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Case presentation of paediatric peptic ulcer disease

Case presentation of paediatric peptic ulcer disease, h pylori peptic ulcer with treatment and latest guidelines

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Case presentation of paediatric peptic ulcer disease

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  1. CASE PRESENTATION BY DR MAHEEN INTERN PEDIATRIC UNIT I, CHK

  2. A 9-year-old, female child, completely vaccinated, with NKCM, resident of Kemari, Karachi, presented to the emergency with the complaints of : • Fever - 4 months • Blood in vomitus - 8 days • Blood in stool - 1 day

  3. HISTORY OF PRESENTING COMPLAINTS According to the patient’s mother, she was in her usual state of health 4 months back when she started having fever on and off. The fever was undocumented, low-grade in nature not associated with rigors or chills. The patient was taken to local clinics multiple times during this period, where the fever subsided temporarily with oral medication but recurred after a week or two.

  4. Since last 8 days, patient has developed blood in vomitus, 3 to 4 times per day, fresh, bright red in colour, 1-2 tsp in quantity. It is associated with blood in stools as well for 1 day before arrival in ER

  5. No history of bleeding from any other site (hematuria, epistaxis) • No history of jaundice or abdominal distention • There is history of abdominal pain in the epigastric region that is moderate in intensity and is relieved by taking food. • No history of joint pain , photophobia or alopecia however there is history of recurrent oral ulcers for 8 months • No history of prolonged bleeding after trauma or swelling at injection site previously

  6. Systematicreview: CNS: No history of fits, altered level of consciousness Chest: no history of shortness of breath, cough or orthopnea CVS: no hx of palpitations, no hx of dyspnea on exertion or rest Genitourinary: no hx of hematuria, burning micturition, urgency, or other urinary complaints Musculoskeletal: body aches, no joint swellings Gastrointestinal: history of mild abdominal pain, epigastric, for the last 2 months, more on an empty stomach, relieved by eating meals. no hx of loose stools hx of oral ulcers on and off for the last 8 months hematologic: no hx of hematoma after IM injections, no hx of gum bleeding

  7. PAST MEDICAL HISTORY: • No history of hospital admission previously. BIRTH HISTORY: • Delivered via SVD at term with no postnatal complications.

  8. IMMUNIZATION HISTORY: • Patient is completely vaccinated according to EPI schedule although no record available but BCG scar is present NUTRITIONAL HISTORY: • Breakfast: 1/2 roti, fried egg, 1 glass cow milk • Lunch: 2-3 boiled potatoes with a small plate of rice • Dinner: 1 small plate rice with a chicken piece • Pulses 4 times / week • Fruits 1-2 times per month • Meat: chicken 1-2 times per week, red meat 1 time per month • Fond of eating spicy junk food • Taking 830 KCal/day approximately (50% of required)

  9. DEVELOPMENTAL HISTORY : • All milestones were achieved on time. Developmental age is corresponding to the chronological age TRANSFUSION HISTORY: • No history of transfusion previously

  10. DRUG HISTORY : • No history of chronic drug intake FAMILY HISTORY • Second product of consanguineous marriage • No history of miscarriage or stillbirths in the family • History of a bleeding disorder in cousin in maternal side of the family • No history of menorrhagia in mother or aunts

  11. SOCIOECONOMIC STATUS: • Father is a labor and sole earner for a family of 5. • They use unboiled tap water • Overall belong to a low socioeconomic status

  12. EXAMINATION A cooperative female child, well oriented to time place and person, average built and height, with no dysmorphic features lying comfortably on the bed with following vitals • HR : 89 beats/min • R/R : 26 breaths/min • Temp : 37 C • Sp02: 99% • CRT: < 2 secs • Peripheral pulses: palpable • Rbs : 99 mg/dl • BP : 100/70 A+,J-,Cy-,E-,D-, LN-

  13. ANTHROPOMETRIC MEASUREMENT • Length : 126 cm (b/w 10th and 25th centile) • Weight : 19 kg (<5th centile)

  14. Systemic Examination • CVS : S1+S2+0 • CHEST : Bilateral normal vesicular breathing with equal air entry and no added sound • CNS : GCS 15/15, pupil, BERL overall INTACT • ABDOMEN : soft, some tenderness at the epigastric region, no visceromegaly, gut sounds audible

  15. Head to toe Examination • Head : normal • Eyes : normal, no subconjunctival hemorrhage • Mouth: no active bleeding, oral cavity normal. • Ears: normal. no discharge • Face : no dysmorphic features • Skin : normal, no bruises or petechiae. • Spine : normal • BCG Scar present • Digital Rectal Exam: normal

  16. Case Summary • A 9 years old female patient presented with complaints of: • Fever on and off for 4 months • Blood in vomitus for 8 days • Blood in stool for 1 day • History of epigastric pain is significant relieved by food intake • History of recurrent oral ulcers since last 8 month. • No history of bleeding from any other site or bleeding previously • Positive family history of bleeding disorder • Systemic examination is completely unremarkable except for mild tenderness in epigastric region

  17. DIFFERENTIAL DIAGNOSIS?

  18. INITIAL MANAGEMENT • On room air • Orally allowed • Maintenance fluid 0.9% DS 725ml over 24h (50% maintenance fluid) • Labs sent

  19. INVESTIGATIONS

  20. Urine DR: normal • Stool DR: no evidence of bleeding • Stool for occult blood: +VE • Stool for H. Pylori antigen : +VE

  21. COURSE DURING HOSPITAL STAY • Treatment of H. Pylori started (triple regime) • Inj. Omeprazole 20 mg IV X BD (1mg/kg/dose BD) • Syp. Clarithromycin (125 mg/5ml) 10 ml x BD (500mg BD) • Syp. Metronidazole (200 mg/5ml) 6 ml X BD (250mg BD) • Patient was well during the hospital stay. No episode of bleeding from mouth occurred. No fever documented. Epigastric pain improved with treatment. • Endoscopy is in plan (20/9/25). • Patient was discharged with following up advice and danger signs explained. • Continue treatment at home: • Omeprazole for 1 month • Clarithromycin and Metronidazole for 2 weeks • Repeat Stool for H. Pylori antigen 2 weeks after stopping PPIs.

  22. FINAL DIAGNOSIS Peptic Ulcer Disease secondary to H. Pylori infection

  23. Latest Guidelines for treatment • for H pylori= First-line therapy: use of potent acid suppression (PPIs) or newer agents like P-CAB (potassium-competitive acid blocker; e.g. vonoprazan) along with appropriate antibiotic regimens. JSGE guidelines recommend vonoprazan + antibiotics as first-line in certain settings. • For drug-induced ulcers= (NSAIDs, low dose aspirin (LDA)), discontinue causal agent if feasible. If not, use PPIs. PMC+1 • In patients with prior ulcer history who need NSAIDs, co-therapy with PPIs is recommended; using COX-2 selective inhibitors may reduce risk. SpringerLink+1

  24. Deterrence and Patient Education • Patients with peptic ulcer disease (PUD) should be counseled about potentially injurious agents like nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin. • If it is necessary to use NSAIDs, use the lowest possible dose and also consider prophylaxis for patients who use NSAIDs. • Obesity has a strong association with peptic ulcer disease, and patients should be asked to lose weight. • Stress reduction counseling can be helpful in some cases. • Patients should be counselled about consuming very spicy foods and should be discouraged from eating out or eating unhygienic and fried food.

  25. THANK YOU !

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