Psychosocial, psychological and psychiatric aspects

Twenty-five children with radiologically confirmed primary peptic ulcers were investigated. All patients suffered from duodenal ulcer and there was an unexpected female preponderance. The frequency of introverted personalities was greater in the patients than in the controls. Five patients suffered from psychiatric disorders, three had histories of suicidal attempts and three reported homosexual experiences. Six patients had nicknames. Eight patients had been operated on for appendicitis. The above parameters were negative in all control cases. The patients had lower mean IQ, worse adaptation to school, more anxious and overprotective parents, higher frequency of faddiness in food and lower frequency of nail-biting than the controls. The onset of symptoms was preceded by psychotraumatic events in eight cases. The findings suggest that the manifestation of the genetic background of duodenal ulcer is strongly influenced by environmental factors and factors associated with the personality of the patients.

Duodenal ulcers: early and late onset

A hospital series of 1042 duodenal ulcer patients was examined to determine the relationship of the age of onset of ulcer dyspepsia with the blood group and with the family history of ulcer dyspepsia. It was found that those patients whose symptoms begin in the first two decades of life (early onset patients) contain a significantly larger proportion of group A, B, and AB subjects and a significantly stronger family history of dyspepsia than those whose symptoms begin from the fourth decade of life onwards (late onset patients), in whom blood group O prevails. The group O status is shown to be associated with a significant proneness to duodenal ulceration and a significant proneness to bleed, and in the late onset patients a significant proneness to bleed recurrently and severely. Bleeding is the predominent complication in the early onset patients. There is a significantly increased tendency for the late onset ulcers to perforate, to become stenosed, to have severe pain, and to be virulent--that is, to be multiple, post-bulbar, or giant. While these features do not appear to be related to the effect of ageing, the occurrence of associated gastric ulceration and the mortality rate was shown to be related.

Duodenal ulcer in children

Forty-nine cases of duodenal ulcer in children are presented. Strict radiological and clinical criteria were observed in making this diagnosis. The children came from a population of approximately 100,000 children over a 10-year period. Upper abdominal pain was the commonest presenting symptom, and exacerbations and remissions of the disease were observed to be shorter than is expected in the adult. Haemorrhage occurred as a complication in 24% and there were no cases of perforation or stenosis. A family history of duodenal ulcer was found to be highly significant, and it was found that in 55% of patients there was an important element of stress. Treatment was conservative in all but 2 cases, in both of which a vagotomy and pyloroplasty were performed. These operations were judged to have been successful. 6 cases had appendicectomy in the hope of relieving undiagnosed abdominal pain, in which it was unsuccessful. A plea is made for keeping this diagnosis in mind when dealing with abdominal pain in children.

Operative treatment of chronic duodenal ulcer in childhood

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