Helicobacter pylori and peptic disease in the pediatric patient

The relationship between helicobacter pylori infection and nodular antral gastritis in pediatric patients

BACKGROUND

Helicobacter pylori (H. pylori) is a spiral-shaped gram-negative bacterium that colonizes the gastric mucosa. It is a common infectious agent in children. In this study, we aim to evaluate the demographic data, and the clinical and histopathological findings of pediatric patients that underwent upper gastrointestinal endoscopy (UGSE) in our clinic.

METHODS

Between July 2017 and February 2019, 636 patients applied to the Selcuk University Faculty of Medicine, Pediatric Gastroenterology outpatient clinic with complaints of epigastric abdominal pain and/or dyspeptic complaints. Patients who underwent upper gastrointestinal endoscopy were evaluated retrospectively. Data on age, gender, family history of peptic ulcer disease, and family history of H. pylori were recorded. Endoscopic and histopathological findings were collected from medical records.

RESULTS

235 (36.9%) of the patients participating in the study were male, and 401 (63.1%) were female. H. pylori infection was detected in 277 (43.6%) patients as a result of histopathological examination of H. Pylori, urea breath tests and H. Pylori antigen tests in the stools of patients are included in the study. Nodular antral gastritis was detected in 282 (44.3%) of our patients endoscopically. H. pylori was detected in 83.7% (n: 236) of the 282 patients with nodular antral gastritis. Nodular antral gastritis was observed to be significantly higher in H. pylori-positive patients than in H. pylori-negative cases (odds ratio (OR), 39.16; 95% confidence interval (CI), 24.88-61.64; p: <0.001).

CONCLUSION

Nodular antral gastritis is caused by chronic H. pylori infection. It is predicted that early detection of H. pylori infection in children is important and may decrease complications later in life. Our study shows that all the markers evaluated are very good predictors of H. pylori infection. Positive significant association was found between the prevalence of H. pylori infection and nodular antral gastritis.

Helicobacter pylori antimicrobial resistance in a pediatric population

BACKGROUND

The increasing prevalence of Helicobacter pylori (H. pylori) antimicrobial resistance, primarily for clarithromycin decreases the success of treatment. The aim of this study is to determine the local pattern of first-line antimicrobials resistance and the eradication rate.

MATERIAL AND METHODS

Prospective cohort study of H. pylori infected patients (positive histological or cultural exams) treated at Centro Materno-Infantil do Norte from January of 2013 to October of 2017. Susceptibility to 4 antibiotics: amoxicilin, metronidazole, clarithromycin, and levofloxacin were analyzed by E-test (phenotypic resistance). The E-test was chosen because it is simple and cost-effective for routine susceptibility testing. Point mutations that confer clarithromycin resistance were surveyed (genotypic resistance). Eradication of H. pylori infection was defined by a negative urea breath test or fecal antigen 6-8 weeks after the end of treatment.

RESULTS

Of a total of 74 H. pylori infected patients, 16 were excluded because they had previous H. pylori treatment or severe systemic disease. Median age of infection cases was 15 years (3-17 years). Eradication regimen used in all patients combined the use of 3 antibiotics (amoxicillin and metronidazole or clarithromycin) and proton pump inibhitor for 14 days and was tailored according antimicrobial susceptibility. 79.5% of the patients completed the treatment. The resistance rate for metronidazole and clarithromycin was 3.3% and 23.3%, respectively. There was no resistance for amoxicilin and levofloxacin. The rate of genotypic resistance to clarithromycin was 37.2%. The eradication rate was 97.8%.

CONCLUSIONS

The authors found a high resistance rate of H. pylori for clarithromycin in this northern portuguese pediatric center. This factor should determine a change in local current treatment, contraindicating the use of clarithromycin as a first-line treatment for H. pylori infection in children. The high eradication rate maybe explained for the eradication treatment tailored according antimicrobial susceptibility.

Nationwide survey of Helicobacter pylori treatment for children and adolescents in Japan

BACKGROUND

To prevent gastric cancer, a test-and-treat strategy for Helicobacter pylori has been proposed. This retrospective study assessed the clinical features, efficacy and safety of treatment for H. pylori infection in children and adolescents.

METHODS

Questionnaires concerning the clinical features and treatment of H. pylori in children and adolescents were sent to doctors in 2013. It included questions on patient background, H. pylori-associated disease, first- and second-line treatment, success or failure of eradication, resistance to antibiotics, and occurrence of adverse events. In 2014, serious adverse events associated with treatment were analyzed.

RESULTS

Invitation letters and questionnaires were sent to 1097 doctors, of whom 409 (37.3%) participated. Finally, 332 patients (mean age, 11.6 ± 3.4 years; male, n = 200) treated from 1997 to 2013 were analyzed. H. pylori-associated gastritis, iron deficiency anemia, and duodenal ulcer occurred most frequently. Success rates for first- and second-line treatments were 73.1% and 79.6%, respectively. Seventy-six H. pylori strains were analyzed for resistance to amoxicillin (AMPC) and clarithromycin (CAM), and 64 were analyzed for resistance to metronidazole (MNZ). CAM resistance was most frequent, occurring in 43.4% of patients; that of MNZ was 21.9%. Adverse events were observed in 13.8% of cases. In total, 587 cases of H. pylori infection were analyzed and no serious adverse events were observed.

CONCLUSIONS

Treatment for H. pylori in children and adolescents is safe, but further studies on treatment regimens should be conducted to improve eradication rates and monitor increasing CAM resistance.

Prevalence of the Helicobacter pylori in the tonsils and adenoids

Introduction

There is an ongoing debate about the existence and effects of Helicobacter pylori (Hp) in adenotonsillar tissue.

Objective

A clinical study was conducted to assess the existence of Hp in the adenoid and/or adenotonsillar tissues, which were surgically excised due to chronic adenotonsillitis.

Methods

Phosphoglucosamine mutase gene for the detection of Hp and cytotoxin-associated gene as virulence gene were examined in 84 adenotonsillar tissues obtained from 64 patients and patients’ serum by using polymerase chain reaction.

Results

Hp IgG was detected in 57 (89%) patients’ serum. A total of seven tissue samples from 64 patients (10.9%) were found positive for Hp DNA, of which five were adenoids and two were tonsil tissues. All polymerase chain reaction positive samples were also positive for the cytotoxin-associated gene, which is a virulence determinant for the organism.

Conclusion

This study suggests that children are exposed to Hp at an early age of their life in this province. Hp may have a role in the pathogenesis of chronic adenotonsillitis, especially in endemic areas.

What do we know about benefits of H. pylori treatment in childhood?

Policy analysis shows that H. pylori test and treat strategies targeting adults at moderate to high risk of H. pylori-induced disease is likely to be cost-effective for preventing digestive diseases responsible for a large global disease burden. Little is known, however, about health benefits to children from eliminating this infection. We conducted a systematic review of the evidence regarding health benefits to children from treatment to eliminate H. pylori infection.   We systematically searched Ovid MEDLINE for pertinent review articles published through 2012. We excluded reviews focused on treatment efficacy and scrutinized reference lists of selected reviews to identify additional eligible reviews. Fifteen reviews met specified inclusion criteria. Overall, they show that few reported studies investigating pediatric health effects of treatment for H. pylori infection were well designed with adequate statistical power. Thus, there is insufficient evidence for drawing conclusions about health benefits to children from treatment to eliminate H. pylori infection.

The role of prohepcidin in anemia due to Helicobacter pylori infection

BACKGROUND

Hepcidin, a key regulator of iron homeostasis, increases when inflammation and some infections occur. It plays a critical role in macrophage iron retention, which underlies inflammation/infection caused anemia. It is known that Helicobacter pylori (HP) may lead to iron deficiency (ID) due to occult blood loss or reduced iron absorption. This study investigates the role of prohepcidin, hepcidin's precursor, in ID and ID anemia (IDA) with a concurrent HP infection.

METHODS

In this prospectively designed study, 15 patients with IDA and a concurrent HP infection (group 1), 11 patients with an ID and a concurrent HP infection (group 2), and 18 patients with HP infection (group 3) were observed. All groups received only HP eradication therapy. Twenty-five age- and sex-matched children without ID/IDA and HP infection were included in the study as the control group. In all groups and control group, measurements were taken for pre- and posttreatment hemoglobin, serum prohepcidin, serum ferritin, serum iron (SI), transferrin saturation, erythrocyte sedimentation rate, fibrinogen, and C-reactive protein levels.

RESULTS

The pretreatment prohepcidin levels were significantly higher only in group 1 compared to the control group (P < .05). In group 1, a significant increase in hemoglobin and SI levels and a significant reduction in prohepcidin levels were additionally observed following HP eradication treatment (P < .05). However, in groups 2 and 3, significant differences in hemoglobin, iron, and prohepcidin levels between pre- and posttreatment were not observed.

CONCLUSION

Elevated serum prohepcidin might indicate the role of inflammation in the etiology of anemia concurrent with HP.

Does Helicobacter pylori play a role in the development of chronic adenotonsillitis?

OBJECTIVE

Evaluation of the possible relationship between chronic adenotonsillitis and Helicobacter pylori (HP).

PATIENTS AND METHODS

The study was performed prospectively on 91 pediatric patients who underwent tonsillectomy, adenoidectomy or adenotonsillectomy due to chronic tonsillitis and/or adenoiditis. The adenotonsillectomy specimens were examined for HP colonization by rapid urease test (RUT) and immunohistochemical evaluation. Before surgery, anti-HP IgG and IgA antibody titers were detected by enzyme linked immunosorbent assay (ELISA) test in venous blood samples of the patients.

RESULTS

The RUT was positive in only two of the adenoidectomy specimens (2.2%) and in none of the tonsillectomy specimens. A positive result was not detected in any tonsillectomy specimens using immunohistochemical examination. Serum IgG antibody was positive in 21 (23%) patients, IgA antibody was detected in 7 (7.69%) patients and both tests were positive only in 3 (3.29%) patients.

CONCLUSION

The results of this study suggested that HP would not colonize in tonsil tissue of patients with chronic tonsillitis.

Differences in peripheral blood lymphocyte phenotypes between Helicobacter pylori-positive children and adults with duodenal ulcer

The immunological mechanisms involved in the development of duodenal ulcer, especially in childhood, are unclear. Helicobacter pylori-positive children and adults, with and without duodenal ulcer, were therefore compared with respect to CD4(+) T-cells, and CD8(+) T-cells, B-cells and B1a-cells, as well as cell activation (CD4(+)/HLA-DR(+) and CD8(+)/HLA-DR(+)) and co-stimulatory (CD4(+)/CD28(+) and CD8(+)/CD28(+)) markers, in peripheral blood. Children with and without duodenal ulcer differed significantly. In particular, there was a phenotypic change in CD8(+) T-cells from children with ulcer that involved a 200% increase in the number of CD8(+)/HLA-DR(+) cells/mm(3) and a decrease of 34.2% in the number of CD8(+)/CD28(+) cells/mm(3). This phenotype of chronically activated memory CD8(+) T-cells, which has also been observed in patients with AIDS and tuberculosis, is associated with disease severity and progression. A lower frequency of B1a-cells was also observed in the group of children with ulcer. Conversely, no difference between infected adults with and without ulcer was observed, but the percentage of CD4(+)/HLA-DR(+) cells was lower in adults with ulcer, suggesting that a down-regulated immune response may play a role in the development of duodenal ulcer in adults. Gastric inflammation correlated positively with CD4(+) and chronically activated CD4(+) T-cells in children and adults without duodenal ulcer, respectively. These results suggest that there are differences in the immunophenotyping profile between H. pylori-positive children and adults with duodenal ulcer, indicating the possibility of distinct immune mechanisms in the development of the disease according to age.

Nodular gastritis and pathologic findings in children and young adults with Helicobacter pylori infection

PURPOSE

The aim of this study was to investigate the pathologic characteristics of nodular gastritis in children and young adults infected with Helicobacter pylori (H. pylori).

MATERIALS AND METHODS

A total of 328 patients were enrolled in this study, and the diagnosis of H. pylori infection was done with gastroduodenal endoscopy concomitant with a CLO(TM) test and pathologic analysis of the biopsy specimens. Diagnoses of normal, superficial gastritis, nodular gastritis, and peptic ulcer disease were made from the gastroduodenal endoscopic findings. The density of H. pylori organisms in the gastric mucosa was rated as normal, mild, moderate, or marked. The pathologic findings of nodular gastritis were based on the histopathologic findings of inflammation, immune activity, glandular atrophy and intestinal metaplasia. Each of these findings was scored as either normal (0), mild (1), moderate (2), or marked (3) according to the updated Sydney system and using visual analog scales. The gastritis score was the sum of the four histopathologic scores.

RESULTS

In this study, nodular gastritis (50.6%) was most common, and mild density (51.5%) H. pylori infection was also common upon microscopic examination. Intestinal metaplasia occurred in 9 patients (2.7%).

CONCLUSION

Logistic regression revealed a significant increase in the incidence of nodular gastritis with gastritis score (p=0.008), but not an association with sex, age, or H. pylori density. Gastritis score was the only significant factor influencing the occurrence of nodular gastritis. Intestinal metaplasia, which was originally thought to be a pre-malignant lesion, occurred in 2.7% of the patients with H. pylori infection.

Meta-analysis: Helicobacter pylori eradication treatment efficacy in children

BACKGROUND

Several meta-analyses assessing the efficacy of anti-Helicobacter pylori treatment in adults have been published but a comparable meta-analysis in children is lacking.

AIMS

To summarize the efficacy of treatments aimed at eradicating H. pylori in children and to identify sources of variation in treatment efficacy across studies.

METHODS

We searched Medline, reference lists from published study reports, and conference proceedings for anti-H. pylori treatment trials in children. Weighted meta-regression models were used to find sources of variation in efficacy.

RESULTS

Eighty studies (127 treatment arms) with 4436 children were included. Overall, methodological quality of these studies was poor with small sample sizes and few randomized-controlled trials. The efficacy of therapies varied across treatment arms, treatment duration, method of post-treatment assessment and geographic location. Among the regimens tested, 2-6 weeks of nitroimidazole and amoxicillin, 1-2 weeks of clarithromycin, amoxicillin and a proton pump inhibitor, and 2 weeks of a macrolide, a nitroimidazole and a proton pump inhibitor or bismuth, amoxicillin and metronidazole were the most efficacious in developed countries.

CONCLUSIONS

Before worldwide treatment recommendations are given for eradication of H. pylori, additional well-designed randomized placebo-controlled paediatric trials are needed, especially in developing countries where both drug resistance and disease burden is high.

Helicobacter pylori stool antigen test

OBJECTIVE

Helicobacter pylori ( H.pylori ) infection is usually acquired in early childhood. Invasive techniques used for diagnosis of H.pylori infection require endoscopic examination which is expensive and inconvenient and may cause complications. The aim of this study was to evaluate the performance of a new noninvasive diagnostic method, stool antigen test for H.pylori in untreated children with recurrent abdominal pain.

METHODS

Eighty children (35 female, 45 male) who have undergone upper gastrointestinal endoscopy due to recurrent abdominal pain were included in the study. The H.pylori stool antigen test (HpSA) is based on a sandwich enzyme immunoassay with antigen detection. HpSA sensitivity, specificity, and positive and negative predictive values were determined with reference to the results of both histology and rapid urease test as a gold standard ( H. pylori status).

RESULTS

While 49 of the 80 children (61%) tested were positive for H.pylori according to the results of both histology and rapid urease test, 28 children had negative H.pylori status. Among those 49 children, 48 were found to be positive by HpSA. Of 28 patients with negative H.pylori status, 28 were H.pylori -negative also in the stool test. The sensitivity, specificity, and positive and negative predictive values of HpSA were found to be 98%, 100%, 100%, and 96.5%, respectively.

CONCLUSION

These findings have demonstrated that HpSA as a relatively simple, inexpensive and time saving noninvasive test is a reliable method for detection of H.pylori infections in children.

Evidence of mother-child transmission of Helicobacter pylori infection

BACKGROUND

Low socioeconomical status is a major risk factor for natural acquisition of Helicobacter pylori (H. pylori) infection in developing countries. Its transmission route is unknown but studies suggest person-to-person transmission.

AIM

To evaluate seropositivity of anti-H. pylori antibodies in family members of infected symptomatic index patients as compared to family members of symptomatic uninfected index patients.

PATIENTS AND METHODS

One hundred and twelve family members of 38 patients who underwent endoscopy to exclude peptic disease were studied. Patients were deemed H. pylori infected or not infected when rapid urease test and histology were both positive or both negative. The family members underwent ELISA serology using the Cobas Core II Kit (Roche) and were classified into three groups: I - 29 family members of 10 H. pylori (+) duodenal ulcer index patients; II - 57 family members of 17 H. pylori (+) index patients without duodenal ulcer; III - 26 family members of 11 H. pylori (-) index patients.

RESULTS

Seropositivity of group I and II (infected patients) was higher than the control group, 83% vs 38%, specially in mothers, 81% vs 18%, and in siblings 76% vs 20%. Differences between fathers' seropositivity was not statistically significant in the three groups: 100% vs 86% vs 70%. Seropositivity of all family members (mother, father and siblings) between infected group (I vs II) was similar.

CONCLUSION

Prevalence of H. pylori infection was higher in family members of infected patients, but was similar among family members of infected patients with and without duodenal ulcer. H. pylori infection is more frequent in mothers and siblings of infected index children. A common source of infection cannot be excluded, but facts suggest that person-to-person transmission occurs, specially from mother to child.

Correlation between Helicobacter pylori infection and vitamin C levels in whole blood, plasma, and gastric juice, and the pH of gastric juice in Korean children

BACKGROUND

It is well known that chronic gastritis induced by Helicobacter pylori may be associated with hypochlorhydria and may also be accompanied by low levels of vitamin C in plasma and gastric juice in adults. This study investigates the relationship between H. pylori infection and vitamin C levels in the blood, plasma and gastric juice and the gastric juice pH of Korean children.

METHODS

During a 5-year period, multiple gastric antral biopsies were taken from 452 children who underwent gastroduodenoscopy. The biopsy specimen was inoculated into phenol red buffered urea broth and incubated for 48 hours to detect color changes. The histopathologic findings were evaluated using the Sydney System. Concentrations of vitamin C in whole blood, plasma, and gastric juice aspirate were measured using the 2,4-dinitrophenylhydrazine method.

RESULTS

Four hundred fifty-two patients (228 boys, 224 girls) aged 1 to 15 years were enrolled in this study. H. pylori was detected in 112 patients (24.8%) using histology, whereas it was found in 204 patients (45.1%) using the urease test. One hundred seven patients (23.7%) had active gastritis, and 421 patients (93.1%) had chronic gastritis. Vitamin C levels in whole blood, plasma, and gastric juice exhibited significant negative correlation with the age of patients, the histologic density of H. pylori, the degree of active and chronic gastritis, and the severity of H. pylori infection (based on urease positivity and histologic density of H. pylori). Gastric juice pH was correlated with the degree of chronic gastritis and was significantly higher in urease-positive patients.

CONCLUSIONS

The data demonstrate that vitamin C levels in whole blood, plasma, and gastric juice and the gastric juice pH in Korean children are closely related to the severity of H. pylori infection and the histologic changes in the stomach. These data suggest that vitamin C may play a role in determining infection and progression, and vitamin C supplementation may be an important axis for the management of H. pylori infection in children.

Endoscopic nodular gastritis: an endoscopic indicator of high-grade bacterial colonization and severe gastritis in children with Helicobacter pylori

OBJECTIVE

To investigate the significance of endoscopic nodular gastritis associated with Helicobacter pylori infection.

METHODS

This prospective study included 185 children (50.8% boys) aged 1 to 12 years (mean, 6.9 +/- 3.0 years) who underwent upper intestinal endoscopy during evaluation of chronic abdominal pain. The authors assessed the endoscopic appearance of the stomach, noting those patients with endoscopic nodular gastritis. Urease activity of gastric mucosal biopsies was measured. With histologic examination, the presence and density of H. pylori organisms, the presence of follicular gastritis, the nature of inflammation, and the gastritis activity grade and overall gastritis score were assessed.

RESULTS

H. pylori infection was identified in 50 children (27%). Endoscopic nodular gastritis was significantly associated with active chronic gastritis and follicular gastritis. Nodularity in the stomach showed a high specificity (98.5%) and positive predictive value (91.7%) for the diagnosis of H. pylori infection and was observed in 22 of 50 (44%) H. pylori-positive patients and in 2 of 135 (1.5%) H. pylori-negative patients. A significant association was observed between older age and the prevalence of this finding (P< 0.001). There was a significant increase in endoscopic nodular gastritis with increased H. pylori density and a positive correlation (Pearson coefficient = 0.97) with increased gastritis score on histologic examination. Increase in gastritis score was dependent on increased H. pylori density in patients with gastric nodularity; this finding was independent of age.

CONCLUSIONS

Endoscopic findings of antral nodularity in children suggest the presence of H. pylori infection and follicular gastritis and may identify cases of severe gastritis and marked bacterial colonization.

Breath test using a single 50-mg dose of 13C-urea to detect Helicobacter pylori infection in children

BACKGROUND

The 13C-urea breath test is an accurate, noninvasive method for the diagnosis of in adults. A dose of 75 to 100 mg of urea is generally used, especially in adults, but the optimal dose in children is still unknown. Our aim was to determine whether urea breath test performed with a single 50-mg dose of 13C-urea was sufficient and accurate for diagnosing infection in children.

METHODS

Consecutive children 4 to 14 years of age undergoing upper intestinal endoscopy to evaluate symptoms of recurrent abdominal pain were prospectively included. Exclusion criteria included use of antibiotics or proton pump inhibitors during the last month, gastric surgery, and previous eradication therapy. Reference criteria for diagnosis of infection were based on histology, culture, and serology. Urea breath test (TAU-KIT; Isomed, S.L., Madrid, Spain) was performed as follows: citric acid (Citral pylori) dissolved in 100 mL of water was initially given. Ten minutes later, a baseline exhaled breath sample was collected, and thereafter 50 mg of 13C-urea dissolved in 50 mL of water was given. A second breath sample was obtained 30 minutes later. Breath samples were analyzed by isotope ratio mass spectrometry. The endoscopist, the pathologist, the microbiologist, and the person responsible for reading the serology and the urea breath test were all unaware of status by the other diagnostic methods.

RESULTS

One hundred children were included (40% males; mean age, 9.2 +/- 2 years; mean weight, 33.9 +/- 12 kg). Based on the reference criteria, 45% were infected, 37% were not infected, and 18% were indeterminate. Sensitivity, specificity, positive predictive value, and negative predictive value were, respectively, 91% (95% confidence interval [CI], 79%-96%), 97% (95% CI, 86%-99%), 98% (95% CI, 87%-91%), and 90% (95% CI, 76%-96%). Positive and negative likelihood ratios were of 33 and 0.09. Any cutoff point between 2 and 14 delta units had the same high diagnostic accuracy. The area under the receiver operating characteristic curve was 0.94. No adverse effects were reported.

CONCLUSION

Urea breath test using 50 mg of urea is sufficient and accurate for the diagnosis of infection in children. Use of a small test dose significantly lowers the cost of the test.

13 C-urea breath test with infrared spectroscopy for diagnosing helicobacter pylori infection in children and adolescents

BACKGROUND AND OBJECTIVE

Studies support the accuracy of 13C-urea breath test for diagnosing and confirming cure of Helicobacter pylori infection in children. Three methods are used to assess 13CO2 increment in expired air: mass spectrometry, infrared spectroscopy, and laser-assisted ratio analysis. In this study, the 13C-urea breath test performed with infrared spectroscopy in children and adolescents was evaluated.

METHODS

Seventy-five patients (6 months to 18 years old) were included. The gold standard for diagnosis was a positive culture or positive histology and a positive rapid urease test. Tests were performed with 50 mg of 13C-urea diluted in 100 mL orange juice in subjects weighing up to 30 kg, or with 75 mg of 13C-urea diluted in 200 mL commercial orange juice for subjects weighing more than 30 kg. Breath samples were collected just before and at 30 minutes after tracer ingestion. The 13C-urea breath test was considered positive when delta over baseline (DOB) was greater than 4.0%.

RESULTS

Tests were positive for H. pylori in 31 of 75 patients. Sensitivity was 96.8%, specificity was 93.2%, positive predictive value was 90.9%, negative predictive value was 97.6%, and accuracy was 94.7%.

CONCLUSIONS

13C-urea breath test performed with infrared spectroscopy is a reliable, accurate, and noninvasive diagnostic tool for detecting H. pylori infection.

Treatment of Helicobacter pylori gastritis improves dyspeptic symptoms in children

BACKGROUND

In adults, the treatment of Helicobacter pylori infection is only recommended for patients with active gastric or duodenal ulcers. It is not known whether similar guidelines can be applied to children because the prevalence of peptic ulcer disease in childhood is estimated to be much lower than in adults. The purpose of this study was to determine whether treatment of H. pylori gastritis would improve symptoms of dyspepsia in children.

METHODS

Sixteen patients (5 boys, 11 girls) aged 14 +/- 1.2 years who had symptoms of dyspepsia were evaluated using upper gastrointestinal endoscopy with biopsies to establish the diagnosis of H. pylori gastritis. They were treated for 2 weeks with clarithromycin, amoxicillin, and a proton pump inhibitor. Dyspepsia symptoms were evaluated by a questionnaire before and after treatment of the infection. The effect of H. pylori treatment on the total symptom score was analyzed with use of the Student t test. Values are presented as mean +/- SEM.

RESULTS

All patients had antral nodularity and chronic active gastritis with spiral-shaped organisms but no evidence of peptic ulcer disease. Mean total symptom score decreased significantly at 2 to 4 weeks after treatment (12.6 +/- 0.9 vs. 2.1 +/- 0.5 P < 0.001), and it remained low (2.9 +/- 0.7) at follow-up 9.7 +/- 1.4 months (range, 2-24 months later).

CONCLUSION

These results suggest that the treatment of H. pylori gastritis can improve dyspeptic symptoms in children.

Recurrent abdominal pain in children

Functional abdominal pain can occur in a well-defined clinical entity (e.g., IBS) or as a part of a poorly defined clinical syndrome. Although the clinician may feel compelled to exclude disease in all cases, the authors suggest that it is more appropriate to take a biopsychosocial approach. In so doing, there can be an appreciation of the close interaction of the gut and the brain, allowing the child, family, and physician the opportunity to address the pain on many levels. Although the parameters set forth by the pediatric ROME II committee have facilitated the authors' description of these disorders greatly, basic research likely will further delineate biochemical processes in the enteric and central nervous systems that will expand therapeutic horizons.

Triple therapy with clarithromycin, amoxicillin and omeprazole for Helicobacter pylori eradication in children and adolescents

BACKGROUND

Helicobacter pylori infection presents high prevalence in developing countries, but there are few pediatric assays evaluating antimicrobial treatment.

OBJECTIVE

The aim of this study was to investigate Helicobacter pylori eradication rate using a short regimen (7 and 10 days) of triple therapy with clarithromycin, amoxicillin and omeprazole.

PATIENTS AND METHODS

Twenty-five Hp positive patients who presented severe epigastralgia, were submitted to antimicrobial treatment with amoxicillin (50 mg/kg/day--maximum dose 1 g bid), clarithromycin (30 mg/kg/day--maximum dose 500 mg bid) and omeprazole (0.6 mg/kg/day--maximum dose 20 mg bid) during 7 or 10 days. After 2 months, clinical symptoms were evaluated and gastric biopsies were taken to test Hp eradication.

RESULTS

Overall eradication rate was achieved in 16/25 patients (64%--IC(95% = 45-83%), in 11/15 (73%--IC(95%) = 51-95%) patients who used 10 days therapy course and in 5/10 (50%--IC(95%) = 19-81%) who used 7 days therapy course. Eradication drugs were well accepted and adverse effects were reported in two patients (8%).

CONCLUSIONS

This triple therapy regimen had moderate efficacy (64%). The data suggests that 10 days therapy course achieves better eradication rate (73%) than 7 days course (50%) to treat Hp infection in our population.

Helicobacter pylori infection and eradication in paediatric patients

Helicobacter pylori is now recognised to be typically acquired during childhood. Studies also indicate that the infection is frequently lost in childhood; however, it is still unclear whether this is related to the use of antibacterials, the natural history of the infection, or both. H. pylori colonises gastric mucosa and is causally related to chronic gastritis and peptic ulcer disease in both children and adults. Successful eradication of H. pylori has resulted in the healing of duodenal ulcers and the lowering of the ulcer relapse rate in children. Therapy to cure the infection should be started in all children with peptic (duodenal or gastric) ulcer who are still infected. The ideal anti-H. pylori regimen should be safe, cheap, easy to comply with, well tolerated by children and able to achieve a high cure rate. Although US data are lacking, it is anticipated that the treatment regimen for children should be similar to that in adults (a triple therapy regimen that combines a proton pump inhibitor with 2 antimicrobial agents for 14 days). It is inappropriate to prescribe anti-H. pylori therapy without a firm diagnosis. The use of multiple antibacterials in a paediatric patient with an ulcer but without H. pylori infection cannot provide any benefit to the patient or the community. Such an approach only provides the possibility for adverse effects, for example development of antibacterial resistance among bystander bacteria. It is very important to confirm the diagnosis of H. pylori infection. The [13C]urea breath test is the noninvasive method of choice to determine H. pylori status in children and the ideal test for post-therapy testing. There is a need for post-therapy confirmation because of the likelihood of poor outcome for some treatment regimens, which is why post-therapy testing should be the standard of care. There is weak and inconsistent evidence of an association between H. pylori infection and recurrent abdominal pain (RAP) in children, in part because of the unclear definition of RAP in the literature. Therefore, there is still considerable debate regarding the treatment of infected children with RAP.

Accuracy of the [13C]-urea breath test in diagnosing Helicobacter pylori gastritis in pediatric patients

BACKGROUND

The causal association between Helicobacter pylori (H. pylori) colonization of the gastric mucosa and gastritis is now well established. Histologic examination of endoscopic biopsy specimens has long been regarded as the gold standard for diagnosis. However, the changes can be focal in nature and presence of the organism may be missed in nonsampled areas. The urea breath test, which uses a stable isotope, offers distinct advantages, in that it is noninvasive and measures the activity of the micro-organism. It thus represents a potentially invaluable tool in the initial diagnosis of the infection and in verifying its eradication.

METHODS

The study design was that of a prospective, blinded comparison of the [13C]-urea breath test with histologic assessment of antral biopsy specimens using the Warthin-Starry stain, to diagnose H. pylori infection in a group of 79 consecutive pediatric patients.

RESULTS

Patients classified as negative by histology (n=67) had breath 13C enrichment of 0.97+/-0.07 delta per thousand (mean+/-SEM), with a range of -0.20 and 2.83 delta per thousand. In contrast, those with a positive histologic results (n=12) had an enrichment of 25.41+/-5.01 delta per thousand (range, 3.43-58.80; p < 0.001). At the chosen cutoff point of 3 delta per thousand, the sensitivity and specificity as well as the positive and negative predictive values of the breath test were uniformly 100%.

CONCLUSION

The [13C]-urea breath test is a highly reliable, noninvasive method for the diagnosis of H. pylori gastritis in children and adolescents.

One-week triple therapy with omeprazole, clarithromycin, and nitroimidazole for Helicobacter pylori infection in children and adolescents

BACKGROUND

Resolution of Helicobacter pylori infection is important in the management of peptic ulcer disease and reduces peptic ulcer recurrence in both adults and children. Various anti-H pylori treatment regimens have been proposed, reflecting the incomplete clinical success of each. A combination of omeprazole, clarithromycin, and tinidazole, given for 1 week, has been shown to be highly tolerable and effective, achieving a success rate of >90% in the adult population.

OBJECTIVE

The aim of this study was to evaluate this short-term regimen in pediatric and adolescent populations.

METHODS

The study group consisted of 35 children referred for evaluation of dyspeptic symptoms. They all underwent upper gastrointestinal endoscopy, in which H pylori infection was confirmed by rapid urease test and/or histologic staining. They were given omeprazole (20 mg twice daily), clarithromycin (250 mg twice daily), and tinidazole or metronidazole (500 mg twice daily) for 1 week. The patients were divided into two groups: those who received the first course of anti-H pylori therapy during this study (group 1) and those who had previously received standard metronidazole and bismuth combination therapies that failed to eradicate H pylori (group 2). Therapeutic efficacy was assessed by a 13C-urea breath test performed 4 weeks after completion of treatment. Results. The 35 study patients had a mean age of 15.9 years (range, 10 to 19) and included 19 males and 16 females, of whom 22 were born in Israel and 13 were immigrants from the former USSR. There were 27 patients (77. 1%) in group 1 and 8 patients (22.9%) in group 2. Endoscopic findings were nodular gastritis (14), gastritis (11), gastric ulcer (1), duodenal ulcer (5), and duodenitis (4). H pylori resolution was significantly higher in group 1 patients (24/27, 88.9%) than in group 2 patients (1/8, 12.5%). There was no difference between patients with nodular gastritis and those with nonnodular gastritis, and between Israeli-born patients and patients born in the former USSR. Compliance in both groups was equally good, and no major side effects were recorded.

CONCLUSIONS

One-week omeprazole/clarithromycin/tinidazole triple therapy is highly tolerable and effective for treating H pylori in the pediatric age group, but previous treatment failure diminishes the likelihood of success with this regimen.