Treatment of Helicobacter pylori gastritis improves dyspeptic symptoms in children

Helicobacter pylori Infections in Children

In the context of epidemiology, host response, disease presentation, diagnosis, and treatment management, the manifestation of Helicobacter pylori (H. pylori) infection diverges between children and adults. H. pylori infection stands out as one of the most prevalent bacterial infections globally, and its prevalence in both children and adults is decreasing in many developing countries but some still struggle with a high prevalence of pediatric H. pylori infection and its consequences. The majority of infected children are asymptomatic and pediatric studies do not support the involvement of H. pylori in functional disorders such as recurrent abdominal pain. The pathophysiology of H. pylori infection relies on complex bacterial virulence mechanisms and their interaction with the host immune system and environmental factors. This interaction gives rise to diverse gastritis phenotypes, which subsequently influence the potential development of various gastroduodenal pathologies. In clinical settings, the diagnosis of this infection in childhood requires an upper gastrointestinal endoscopic exam with mucosal biopsy samples for histology and culture, or Polymerase Chain Reaction (PCR) at the very least. When warranted, eradication treatment should be given when good compliance is expected, and there should be systematic use of a treatment adapted to the antimicrobial susceptibility profile. To combat the burgeoning threat of multidrug resistance, vigilant surveillance of resistance patterns and strategic antibiotic management are paramount.

Polymerase chain reaction-based tests for detecting Helicobacter pylori clarithromycin resistance in stool samples: A meta-analysis

BACKGROUND

Helicobacter pylori (H. pylori) infection is closely associated with the etiology of a variety of gastric diseases. The effective eradication of H. pylori infection has been shown to reduce the incidence of gastric carcinoma. However, the rate of H. pylori eradication has significantly declined due to its increasing resistance to antibiotics, especially to clarithromycin. Therefore, the detection of clarithromycin resistance is necessary prior to the treatment of H. pylori. Although many studies have been conducted on the use of polymerase chain reaction (PCR)-based tests to detect clarithromycin resistance in stool samples, no accurate data on the feasibility of these tests are available. Here, we performed a meta-analysis to assess the feasibility of these noninvasive tests.

AIM

To evaluate the reliability of PCR-based tests for detecting H. pylori clarithromycin resistance in stool samples.

METHODS

We searched PubMed, Medline, Embase, and other databases for articles that evaluated the value of the PCR analysis of stool samples for detecting the resistance of H. pylori to clarithromycin. We collected cross-sectional studies that met the inclusion criteria. Diagnostic accuracy measures were pooled using a random-effects model. The risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Subgroup analysis was also conducted according to PCR type, purification technique, reference standard, mutation site, sample weight, number of patients, and age group, and the clinical utility of diagnostic tests was evaluated using the Likelihood Ratio Scatter Graph.

RESULTS

Out of the 1818 identified studies, only 11 met the eligibility criteria, with a total of 592 patients assessed. A meta-analysis of the random-effect model showed that PCR-based analysis of stool samples had high diagnostic accuracy for detecting clarithromycin resistance in patients infected with H. pylori. The combined sensitivity was 0.91 [95% confidence interval (CI): 0.83-0.95], Q = 30.34, and I² = 67.04, and the combined specificity was 0.97 (95%CI: 0.62-1.00), Q = 279.54, and I² = 96.42. The likelihood ratio for a positive test was 33.25 (95%CI: 1.69-652.77), and that for a negative test was 0.10 (95%CI: 0.05-0.18), with an area under the curve of 0.94. The diagnostic odds ratio was 347.68 (95%CI: 17.29-6991.26). There was significant statistical heterogeneity, and the sub-analyses showed significant differences in the number of patients, sample weight, purification methods, PCR types, mutation points, and reference standards. The included studies showed no risk of publication bias.

CONCLUSION

PCR-based tests on stool samples have high diagnostic accuracy for detecting H. pylori clarithromycin resistance.

Efficacy of a novel sequential treatment regimen containing bismuth for Helicobacter pylori eradication in Turkish children

BACKGROUND

Eradication rates of Helicobacter pylori (H pylori) with standard triple therapy are gradually decreasing all over the world, including in children, due to the development of strains resistant to antimicrobials. Sequential therapy can be used as an alternative method to increase eradication rates.

MATERIALS AND METHODS

A total of 75 patients ≥ 8 years of age with H pylori gastritis were included in the study. According to Rome IV criteria, 38 patients had functional abdominal pain and dyspepsia, and 37 patients had alarm findings suggesting organic disease. Patients were treated with a novel sequential therapy consisting of the proton pump inhibitor (PPI)-lansoprazole (1 mg/kg/day, maximum 30 mg daily), amoxicillin (50 mg/kg/d in two doses, maximum 2 × 1000 mg) for 7 days followed by PPI-lansoprazole (1 mg/kg/d, maximum 30 mg daily), metronidazole (20 mg/kg/day in two doses, maximum 2 x 500 mg), tetracycline (50 mg/kg/d divided into four equal doses, maximum 4 x 500 mg), and bismuth subsalicylate (262 mg QID in patients ≤ 10 years of age, 524 mg QID in patients > 10 years of age in days 8-14). Eradication status was evaluated by H pylori stool antigen test 8 weeks after the completion of treatment.

RESULTS

The mean age of the patients was 15.1 ± 2.4 years and 51 (68%) were female. No patient discontinued therapy due to side effects. All patients had antral gastritis (76.0%) or pangastritis (24.0%). The peptic ulcer rate was 6.6%. Eradication therapy was given to all patients with or without peptic ulcer. H pylori eradication was achieved in 69 (92.0%) patients and symptoms improved in 61 of those eradicated.

CONCLUSIONS

As a first-line treatment for H pylori eradication in children, administering a novel sequential therapy including bismuth for 14 days provides a high rate of eradication.

Comparison of clinical symptoms after Helicobacter pylori eradication in functional dyspepsia patients based on endoscopic view of antral gastropathy

Functional dyspepsia is a common gastric disease that can be associated with Helicobacter pylori infection. The aim of this study is to evaluate antral endoscopy of individuals who presented with functional dyspepsia, H. pylori infection status and the effects of eradication therapy on the symptoms. Following the diagnosis of dyspepsia as per Rome III criteria, 260 individuals who were eligible for the study underwent upper gastrointestinal endoscopy and were divided into four groups of 65 according to the endoscopic view, grades I, II, III and IV (negative). Stool antigen test was also performed for all patients to identify H. pylori infection. The early signs of dyspepsia were assessed by a standard questionnaire. In all groups, omeprazole, amoxicillin, clarithromycin and metronidazole were used for eradication treatment, and 1 month after the treatment, a faecal antigen test was repeated to evaluate the eradication of H. pylori. There was no statistically significant difference between the groups in terms of clinical symptoms before treatment. The highest response to eradication treatment was seen in individuals with antral gastropathy grade III (66.2%) and the lowest response was in patients without antral gastropathy Grade IV (32.3%). This difference was statistically significant. There was no statistically significant relationship between the participants in terms of family history, age, gender and response to treatment. Eradicating H. pylori reduces the symptoms of dyspepsia. The response of eradication therapy was greatest among the patients with grade III antral gastropathy.

Helicobacter pylori Infection in Pediatric Patients: Update on Diagnosis and Eradication Strategies

Helicobacter pylori infection is acquired mainly in childhood and remains an essential cause of peptic ulcer disease and gastric cancer. This article provides commentary on the last ESPGHAN/NASPGHAN guidelines and on publications made after the consensus conference of 2015. The majority of infected children are asymptomatic and pediatric studies do not support a role for H. pylori in functional disorders such as recurrent abdominal pain. The role of H. pylori infection in failure to thrive, children's growth, type I diabetes mellitus (T1DM), and celiac disease remains controversial. The diagnosis of infection should be based on upper-digestive endoscopy with biopsy-based methods. Eradication control after treatment should be based on validated non-invasive tests. Nodular gastritis is the main endoscopic finding of childhood H. pylori infection, but gastroduodenal erosions/ulcers are seen in some children, especially after 10 years of age. When indicated, eradication treatment should be given when good compliance is expected and based on the antimicrobial susceptibility profile.

The effect of Helicobacter pylori eradication on functional dyspepsia in Turkish children

BACKGROUND

The aim of this study was to evaluate the effect of Helicobacter pylori (H. pylori) eradication on dyspepsia symptom scores in children with functional dyspepsia (FD).

MATERIALS AND METHODS

One hundred and fifty functional dyspeptic children (ages 8-18 years, mean: 13.3 ± 2.84 years; 30% male) were enrolled to this prospective study. Upper gastrointestinal endoscopy was performed on all patients, and the samples from the gastric antrum and corpus were obtained for the existence of H. pylori. ¹³ Carbon-urea breath test was performed to evaluate the eradication therapy's efficacy. The symptoms were assessed at first visit and at the 8th week and 16th week.

RESULTS

Forty-nine (33%) children were in the H. pylori-positive group, and 101 (67%) children were in the H. pylori-negative group. Dyspepsia symptom scores improved at 8th week in both groups (P < .05). Helicobacter pylori was eradicated in 30 patients (61%), while in the H. pylori-eradicated group, all dyspepsia symptoms' scores decreased, and in the H. pylori-uneradicated group, only three symptoms' scores decreased. Symptom scores were lower in H. pylori-eradicated group than H. pylori-uneradicated group.

CONCLUSIONS

Although the tests used for the diagnosis of H. pylori in functional dyspeptic patients increased the cost of health care, the dyspepsia symptom scores decreased with the eradication therapy in a high prevalence community. The findings may differ in low prevalence communities where the diagnostic tests for H. pylori infection are not recommended in children in the absence of alarm signs or symptoms.

Eradication rate of Helicobacter Pylori infection is directly influenced by adherence to therapy in children

BACKGROUND

Current commonly accepted strategies to eradicate Helicobacter pylori in children are a 10-day sequential treatment or a triple therapy for 7-14 days. To avoid further expensive and possibly risky investigations as well as induction of secondary antimicrobial resistance, a success rate of elimination strategies over 90% in a per-protocol analysis is the target goal but rates observed in clinical trials are lower. Antimicrobial resistance is a well-recognized risk factor for treatment failure; therefore, only a treatment tailored to susceptibility testing should be recommended. Adherence to therapy is also a risk factor for treatment failure but that has been poorly studied. The purpose of this study was to evaluate the influence of adherence to therapy on the elimination rates obtained with different treatment regimens.

METHODS

Cohort study analysis of children, aged 2-17 years, treated for Helicobacter pylori infection between October 2011 and December 2013. As a routine clinical practice, children infected with a strain susceptible to clarithromycin and to metronidazole received either a sequential regimen or a 10-day triple therapy while children infected with a strain resistant to clarithromycin or metronidazole received a 10-day triple regimen tailored to antimicrobial susceptibility. The eradication rate was assessed by a negative ¹³ C-urea breath test performed at least 8 weeks after the end of the treatment and adherence evaluated using a diary.

RESULTS

One hundred forty-five children (67 girls/78 boys, median age 9.7 years) fulfilled the inclusion criteria, 118 being infected with a strain susceptible to both clarithromycin and metronidazole, 10 with a clarithromycin resistant, and 17 with a metronidazole resistant strain. A sequential regimen was prescribed in 44, a triple therapy containing clarithromycin in 84 and containing metronidazole in 17. Follow-up data were available for 130/145 and clearance of the infection observed in 105 of them. A concordance of more than 90% between the prescribed and the ingested drugs was observed in 109 children, between 50 and 90% in eight, less than 50% in 11 while these data were unknown for 2/130. A successful eradication was achieved for 89.9% of patients that received at least 90% of the prescribed drugs, whereas the eradication rate for nonadherent patients was 36.6%. Adherence above 90% was significantly higher in the absence of chronic concomitant disease, in the absence of adverse event and results in a significantly higher eradication rate. With the proposed strategy and an adherence higher than 90%, eradication was obtained in 98/109 children, the rate being only significantly superior to 90% with the sequential regimen.

CONCLUSION

Adherence to therapy is a very important factor for the outcome and has to be assessed when evaluating the outcome of an H. pylori eradication regimen in order to understand the reasons of treatment failure. As we treated only after evaluation of the resistance of the H. Pylori strains, we were expecting to reach the given objective of 90% successful treatment. Children with adherence to treatment above 90% had a successful outcome of 89,9%, whereas nonadherent had a successful outcome of 36,8%. This is the first time that adherence has been assessed accurately.

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.

Frequency of Helicobacter pylori infection among Egyptian children presenting with gastrointestinal manifestations

BACKGROUND AND AIMS

Recurrent abdominal pain (RAP) and other gastrointestinal (GI) symptoms are common complaints among children. The role of Helicobacter pylori in the causation of these complaints remains controversial. The aim of this study was to determine the frequency of H. pylori infection among children presenting with GI manifestations and to determine the most common clinical presentation of the infection in Egyptian children.

PATIENTS AND METHODS

This prospective cross-sectional study included 150 consecutive patients aged 5-15 years who presented to the outpatient clinic of Cairo University's Specialized Pediatric Hospital with GI complaints. Screening for H. pylori infection was performed using a 13C-urea breath test (13C-UBT), and in patients whose 13C-UBT was positive, diagnosis was confirmed by visualizing the bacterium in biopsy specimens obtained by GI endoscopy.

RESULTS

RAP was the most frequent GI complaint of the study population (82%), followed by anorexia (6.7%), vomiting (6.7%), and chronic diarrhea (4.7%). Seventy percent of these patients were positive for the 13C-UBT. Ninety-one of the patients who complained of RAP had a positive 13C-UBT, whereas the remaining 32 patients who had RAP had a negative 13C-UBT, a difference that was statistically significant (P=0.023). However, no statistically significant differences were found between the 13C-UBT result among patients with anorexia, vomiting, or diarrhea (P=0.153, 1.00, and 0.447, respectively).

CONCLUSION AND RECOMMENDATIONS

Screening for H. pylori infection should be performed for school-aged children who have GI complaints, especially for those who complain of RAP.

Consequences of Helicobacter pylori infection in children

Although evidence is emerging that the prevalence of Helicobacter pylori (H. pylori) is declining in all age groups, the understanding of its disease spectrum continues to evolve. If untreated, H. pylori infection is lifelong. Although H. pylori typically colonizes the human stomach for many decades without adverse consequences, children infected with H. pylori can manifest gastrointestinal diseases. Controversy persists regarding testing (and treating) for H. pylori infection in children with recurrent abdominal pain, chronic idiopathic thrombocytopenia, and poor growth. There is evidence of the role of H. pylori in childhood iron deficiency anemia, but the results are not conclusive. The possibility of an inverse relationship between H. pylori and gastroesophageal reflux disease, as well as childhood asthma, remains a controversial question. A better understanding of the H. pylori disease spectrum in childhood should lead to clearer recommendations about testing for and treating H. pylori infection in children who are more likely to develop clinical sequelae.

Indications to upper gastrointestinal endoscopy in children with dyspepsia

OBJECTIVES

The objective of the study was to ascertain the appropriateness of indications for upper gastrointestinal (UGI) endoscopy in children with dyspepsia.

METHODS

We used the RAND/University of California at Los Angeles method to investigate the appropriateness of the opinions of a panel of experts. The panel judged 2304 theoretical patient scenarios defined by a combination of demographic and clinical variables. Descriptive and multivariate logistic regression analyses were performed.

RESULTS

The panel rated UGI endoscopy as appropriate in 27.2% of cases, inappropriate in 14.3%, and dubious in 58.5%. Disagreement emerged for 21% of cases. UGI endoscopy was considered increasingly appropriate in cases with a positive family history of peptic ulcer and/or Helicobacter pylori infection (odds ratio [OR] 8.518, P < 0.0001), when dyspepsia interfered with activities of daily living ("sleep" OR 7.540, P < 0.0001; "normal activities" OR 5.725, P < 0.0001), and when patients were older than 10 years ("<or=10 years" OR 0.310, P < 0.0001) the longer the duration ("0-2 months" OR 0.002, P < 0.0001; "3-5 months" OR 0.059, P < 0.0001; "6-11 months" OR 0.516, P = 0.0005) and the greater the severity ("mild" OR 0.002, P < 0.0001; "moderate" OR 0.013, P < 0.0001) of their dyspeptic symptoms.

CONCLUSIONS

UGI endoscopy is not appropriate for all children with dyspeptic symptoms, but only for cases with a family history of peptic ulcer and/or Helicobacter pylori infection, older than 10 years of age, with symptoms persisting for more than 6 months and severe enough to affect activities of daily living.

Positive association between Helicobacter pylori and gastroesophageal reflux disease in children

OBJECTIVES

The role of Helicobacter pylori (H pylori) in gastroesophageal reflux disease (GERD) remains controversial, particularly in children, because there are limited published data. Adult studies suggested that H pylori infection may protect against GERD by causing atrophic gastritis, which leads to reduced gastric acid secretion. The objective of our study was to determine the role of H pylori infection in the development of GERD in a pediatric population.

PATIENTS AND METHODS

A retrospective analysis of 420 patients (M:F = 214:206) who underwent esophagogastroduodenoscopy (EGD) with biopsies between January 2000 and April 2006 was conducted. Patient demographics, clinical indications for EGD and the prevalence of reflux esophagitis (RE), the biomarker for GERD, in 2 groups, H pylori positive and H pylori negative, were reviewed. The prevalence of RE in the H pylori-positive and H pylori-negative groups was further analyzed on the basis of sex and age (<1 year, 1-10 years, >10 years). The mean age of the study population was 8.2 years (range 0-20 years). The clinical indications for EGD were as follows: recurrent abdominal pain (n = 186, 44%), malabsorption (n = 80, 19%), persistent vomiting (n = 80, 19%), suspected eosinophilic gastrointestinal disorders (n = 63, 15%), and others such as upper gastrointestinal bleeding or inflammatory bowel disease surveillance (n = 11, 3%). Statistical analysis was performed by using chi test, Fisher exact test, and multivariate logistical regression analysis.

RESULTS

Among the 420 patients, 16 patients (3.8%) were positive for H pylori and 167 patients (39.8%) were found to have RE. Thirteen patients with H pylori were found to have histologic evidence of RE. The prevalence of RE in the H pylori-positive population was 81.3% compared with 38.1% in the H pylori-negative population (P < or = 0.05). There were no patients with H pylori in the youngest age group. In the second age group (1-10 years), 100% of the H pylori-positive patients had RE, whereas 44.6% of the H pylori-negative patients had RE (P < or = 0.05). Both male and female patients with H pylori had a higher prevalence of RE, 77.8% and 85.7%, respectively. On a multivariate logistical regression, for the overall study cohort, H pylori-positive patients had an odds ratio of 5.79 of developing RE compared with H pylori-negative patients (P < or = 0.05).

CONCLUSIONS

Our study results indicate that there is a significantly higher prevalence of RE in an H pylori-infected cohort independent of age or sex. The findings suggest that H pylori infection in children is positively associated with RE.

Helicobacter pylori infection in children

Helicobacter pylori infection is a common problem in pediatric practice, and its acquisition is related with poor socioeconomic conditions. Although the organism is thought to be responsible for many diseases, only a handful of them have a direct causal relationship. At present, only a small number of children with well-defined clinical syndromes are benefited from testing and treatment. The treatment should include at least two antibiotics with a proton pump inhibitor.

Dyspeptic symptoms in children: the result of a constipation-induced cologastric brake?

BACKGROUND & AIMS

Patients with constipation frequently complain of dyspeptic symptoms that may be explained by reflex inhibition of upper-gastrointestinal motor activity by colonic stimuli. We sought to evaluate the following: (1) the prevalence of functional constipation (FC) and gastric emptying characteristics in children with functional dyspepsia (FD), and (2) the efficacy of osmotic laxatives on constipation, dyspeptic symptoms, and gastric motility.

METHODS

We recruited 42 children (males/females, 22/20; mean age, 80.5 mo) affected by FD (Rome II criteria). All subjects underwent ultrasonographic measurement of the total gastric emptying time (TGEt) at baseline (T0) and after 3 months (T3). Children's bowel habits and the dyspeptic symptomatic score were evaluated at entry and after 1 (T1), 2 (T2), and 3(T3) months. Constipated patients were treated with osmotic laxatives for 3 months. Dyspeptic children without constipation represented the comparison group.

RESULTS

FC was present in 28 of 42 (66.6%) patients. Constipated dyspeptic children had significantly more prolonged TGEt than subjects without constipation (median value [interquartile range], 180 (50) vs 150 (28) min, respectively; P = .004). Patients on osmotic laxatives had a significant decrease in TGEt at 3 months (P < .001). The median dyspeptic symptomatic score as well as the number and consistency of evacuations per week significantly improved at T1 in comparison with T0 and even more at T2 and T3 (P < .001, for each).

CONCLUSIONS

In our study group, the majority of children with FD were affected by FC associated with delayed gastric emptying. Normalization of bowel habit may improve gastric emptying as well as dyspeptic symptoms.

[Helicobacter pylori infection in children]

Knowledge about Helicobacter pylori infection in children continues to advance. While its prevalence appears to be falling in developed countries, it remains a major problem in developing nations. Its transmission pathway remains highly controversial. It has not yet been definitively elucidated, although the oral-oral route seems most probable. Infection is most often intrafamilial. Risk factors for infection are associated with low socioeconomic level, including overcrowding, unhygienic conditions, sharing beds in childhood, low maternal educational level. Infection in children differs from that in adults in three respects: symptoms, endoscopic appearance of the gastric mucosa, and histologic appearance of lesions. No study has established a clear association between recurrent abdominal pain and H. pylori infection. Nonetheless, in proven infections, recurrent abdominal pain is the most common marker. More recently, an association has been reported between H. pylori infection and iron deficiency anemia. The endoscopic aspect most suggestive of H. pylori infection in children is micronodular gastritis, but it is not specific to H. pylori infection. In children as in adults, H. pylori infection is always associated with histologic gastritis. Many questions about H. pylori remain unanswered, and numerous studies are still needed.

Does Helicobacter pylori colonize the nasopharynx of children and contribute to their middle ear disease?

OBJECTIVE

There is growing interest in studying the presence of HP in the upper aerodigestive tract. It was shown in several pilot studies that it colonizes the area, while other authors found no evidence of its presence there and a third group of authors believed that it had only a transient presence there. In this study we investigated a possible role for HP in middle ear disease in children.

MATERIAL AND METHODS

Consecutive patients undergoing myringotomy and adenoidectomy for chronic otitis media with effusion or recurrent otitis media were enrolled. Middle ear fluids were cultured on three types of agar plate (Brucella + laked horse blood; Brucella + sheep blood; and chocolate). A double polymerase chain reaction (PCR) was run to detect urease-C and adhesion subunit genes. Rapid urease enzyme testing and PCR were used on the adenoid specimens. Parents were interviewed regarding symptoms suggestive of gastroesophageal reflux in their children.

RESULTS

Eighteen patients were enrolled in the study (mean age 4.4 years; age range 3-8 years) with an equal gender distribution. All 28 middle ear fluid cultures were negative in all 3 media. Twenty-one of the 28 samples contained DNA, yet PCR revealed that none of them belonged to HP. Ten of the 13 adenoid specimens obtained were positive on rapid urease testing, but none on PCR. Seven of the 18 patients had at least 1 symptom suggestive of gastroesophageal reflux during the 6 months preceding the study but this did not have an impact on any of the results.

CONCLUSION

There was no evidence from this study that Helicobacter pylori (HP) colonizes the nasopharynx of children with middle ear disease, whether dyspeptic or not. There is also no apparent role for this bacterium in middle ear pathology.

Improved efficacy of 10-Day sequential treatment for Helicobacter pylori eradication in children: a randomized trial

BACKGROUND & AIMS

The currently recommended first-line eradication treatment of Helicobacter pylori in children is usually successful in about 75%. Recently, in adults, a novel 10-day sequential treatment has achieved an eradication rate of 95%. The aim of the study was to assess the H pylori eradication rate of the sequential treatment regimen compared with conventional triple therapy in children.

METHODS

Seventy-eight consecutive children with H pylori infection were randomized to receive either sequential treatment (omeprazole plus amoxicillin for 5 days, followed by omeprazole plus clarithromycin plus tinidazole for another 5 days) (n = 38; 15 boys [39.5%]; median age, 11.0 years [range, 3.3-16 years]) or triple therapy (omeprazole, amoxicillin, and metronidazole) for 1 week (n = 37; 15 boys [40.5%]; median age, 9.9 years [range, 4.3-16 years]). H pylori infection was based on 2 out of 3 positive tests results: 13C-urea breath test, rapid urease test, and histologic analysis. Eradication was assessed by 13C-urea breath test 8 weeks after therapy.

RESULTS

Seventy-four patients completed the study. H pylori eradication was achieved in 36 children receiving sequential treatment (97.3%; 95% confidence interval, 86.2-99.5) and 28 children receiving triple therapy (75.7%; 95% confidence interval, 59.8-86.7) (P < .02). Compliance with therapy was good (>95%) in all.

CONCLUSIONS

Our study shows, for the first time in children, that 10-day sequential treatment achieves a higher eradication rate than standard triple therapy, which is consistent with the results of adult studies.

Application of a stool antigen test to evaluate the incidence of Helicobacter pylori infection in children and adolescents from Tehran, Iran

Helicobacter pylori infection is acquired mainly in childhood, especially in developing countries, where a low-cost, rapid diagnostic technique which is reliable for all age groups may be useful for the management of H. pylori infection. For this purpose, we used an HpSA test (Equipar) to detect H. pylori infection in children and adolescents from Tehran, Iran. Thirty-five children who were positive or negative for H. pylori infection by endoscopy-based tests were used as positive and negative controls for the HpSA test. Stools were collected from 430 randomly selected children and adolescents (4 to 18 years old) from southwest, near the center, and northwest of Tehran. A questionnaire that included presence of recurrent abdominal pain (RAP), family history of infection and/or peptic ulcer disease (PUD), and income of parents was completed. A good agreement was found between the results of endoscopy-based tests and those of the HpSA test; the sensitivity and specificity of the Equipar-HpSA test were 100% and 83.4%, respectively. Among 430 children and adolescents, 47% were positive by the HpSA test, of whom 82% had RAP. No difference in incidence was observed between the two sexes; the various categories of age showed an increasing incidence, ranging from 24% (ages 4 to 6) to 58% (ages 16 to 18). The rate of infection in children and adolescents from the southwest was significantly higher (70%) than the rate in those from the northwest (32%), and a family history of H. pylori infection or PUD was observed in 59% of the HpSA positive subjects. The HpSA test is a useful test to detect H. pylori infection in children and adolescents from developing countries.

Nonulcer dyspepsia and Helicobacter pylori eradication in children

BACKGROUND

Controversy exists over Helicobacter pylori eradication therapy in the treatment of patients with nonulcer dyspepsia. The lack of pediatric studies has made it difficult to draw conclusions about the use of eradication in dyspeptic children. The aim of this study was to examine long-term symptom severity in pediatric patients with nonulcer dyspepsia and H pylori gastritis after H pylori eradication.

METHODS

Thirty-nine children (mean age, 9.0 years) with dyspepsia and H pylori gastritis were prospectively recruited. Severity of symptoms was graded before H pylori eradication. Each patient was followed up at 6, 12, and on average, 61.6 months after eradication, with reassessment of symptoms and H pylori status.

RESULTS

There was a significant reduction in the severity of symptoms at 6 and 12 months, and at long-term follow-up compared with the preeradication scores (all P < . 001). At long-term follow-up, reinfection with H pylori was associated with more severe symptoms than if the patients remained free of infection (P = .045).

CONCLUSIONS

This study has demonstrated a significant long-term improvement in nonulcer dyspepsia in children after eradication of H pylori. This provides further evidence for the consideration of H pylori eradication in pediatric patients presenting with nonulcer dyspepsia.

Helicobacter pylori infection is not associated with specific symptoms in nonulcer-dyspeptic children

OBJECTIVES

To assess symptoms associated with Helicobacter pylori infection in children presenting with nonulcer dyspepsia (NUD).

STUDY DESIGN

A prospective double-blind study was conducted between March 2001 and April 2002 in children at least 6 years old with NUD who had been referred for upper gastrointestinal endoscopy for epigastric pain. A standardized questionnaire was administered blindly by a pediatric gastroenterologist. This questionnaire characterized epigastric pain and associated factors. Infection was confirmed by positive culture and histologic examination of the gastric mucosa.

RESULTS

From 100 children enrolled, 26 proved infected (12 female, 14 male; mean age: 11.4 +/- 2.6 years), and 74 were noninfected (44 female, 30 male; mean age: 10.4 +/- 3.1 years). There were no differences in age or symptom characteristics between groups except for epigastric pain during meals that was more frequent in noninfected than in infected children (25.6% vs 3.8%).

CONCLUSION

There were no specific characteristics of symptoms in nonulcer-dyspeptic H pylori-infected children as compared with noninfected children.

Inhibidores de la bomba de protones en pediatría

In last years the use in the pediatric area of proton pump inhibitors (omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole) is more often, nevertheless the clinical trials carried out are poor. The aim of this work is to analyse the bibliography published about this kind of drugs in children and to make a revision of its use in the last seven years. More studies with omeprazole and lansoprazole have been developed, to be exact omeprazole and lansoprazole is present in 122 bibliographic appointments and 34 for lansoprazole, which include studies that demonstrate a good tolerance and efficacy. The remaining proton pump inhibitors count with very few studies. The main therapeutic indications were the eradication of Helicobacter pylori, gastroesophageal reflux disease and esophagitis. The number of patients included in the reviewed studies is quite heterogeneous, from 8 to 122 and the age range between 8 days and 17 years. On the other hand, it could be highlighted the non-existence of formulations adapted to the pediatric population and the difficulty of administration specially in the youngest patients. As in many other drugs, it would be necessary to carry out clinical trials in order to determinate the pharmacologic parameters at difference ages, which will allow a safe and effective administration, and its authorization by all Health Authorities.

Pediatric gastric and duodenal disorders

PURPOSE OF REVIEW

This review provides a summary of new developments regarding common diseases affecting the stomach and duodenum in children.

RECENT FINDINGS

Celiac disease seems to be more prevalent than previously thought in different areas of the world, including the United States. The value of different serologic screening tools and other noninvasive tests has been carefully assessed. HLA-DQ typing has been proposed as part of celiac disease screening testing for high-risk groups. The use of the newly defined pediatric Rome criteria is allowing recognition of nonulcer (or functional) dyspepsia as an entity that affects a sizable subset of children. Testing of gastric sensory and motor function is clarifying the pathophysiology of this condition in children and adolescents. Intriguing data are also emerging about the possible role of mucosal eosinophils and disaccharidase deficiencies in causing dyspeptic symptoms. Intrasphincteric injection of botulinum toxin A represents a novel technique to treat gastroparesis. In refractory cases, the use of a gastric electric stimulator has shown to be beneficial in idiopathic and diabetic gastroparesis. Progress has been made in understanding the epidemiology of Helicobacter pylori infection in developing countries and its role in causing a wide spectrum of symptoms in children. Several noninvasive methods for its diagnosis have been established.

SUMMARY

Recent developments in the diagnosis and management of gastric and duodenal pathologic conditions are making a significant impact on pediatric clinical care. Future studies will likely continue to explore the use of minimally invasive testing and interventions in such conditions.

Symptomatic response to Helicobacter pylori eradication in children with recurrent abdominal pain: double blind randomized placebo-controlled trial

BACKGROUND

Controlled trials considering the effect of Helicobacter pylori (H. pylori) eradication on gastrointestinal symptoms in children are scant. We aimed to study the connection between recurrent abdominal pain and dyspepsia and H. pylori infection in children.

STUDY

This was a double blind randomised controlled trial. Twenty children with recurrent abdominal pain (RAP) being H. pylori positive as measured with the C urea breath test (UBT) were randomized either to receive omeprazole, amoxycillin and clarithromycin (n = 10), or omeprazole and 2 placebos (n = 10) for 1 week after gastroscopy. Symptoms were registered prior to the treatment and at follow up visits 2, 6, 24, and 52 weeks after stopping the treatment. Control UBT was performed on all patients 6 weeks post-treatment and again at the 52 week follow-up visit, when also re-endoscopy with biopsies was done to all participants.

RESULTS

All infected children had histologic gastritis. Bacterial eradication was achieved in 8/10 in the triple treatment group and in none in the placebo group. There was no change in symptom index in either group at 2 weeks post treatment. At 52 weeks a similar reduction in symptom index was observed in both groups irrespective of the healing of gastritis, which was more commonly achieved along the eradication.

CONCLUSIONS

Bacterial eradication and healing of gastric inflammation does not lead to symptomatic relief of chronic abdominal pain in children.

Dual vs. triple therapy for childhood Helicobacter pylori gastritis: a double-blind randomized multicentre trial

BACKGROUND

Data on the efficacy of eradication treatment for Helicobacter pylori gastritis in children are scarce.

AIM

To evaluate the efficacy of triple therapy with lansoprazole plus amoxicillin and tinidazole vs. dual therapy with amoxicillin and tinidazole in a double-blind randomized multicentre trial, and the usefulness of eradication in terms of long-term symptom resolution.

SUBJECTS

We enrolled 43 consecutive children undergoing endoscopy for upper gastrointestinal dyspepsia with H. pylori gastritis. They underwent a 13C-urea breath test, completed a 2-week symptom diary card, and were randomized. Treatment was given in a Redidose box (Redidose Company Ltd., Brighton, UK) containing either lansoprazole-amoxicillin-tinidazole (triple therapy) or placebo plus amoxicillin-tinidazole (dual therapy) for 1 week. The completion of a 2-week symptom diary card and the performance of a breath test were repeated 6 weeks and 6 months after the end of therapy. One to two years later, a structured telephone interview was conducted with 36 of the children.

RESULTS

According to the breath test, 6 weeks after the end of therapy H. pylori was eradicated in 15 of 22 children on triple therapy [68.2%; 95% confidence interval (CI) = 45-88] and in 15 of 21 children on dual therapy (71%; 95% CI = 48-89; not significant), and 6 months after the end of therapy it was eradicated in 16 of 22 children on triple therapy (72.7%) and in 15 of 21 children on dual therapy. Six months after therapy, symptoms were analysed in 11 H. pylori-positive and 31 H. pylori-negative children, and it was found that dyspeptic symptoms had disappeared or improved in both groups, with no difference between them. One to two years later, 36 children were interviewed. Epigastric pain had recurred in three of 26 H. pylori-negative and in seven of 10 H. pylori-positive children (p = .001); in three of the latter, pain was severe and required additional treatment.

CONCLUSION

One-week triple or dual therapy with two antibiotics achieved similar eradication rates. Soon after treatment, symptoms disappeared or improved in most children irrespective of eradication, but epigastric pain recurred in the majority of the still-infected children within 2 years.

Helicobacter pylori infection in Turkish children: comparison of diagnostic tests, evaluation of eradication rate, and changes in symptoms after eradication

BACKGROUND

Helicobacter pylori infection is most frequently acquired in childhood. After this organism is eradicated, the rate of reinfection is low. Thus, it is very important to diagnose and treat the disease appropriately in childhood, and to be able to assess eradication with certainty. Eradication of H. pylori infection is reported to reduce or eliminate abdominal pain and dyspeptic symptoms in children.

PATIENTS AND METHODS

The study involved 102 children who had already been diagnosed with symptomatic H. pylori infection based on gastric histopathological examination, urea breath test, rapid urease test, serology and culture. Each patient's symptoms and family history of gastrointestinal problems were recorded. Using histology as the gold standard for identifying H. pylori infection, we determined the diagnostic sensitivity of each of the other methods. Omeprazole or lansoprazole, amoxicillin and clarithromycin were administered as eradication treatment, and each patient was re-evaluated by urea breath test 8 weeks later. Each child was re-interviewed about symptoms after treatment. These answers and the results of drug sensitivity testing were recorded. Cases of failed eradication were re-treated with a quadruple-drug regimen of tetracycline, metronidazole, bismuth subsalicylate and omeprazole.

RESULTS

The most frequent symptom was abdominal pain (89.2%). Fifty-four per cent of the subjects had a family history of dyspeptic symptoms. Sixty-six patients (64.7%) exhibited nodularity in the antral mucosa. The sensitivities of the diagnostic tests in histologically proven cases were as follows: urea breath test 100%, rapid urease test 89.2%, serology 71.9%, and culture 54.9%. Metronidazole had the highest frequency of resistance (36.4%) and the rate of clarithromycin resistance was 18.2%. The eradication rate after first-line therapy was 75.5%, and abdominal pain and dyspeptic symptoms were reduced or completely resolved in 75.7% of the successful-eradication cases. The proportion of failed-eradication cases that responded well to quadruple-drug therapy was 93.8%.

CONCLUSION

Symptomatic H. pylori infection in a child should always be treated. The urea breath test is an accurate and reliable way to identify H. pylori-positive patients and to determine the response to treatment. Triple-agent therapy is effective for eradicating H. pylori infection in children and usually helps reduce or eliminate dyspeptic symptoms. The level of H. pylori resistance to metronidazole is high in our region. The significant rate of resistance to clarithromycin (18.1%) may explain the treatment failure observed in this study.

The seroprevalence of Helicobacter pylori in a referral population of children in the United States

OBJECTIVES

The purpose of this study was to determine the prevalence of serum antibodies directed against Helicobacter pylori (H. pylori) in children referred to children's hospitals or medical centers throughout the United States.

METHODS

This multisite cross-sectional prospective study involved 992 children from 12 states using a validated anti-H. pylori IgG enzyme immunoassay. The children were recruited into two groups: those without any GI complaints (non-GI referral, n = 619) and those who were referred for endoscopy because of abdominal pain (GI referral, n = 373).

RESULTS

GI referral children had a higher rate of seropositivity (22.5%) than non-GI referral children (14.1%) from the same geographic regions. In both groups, older children were more likely to be seropositive for H. pylori, as were nonwhite children and those with lower socioeconomic status. H. pylori seropositivity rates were higher in GI referral children with four or more household members (relative risk [RR] = 1.47; CI 1.01-2.14). Multivariate analysis controlling for age, ethnicity, and household income, showed that presence of GI symptoms were associated with a nearly 2-fold risk for H. pylori seropositivity (odds ratio = 1.77, CI 1.27-2.47). Epigastric pain (RR = 2.21; CI = 1.33-3.66) and having three or more episodes of abdominal pain in the last 3 months (RR = 0.59, CI = 0.35-0.99) were the only specific symptoms significantly associated with H. pylori seropositivity.

CONCLUSIONS

The H. pylori seropositivity rate of GI referral children with symptoms of abdominal pain was significantly higher. H. pylori infection in early childhood was found to be associated primarily with the child's household size and socioeconomic status.

Helicobacter pylori infection in pediatrics

In the past year the main interest was focused on the role of family for transmission of Helicobacter pylori to children; the evaluation of noninvasive diagnostic tests, especially in young children; extra-intestinal clinical manifestations; the lack of consensus on treatment; and the problem of high resistance of the microorganism to antibiotics.