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Patient Story

A 10-year-old boy is brought in by his mother because of several episodes of vomiting. The most recent episode was small volume and had some brown-colored material in it. The boy tells you that he has had stomach pain off and on in the past few months and feels nauseated. He has not been having difficulty in school but his mother tells you that they will likely need to move soon as his father lost his job recently and has been unable to find work. The patient is the oldest of the 3 boys and shares a room with his brothers. He worries about his dad and hopes that he will be able to stay at his school. You discuss your concerns and recommend that the patient undergo esophagogastroduodenoscopy (EGD). His mother states that the children have health insurance through a state program and agrees to the testing. You start the patient on generic ranitidine. His EGD reveals a small pyloric ulcer and the biopsy specimens test positive for Helicobacter pylori (Figure 55-1). You prescribe 10 days of triple therapy with bismuth salts, amoxicillin, and metronidazole as the child's insurance does not cover the more expensive alternative medications.


Endoscopic view of a pyloric ulcer and an erosion of the mucosa. (Used with permission from Marvin Derezin, MD.)


Peptic ulcer disease (PUD) is a disease of the gastrointestinal (GI) tract characterized by a break in the mucosal lining of the stomach or duodenum secondary to pepsin and gastric acid secretion; this damage is greater than 5 mm in size and with a depth reaching the submucosal layer.1 PUD can be either primary or secondary; the latter most often due to severe systemic illness (e.g., sepsis) or from ulcerogenic drug ingestion (e.g., nonsteroidal antiinflammatory drugs (NSAIDs) or steroids).


  • PUD is a common disorder affecting approximately 4.5 million people annually in the US. It encompasses both gastric and duodenal ulcers (Figures 55-1 to 55-4).2

  • One-year point prevalence is 1.8 percent, and the lifetime prevalence is 10 percent in the US.2

  • Prevalence is similar in both sexes, with increased incidence with age.1

  • PUD is less common in children. In an Israeli study of 751 symptomatic children referred for endoscopy, peptic ulcers were found in 51 patients (6.8%).3 H. pylori was positive in 112 (66.3%) patients and H. pylori-associated ulcers were more common in children older than age 10 years. A similar rate was demonstrated in a Chinese case series where 43 of 619 children (6.9%) undergoing upper endoscopy for investigation of upper gastrointestinal symptoms had primary PUD.4 Authors of an Italian study (N = 2234 endoscopies in children) reported a lower rate of 3.4 percent positive endoscopies for ...

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