A 13-year-old female came to clinic with new onset of stomach pain for less than 24 hours. The pain began the previous afternoon after a large meal at a family event after which she was running around and was active. She complained to her mother but continued to eat more and be active. The evening after the event she had increased abdominal pain. In the morning she had minor pain and mother decided to come to the clinic. She was otherwise well with normal urination and bowel movements including the morning of her clinic visit. Her mother was concerned because an adult relative had been discussing his own gastric ulcer disease and medication at the event. The past medical history showed occasional constipation that was controlled with diet. The family history was negative except for constipation, gastroesophageal reflux including some with disease and the one relative with the gastric ulcer. The review of systems was negative.
The pertinent physical exam showed a well-appearing female with no pain. Her growth parameters were 50-75% with appropriate growth velocities. Her abdominal examination was negative. The diagnosis of overeating and exercise was made. During his counseling of the family the mother said several times how she became worried because of the relative’s description of his own gastric pain. She was reassured by the physician but asked how common gastric ulcers were in children. The physician said that it was not very common particularly with this history. The physician later decided to do a PUBMED search to find out the incidence of gastric ulcers.
The exact cause of gastric and upper intestinal inflammation and ulceration are not entirely understood. Imbalances between irritative factors and mucosal defenses underlie it. Gastric acid production is at adult levels by 3-4 years. Actual ulceration is associated with a lower acid secretion for gastric ulcerations but are increased in duodenal ulcerations in both adults and children. In adults changes to the mucus layer of the stomach and duodenum and bicarbonate secretion play a part in upper GI inflammation and ulcerations. Genetic studies have been linked to differences in both acid production, and mucosal barriers. Additionally there may also be genetic differences linked to Helicobacter pylori (H. pylori) infections. H. pylori infections are linked to overcrowding and poor socioeconomic conditions, but rates appear to be declining across the world.
Primary ulcerations are defined as upper GI ulcerations in pediatric patients that have no other identified etiology. They are most often caused by H. pylori infection in children. They are much less frequent than secondary ulcerations. Secondary ulcers are due to other causes of upper GI inflammation such as trauma, sepsis, or drugs (i.e. non-steroidal anti-inflammatory drugs), but they can also occur as a secondary problem in specific diseases such as Crohn’s disease and Zollinger-Ellison syndrome. Sickle-cell anemia, reactivation of viral infections such as Epstein-Barr and Varicella infections, and cystic fibrosis also have been identified as secondary causes of upper GI ulcers. Secondary ulcers are the most common causes of upper GI ulcerations in children.
For adults gastroesophageal reflux and disease is reported to be around 10-20%. The incidence of gastroesophageal reflux and disease in children is hard to determine. One study in 2000 reported different percentages depending on age, and specific symptoms and said, “Parents of 3- to 9-year-old children reported that their children experienced a sensation of heartburn (“burning/painful feeling in middle of chest”), epigastric pain (“stomachache above belly button”), and regurgitation (“sour taste or taste of throw up”) 1.8%, 7.2%, and 2.3% of the time, respectively. Parents of 10- to 17-year-old children reported that their children experienced the same symptoms 3.5%, 3.0%, and 1.4% of the time, while children aged 10 to 17 years reported the symptoms 5.2%, 5.0%, and 8.2% of the time, respectively. Complaints of abdominal pain (“stomachache”) were most common, reported by 23.9% and 14.7% of parents of 3- to 9-year-old and 10- to 17-year-old children and by 27.9% of children aged 10 to 17 years.”
Ulcerations are relatively rare in children compared to adults. One study using hospitalization and insurance claims data reported an estimated 24.8 cases/100,000 of upper GI ulceration in the pediatric population, and 17.4% had bleeding of the ulcer. Overall the incidence of upper GI bleeding was 0.5-4.4 cases/100,000.
Questions for Further Discussion
1. What are the treatment options for gastrointestinal ulcerations?
2. How is H. pylori treated?
3. What is the role of endoscopy in management of gastroesophageal reflux and peptic ulcer disease?
- Symptom/Presentation: Abdominal Pain
- Specialty: Gastroenterology
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
Blecker U, Gold BD. Gastritis and peptic ulcer disease in childhood. Eur J Pediatr. 1999 Jul;158(7):541-6.
Nelson SP, Chen EH, Syniar GM, Christoffel KK. Prevalence of symptoms of gastroesophageal reflux during childhood: a pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med. 2000 Feb;154(2):150-4.
Carroll MW, Jacobson K. Gastroesophageal reflux disease in children and adolescents: when and how to treat. Paediatr Drugs. 2012 Apr 1;14(2):79-89.
Brown K, Lundborg P, Levinson J, Yang H. Incidence of peptic ulcer bleeding in the US pediatric population. J Pediatr Gastroenterol Nutr. 2012 Jun;54(6):733-6.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital