GI Bleeding in Infants & Children: Initial Evaluation & Peptic Ulcer Disease Pathogenesis

1. Welcome Applicants!! Morning Report: Thursday, January 26th

2. GI Bleeding in Infants and Children

3. Initial Approach • Step 1: ABCs!! Assess hemodynamic status of the patient • Orthostatic changes- best indicator of significant blood loss • Step 2: Establish severity of bleeding • Coffee ground emesis, melena: lower rate of bleeding • Bright red blood: ?higher rate of bleeding

4. UGI vs. LGI Bleeding • Step 3: Determine the location of the bleeding • UGI: bleeding above the ligament of Treitz • Hematemesis • LGI: bleeding distal to the ligament of Treitz • Bloody diarrhea • Bright red blood mixed with or coating stool • Hematochezia, melena, or occult blood loss can be due to both UGI or LGI bleeds • Passing NGT can determine if the blood is originating from the UGI tract or LGI tract

5. Is It Blood? • Simulates bright red blood • Food coloring • Colored gelatin or children’s drinks • Red candy • Beets • Tomato skins • Antibiotic syrups • Simulates melena • Bismuth or iron preparations • Spinach • Blueberries • Grapes • Licorice

6. Peptic Ulcer Disease in Children

7. Pathogenesis Cytoprotective factors: Mucous layer Local bicarb secretion Mucosal blood flow Cytotoxic factors: Acid Pepsin Medications Bile acids Infection with H.Pylori

8. Clinical Presentation • Epigastric abdominal pain • Recurrent vomiting (at least 3x/mo) • Symptoms associated with eating (anorexia/ wt loss) • Pain awakening the child at night • Heartburn • Oral regurgitation • Chronic nausea • Excessive belching/ hiccuping • FHx of PUD, dyspepsia, or IBS

9. History • Symptoms? • Dietary history? • Specific foods that worsen pain? • Medications? • Alcohol or tobacco use? • Doses of acid-suppressive meds?

10. Physical Exam • Height, weight and BMI PLOT! • HEENT • Funduscopic exam • OP: aphthous ulcers Crohn’sdz, dental enamel erosion GER, Eating d/o • Lungs • Wheezing GER • Abdomen • Splenomegaly portal HTN • Rectum • Perianal disease Crohn’sdz • Extremities • Clubbing Crohn’sdz, Russell sign Eating d/o

11. Evaluation • Screening labs • CBC with diff • ESR • LFTs • Electrolytes • Stool for O&P • UA • Endoscopy • Indications • Evidence of GI bleeding • Abnormality on UGI • Odynophagia • Refusal to eat • Persistant unexplained vomiting • Lack of response to medications

12. Helicobacter pylori Infection

13. The Basics… • Gram negative bacillus • Transmission fecal-oral, gastric-oral, or oral-oral • *Organism associated with a significant proportion of duodenal ulcers & chronic active gastritis • To a lesser extent, gastric ulcers • Also linked to the development of gastric adenocarcinoma and lymphoma

14. Epidemiology • 50 % of the world’s population is infected • Most are asymptomatic • Infection most common in developing countries • Incidence 3-10% in developing countries • Incidence 0.5% in industrialized countries • Asian Americans, African Americans and Hispanic individuals living in North America have a prevalence of infection similar to that of a developing country • Ethnic or genetic predisposition?

15. *Risk Factors • Poor socioeconomic status • Family overcrowding • Child care attendance • Poor hygiene • Living with an infected family member

16. *Testing • The ideal test does not yet exist! • Endoscopy with biopsies from the prepyloricantrum= gold standard • Histologic identification • Culture • Immunologic detection of H.Pyloriurease • PCR • Urease breath test • Anti-H. Pylori IgG • Stool antigen testing

17. *Testing • Stool antigen testing • Sensitivity and specificity> 98% • Sample easy to obtain • Less expensive than the urease breath test • The AAP says…don’t test for it if you are not going to treat it!! • Active peptic ulcer disease • History of ulcers • MALT lymphoma or gastric cancer

18. *Treatment • Goals • Eradicate the organism • Heal the ulcer • Prevent recurrence of infection and the emergence of resistant organisms • Two antimicrobials + PPI • First line: clarithromycin+ Amoxicillin OR metronidazole+ PPI • Alternative (age>8): tetracycline+ metronidazole+ bismuth subsalicylate+ H2 blocker

19. *Treatment • Length of treatment: 14days • Cure rates 75-90% • To check for eradication, wait 6 weeks-3 months after the completion of therapy • Urease breath test • Stool antigen test

20. A Question… • A 12 yo boy who has a h/o recurrent abdominal pain presents to your office for an annual health supervision visit. The boy complains of periumbilical pain, unrelated to meals, occuring twice a month and lasting 15 minutes. PE is normal. FOBT is negative. His father, who is a physician, asks if the boy should undergo testing for H. Pylori. Of the following, a TRUE statement about H. Pylori infection is: • A. All children who have positive H. Pylori serologies should undergo endoscopy • B. Antibiotic therapy for H. Pylori is most effective when combined with a PPI • C. H. Pylori is difficult to detect on gastric histology without special immunofluorescent staining • D. H. Pylori infection is less prevalent in children from the developing world • E. H. Pylori organisms rarely develop antibiotic resistance

21. Thanks for your attention!! Noon Conference: Pseudoasthma, Dr. Pepiak