Pediatric peptic ulcer

　　Acute peptic ulcer is more common than chronic peptic ulcer in pediatric peptic ulcer disease, and secondary cases are more common than primary cases. It often occurs secondary to severe hypoxia or severe infection (sepsis, pneumonia, gastroenteritis, meningitis), severe malnutrition, long-term and large-scale use of adrenal cortical hormones, extensive burns, nervous injury, and other conditions. The primary cases are often caused by excessive gastric acid secretion, which is the main cause. The normal neonate reaches the peak of gastric acid secretion within 48 hours, maintains a high level within one year, slightly lower from 1 to 4 years old, and then increases after 4 years old. Secondly, mental factors are involved, and this disease is 85% likely to occur in older children who are good learners and whose emotions are easily fluctuating. They often trigger the disease when they are stimulated or traumatized by mental factors. As for the genetic issue, there is no definitive conclusion, but 1/3 of the cases have a family history, showing autosomal dominant inheritance characteristics. People with blood type O are more prone to it. In recent years, it has been found that children with peptic ulcer disease have a spiral bacterium in the antrum mucosa called Helicobacter pylori, which may be the cause of the disease. It can be confirmed by silver staining, electron scanning microscopy, and culture, and it also plays an important role in recurrence.

　　Hemorrhage and anemia are the most typical complications of pediatric peptic ulcer disease, and severe hemorrhage can lead to hemorrhagic shock.

　　1. Hemorrhage: Hemorrhage can occur when the ulcer destroys the blood vessels in the gastric wall or duodenal wall. When the amount of hemorrhage is small, it is manifested as positive occult blood in the stool. When the ulcer destroys large blood vessels, it can cause massive hemorrhage, manifested as hematemesis or melena. Due to the action of gastric acid, the amount of blood vomited is often large, and it can be bright red immediately after vomiting, followed by tarry stools, which can be severe and lead to hemorrhagic shock.

　　2. Anemia: Children with peptic ulcer disease often have poor diet and poor absorption, and in addition to the inflammatory consumption of the ulcer, acute or chronic hemorrhage can cause anemia, which is mostly nutritional microcytic anemia, also known as iron deficiency anemia. These children are physically weak and prone to various infections.

　　3. Perforation: Severe ulcers can penetrate the gastric wall or duodenal wall to cause ulcer perforation. Substances in the stomach or duodenum, such as gastric acid, food, bacteria, and air, can flow into the abdominal cavity and cause diffuse peritonitis. Children with this condition may show extreme restlessness, pale complexion, severe abdominal pain, and even shock.

　　4. Pyloric stenosis: It is more common in older children. When the ulcer of the stomach occurs near the pylorus, the stimulation of the inflammatory reaction causes the sphincter to spasm, or the surrounding inflammatory edema can obstruct the passage of food through the pylorus, causing transient pyloric stenosis. If the ulcer recurs and heals repeatedly, it will eventually form scars, adhere to the surrounding tissues, and cause persistent pyloric stenosis.

　　The clinical manifestations of pediatric peptic ulcer disease are various, and the symptoms vary greatly with different ages.

　　1. Neonatal period:It is mainly characterized by sudden upper gastrointestinal hemorrhage or perforation, often with an acute onset, mainly manifested by hematemesis, hematochezia, abdominal distension, and peritonitis. It is easily misdiagnosed. At this stage, it is mostly acute stress ulcer, with a high mortality rate, and the most cases occur within 24 to 48 hours after birth.

　　2. Infancy:This period of children is often characterized by acute onset, restlessness, poor appetite, sudden hematemesis, melena, and in the early stage, there may be symptoms such as decreased appetite, repeated vomiting, abdominal pain, and delayed growth and development.

　　3. Preschool age:Primary ulcers gradually increase during this period, with obvious abdominal pain symptoms, mostly located around the umbilicus, presenting intermittent attacks, with unclear association with diet. Nausea, vomiting, heartburn, anemia, and upper gastrointestinal bleeding are also common.

　　4. School age:Duodenal ulcers are more common, and as age increases, the clinical manifestations become closer to those of adults, with symptoms mainly including abdominal pain around the umbilicus, and sometimes nocturnal pain, heartburn, belching, or chronic anemia. A few people may present with painless black stools, fainting, or even shock.

　　Secondary peptic ulcer

　　Secondary peptic ulcers are often related to stress factors or the use of non-steroidal anti-inflammatory drugs. Common stress factors in children include severe systemic infection, shock, sepsis, surgery, trauma, etc. Ulcers caused by severe burns are called curling ulcers, and those caused by cranial and brain surgery are called cushing ulcers. The mechanism by which stress factors cause ulcers is not yet clear, and it is speculated that it may be related to the constriction of small blood vessels under the gastric mucosa, causing ischemia of the superficial mucosa. Partly, it is due to the destruction of the gastric mucosal barrier, causing H+ back diffusion, followed by abnormal secretion of gastric acid, and also possibly related to prostaglandins. Generally speaking, secondary ulcers are more serious, and some scholars reported 54 cases of pediatric secondary ulcers, of which 55.5% (30/54) were accompanied by bleeding, 14.8% (8/54) were perforated, 11.1% (6/54) were in shock, 9% (5/54) had pain or vomiting, and 62.9% (34/54) were terminal ulcers. The clinical characteristics of secondary ulcers are the lack of obvious clinical symptoms, and they are only discovered when bleeding, perforation, or shock occurs, so the mortality rate is as high as 10% to 77%.

　　Pediatric peptic ulcer is mostly acute ulcer, often presenting with bleeding and perforation, with an incidence rate of about 15%. The younger the age, the more serious it is, especially in the neonatal period, which is the most dangerous. If perforation occurs, the mortality rate is relatively high. Since children have a strong ability to repair, peptic ulcer disease generally has a lighter course than adults, and many patients can be cured quickly with medical treatment for 3-4 weeks. About 50% of cases can recur, and about 25% of cases can lead to local scar狭窄, causing pyloric obstruction, which requires surgical treatment.

　　Specific preventive measures include:

　　1. Have meals at regular intervals and in appropriate amounts: all three meals should be nutritionally balanced. Eat slowly and chew thoroughly, as the large secretion of saliva during chewing also has the function of neutralizing stomach acid. Do not have a bias in food preferences, and do not let children play while eating, or read books or watch TV while eating.

　　2. Prevent overeating and undereating. When encountering favorite food, do not eat to the point of satiety, and do not eat or eat very little of food that is not to one's taste, so that the burden on the gastrointestinal tract fluctuates from light to heavy.

　　3. Do not overemphasize high nutrition. It is necessary to achieve scientific dietary matching, eat more high-protein, low-fat, and easily digestible foods.

　　4. Do not eat刺激性大的食物 for a long time, and do not consume cold drinks in large quantities, such as ice cream and the like.

　　5. Pay attention to the combination of work and rest, reasonably arrange the study and life of children, and do not let them overwork or become too nervous.

　　6, For children with peptic ulcers with bleeding symptoms, according to specific conditions, change the diet continuously, from fasting, liquid, semi-liquid to gradually transition to ordinary food.

　　7, For chronic ulcers, brown rice is preferable, and it is best to avoid foods that cause excessive gastric acid secretion, such as coffee, sweet potatoes, etc. Avoid eating fine foods such as refined grains and specially prepared refined wheat flour. Animal foods should be mainly white meat and fish. Protein should be obtained mainly from soybeans and soy products. Encourage the children to eat more yellow and green vegetables.

　　8, For children with active ulcer disease, arrange the diet with liquid or low-residue semi-liquid foods, and change to ordinary food after the condition improves. Generally, it is not required to eat small meals frequently, as eating can neutralize gastric acid and on the other hand stimulate the stomach, causing an increase in gastric acid secretion. Chewing slowly and producing a large amount of saliva can neutralize gastric acid and also avoid the stimulation of rough food on the ulcer surface.

　　In summary, for children with peptic ulcers, it is emphasized that diet should be 'individualized'. Give them their favorite foods according to each child's habits and tolerance, and it is also important to let them eat in a relaxed and pleasant atmosphere.

　　Since the symptoms and signs of peptic ulcers in children are not as typical as in adults, they are often misdiagnosed and missed. Therefore, for children with symptoms such as burning sensation or hunger pain under the xiphoid process, recurrent abdominal pain that relieves after eating, prominent symptoms at night and in the morning, vomiting related to diet, anemia with positive fecal occult blood test, recurrent gastrointestinal discomfort, and a family history of ulcer disease, especially duodenal ulcer, as well as those with unexplained hematemesis or melena, one should be vigilant about the possibility of peptic ulcer disease and perform upper gastrointestinal endoscopy in a timely manner to make an early and clear diagnosis.

　　One, Helicobacter pylori detection

　　1, Invasive methods: taking gastric mucosal living tissue through gastroscopy for Hp culture, rapid urease determination, and bacterial staining examination.

　　2, Non-invasive methods: measuring serum Hp-IgG as a screening indicator for Hp and urea breath test. A positive breath test indicates active Hp infection, but the 13C-breath test requires certain equipment and is expensive, so its clinical application is limited. The 14C-breath test is less expensive, but as it is a radioactive isotope, it is not suitable for use in children.

　　Two, Gastric acid secretion test

　　It is difficult to perform gastric acid secretion tests in children, and this test has little diagnostic significance for most peptic ulcers, so it is rarely used in clinical practice. However, for refractory ulcers, it can determine the function of gastric acid secretion, and if it persists at a high level, attention should be paid to whether there is a gastrinoma (Zollinger-Ellison syndrome).

　　Three, Occult blood test in stool

　　It is a simple and meaningful examination with practical value for judging the condition of small bleeding or bleeding activity.

　　Four, Endoscopic examination

　　Endoscopic examination is the most important means of diagnosing peptic ulcers. Under the endoscope, ulcers appear as circular or elliptical lesions, a few as linear, with clear boundaries and a grayish-white苔状物 covering the center. The surrounding mucosa is slightly elevated or at the same level. Depending on the course of the disease, ulcers are divided into three stages: active, healing, and scar stages.

　　Five, X-ray barium meal examination

　　Because X-rays can penetrate the gastric wall but not barium, after the child eats barium, the outline of the stomach and duodenum can be seen on the fluorescent screen. If there is a shadow on the wall of the stomach or duodenum, it can be determined that the diagnosis of ulcer disease is correct, which is called a direct sign. The so-called shadow is the filling shadow of barium at the ulcer site, that is, the突出shadow that appears on the wall of the stomach and duodenum under fluoroscopy. Since the ulcer focus of children is shallow and small, and the duodenal ulcer focus is mostly located on the posterior wall of the bulb, which is not easy to observe, typical ulcer shadows are not easy to find. Most children with ulcers can only infer indirectly, such as the spasm of the duodenal bulb is easy to irritate, that is, when the barium passes through the bulb, the speed is too fast; pyloric spasm presents localized tenderness. The detection rate of duodenal ulcer is about 75%, and the detection rate of gastric ulcer is less than 40%. Therefore, a negative barium meal examination cannot be said to rule out the possibility of ulcer disease in children. Since barium is not absorbed, it does not harm the body, and the operation method is simple, children are easy to accept it. Therefore, to date, barium meal examination is still the preferred examination method for diagnosing ulcer disease in pediatrics.

　　Six, fiberoptic gastroscopy

　　This examination can be used to detect HP infection and perform gastric juice analysis at the same time. Because ultra-thin caliber gastroscopy has been used in clinical practice, children have weaker pharyngeal reflexes, and gastroscopy is easier to pass through the throat, with a high success rate and no accidents. Therefore, older children are more likely to accept this examination method. Through gastroscopy, the location, number, shape, and changes in the edge of the ulcer focus can be observed directly. Therefore, the detection rate of ulcer disease can reach 90% to 95%, and it can also perform lesion biopsy and Helicobacter pylori examination without misdiagnosis.

　　Seven, electrogastric examination

　　Like electrocardiogram and electroencephalogram, the gastric electrical activity is recorded through an electroencephalogram by using electrodes, so the children do not feel any pain, and children of all ages can accept it. The coincidence rate between electroencephalogram and endoscopy is 53% to 60%. This examination can only be used for ulcer screening and cannot make a diagnosis.

　　Children with peptic ulcer should pay special attention to not overeating and under-eating, as this can cause great harm to the gastrointestinal tract.

　　One, have meals at regular intervals and in appropriate amounts: all three meals should be nutritionally balanced. Chew food slowly while eating, and the abundant saliva secreted during chewing also has the function of neutralizing stomach acid. Do not have a bias for food, do not let children eat while playing, or eat while reading books and watching TV, etc.

　　Two, prevent overeating and under-eating, do not eat too much when you encounter favorite food, and do not eat or eat very little of food that is not to your taste, so that the burden on the gastrointestinal tract varies from light to heavy.

　　Three, do not overemphasize high nutrition, but achieve scientific dietary matching, eat more high-protein, low-fat, and easily digestible foods.

　　Four, do not eat刺激性大的食物 for a long time, and do not eat cold drinks in excess, such as ice cream, etc.

　　Five, pay attention to the combination of work and rest, reasonably arrange the study and life of children, do not let children be overfatigued or mentally tense.

　　Six, for children with bleeding symptoms due to peptic ulcer, according to specific circumstances, change the diet continuously, from fasting, liquid, semi-liquid, gradually to ordinary food. Specifically, include:

　　1、冷流质饮食促使局部血管收缩，有利于止血，在临床上，如吐血不止或休克的患儿可禁食外，其他均可采用多次少量冷流质饮食。如冷牛奶、凉藕粉、凉稀糊等。

　　2、少量开始给起，避免胃的饥饿性收缩。

　　3、止血2天后，改用半流质饮食。

　　七、对慢性溃疡的饮食以糙米为好，避免食用胃酸分泌过多的食品，如咖啡、红薯等。避免食用精细的食品如精白谷物，特制精白面粉等。动物性食品以白肉、鱼为主。蛋白质应多从大豆以及豆制品中摄取。鼓励患儿使用黄绿色蔬菜。

　　八、溃疡病的活动期患儿可按流质或少渣的半流质安排饮食，待病情好转后改为普食。一般不要求少食者多餐，因为进食可中和胃酸，另方面刺激胃，使胃酸分泌增多。细嚼慢咽，唾液大量分泌可中和胃酸的作用，又可避免粗糙食物对溃疡面的刺激。

　　小儿消化性溃疡治疗的目的是缓解和消除症状，促进溃疡愈合，防止复发，并预防并发症。

　　一、一般治疗：I急性出血时，应积极监护治疗，以防止失血性休克。应监测生命体征如血压、心率及末梢循环。禁食同时注意补充足够血容量，如失血严重时应及时输血。应积极进行消化道局部止血（如喷药、胃镜下硬化、电凝治疗)及全身止血。

　　应培养良好的生活习惯，饮食定时定量，避免过度疲劳及精神紧张，适当休息，消除有害因素如避免食用刺激性、对胃粘膜有损害的食物和药物。

　　二、药物治疗

　　原则为抑制胃酸分泌和中和胃酸，强化粘膜防御能力，抗幽门螺杆菌治疗。

　　1、抑制胃酸治疗是消除侵袭因素的主要途径。

　　(1)H2受体拮抗剂(H2R1)：可直接抑制组织胺、阻滞乙酰胆碱和胃泌素分泌，达到抑酸和加速溃疡愈合的目的。常用西米替丁、雷尼替丁、法莫替丁。

　　(2)质子泵抑制剂(PPl)：作用于胃粘膜壁细胞，降低壁细胞中的H+—K+——ATP酶活性，阻抑H+从细胞浆内转移到胃腔而抑制胃酸分泌。常用奥美拉唑。

　　(3)中和胃酸的抗酸剂：起缓解症状和促进溃疡愈合的作用。常用碳酸钙、氢氧化铝、氢氧化镁等。

　　(4)胃泌素受体阻滞剂：如丙古胺，主要用于溃疡病后期，作为其它制酸药停药后维持治疗，以防胃酸反跳。

　　2、胃粘膜保护剂：

　　(1)硫糖铝：在酸性胃液中与蛋白形成大分子复合物，凝聚成糊状物覆盖于溃疡表面起保护作用，尚可增强内源性前列腺素合成，促进溃疡愈合。

　　(2) Potassium bismuth citrate: It precipitates in an acidic environment, combines with the protein on the ulcer surface, covers it, and forms a solid isolation barrier. It promotes the secretion of prostaglandins and also has the effect of inhibiting Helicobacter pylori. This drug has side effects such as irreversible damage to the nervous system and acute renal failure, so it should be used with caution when used in long-term high-dose applications, and it is best to have blood bismuth monitoring.

　　(3) Montmorillonite powder, Maitaolin-S granule preparation: They also have the effect of protecting the gastric mucosa and promoting ulcer healing.

　　(4) Misoprostol: It has a prostaglandin-like effect, and its mechanism of action may be related to stimulating mucus and bicarbonate secretion, or directly protecting the integrity of the gastric mucosal epithelium. However, due to its side effects, its clinical application is less common, and it is rarely used in pediatrics.

　　3. Helicobacter pylori treatment: Peptic ulcers with H. pylori infection require antibacterial drug treatment. It has been proven that Omeprazole also has the effect of inhibiting H. pylori growth. Due to the special environment where H. pylori resides, it is not easy to be eradicated, and currently, it is mostly advocated to use combined medication.

　　4. Treatment Implementation

　　Initial treatment: H2 receptor antagonists and mucosal protective agents are the first-line drugs, Omeprazole is used for older children and refractory ulcers, and children with positive Helicobacter pylori infection undergo regular anti-Helicobacter pylori treatment at the same time.

　　Maintenance treatment: For children with multiple recurrences, severe symptoms with complications, and combined risk factors such as high gastric acid secretion, continuous use of non-steroidal anti-inflammatory drugs, or Helicobacter pylori infection, H2 receptor antagonists or Omeprazole can be administered for maintenance treatment.

　　(1) Regular daily low-dose treatment with small doses of H2 receptor antagonists or Losec, for 1 to 2 years or longer.

　　(2) Intermittent full dose: Full-dose treatment for one course is given when severe symptoms or recurrence of ulcers confirmed by gastroscopy.

　　(3) Self-monitoring treatment as needed: Short-term treatment is given when symptoms recur, and medication is stopped after symptoms disappear.

　　In cases of massive bleeding from peptic ulcers, internal medicine rescue measures (including medication for hemostasis, endoscopic hemostasis, blood transfusion, etc.) should be taken to prevent hypovolemic shock.

　　If the following conditions occur, surgical treatment should be considered according to individual circumstances: significant blood loss, ineffective drug treatment; combined with ulcer perforation; with pyloric obstruction; or frequent recurrence of refractory ulcers with poor drug efficacy.