Idiopathic peptic ulcers in children

Evolution of Helicobacter pylori associated with gastroduodenal ulcers or erosions in children over the past 23 years: Decline or steady state?

BACKGROUND

Recent data suggest that in children, the proportion of gastroduodenal ulcers/erosions associated with Helicobacter pylori infection is currently lower than expected. In this study, we trace this proportion over two decades.

METHODS

We reviewed the reports of all upper gastrointestinal endoscopies with biopsies for histology and culture over the past 23 years. H pylori status was assessed using several invasive methods. The infection rate during different time periods was compared between children with lesions and controls.

RESULTS

A total of 7849 endoscopies were performed in 5983 children (2874 F/3109 M, median age 7.6 years, range 0.1-17.9 years). The endoscopy report was missing in 316 patients. At the first upper gastrointestinal endoscopy, 12.1% of the children presented with gastric and/or duodenal ulcers or erosions with an H pylori infection rate of 35.4%, whereas no such lesions were observed in 87.9% of children in whom the H pylori infection rate was 21.3%. The risk factors associated with such lesions were older age (P < 0.001), male sex (P = 0.002), and H pylori infection (P < 0.0001). Gastric ulcers were not significantly associated with H pylori (24% infected), whereas 52% of duodenal ulcers, 33% of gastric erosions, and 38% of duodenal erosions were associated with H pylori. The proportion of gastroduodenal lesions associated with H pylori remained stable over time. Children with H pylori infection and ulcers were older than those with H pylori infection without ulcers (P < 0.001).

CONCLUSIONS

Our study indicates that in our pediatric population, the proportion of ulcers without H pylori infection is higher than previously suggested, and this prevalence has not changed over the past two decades.

Antibiotic resistance of Helicobacter pylori in pediatric patients -- 10 years' experience

The aim of this study was to assess the pattern of evolution of resistance to antibiotics in Helicobacter pylori isolated from children who underwent upper endoscopy with antral biopsy during a 10-year period (2001-2010). We retrospectively analyzed data of all children (n = 3,008) who underwent upper endoscopy during the observed period at the Children's Hospital Zagreb, a university tertiary medical center. We calculated the rate, antibiotic susceptibility and risk factors for the H. pylori infection in our cohort. Antral biopsy was performed in 2,313 (76.89%) patients. Altogether, 382 (16.51%) children had positive biopsy for H. pylori (histology and/or culture). There was no significant difference in the incidence of H. pylori during 10 years of observation (p = 0.21). Infected children compared to non-infected group were older (p = 0.005), and had more often antral nodularity (p < 0.0001), and duodenal ulcer (p = 0.002). Altogether, 22.4% of treatment-naïve patients had strains resistant to tested antibiotics: majority to azithromycin (17.9%), followed by clarithromycin (11.9%), metronidazole (10.1%) and amoxicillin (0.6%). In the eradication failure group, 9/11 of children had strains resistant to tested antibiotics, mostly to metronidazole (7/11), followed by azithromycin (3/11) and clarithromycin (1/11). No correlation was found between age or gender and antibiotic resistance (p = 0.32, for both). In conclusion, our data strongly support current guidelines which recommend antibiotic susceptibility testing prior to eradication therapy. Based on our results we recommend the use of amoxicillin-metronidazole-based regimen as the first-line therapy in our study population.

Helicobacter pylori negative, non-steroidal anti-inflammatory drug-negative peptic ulcers in India

INTRODUCTION

The past decade has witnessed a global rise in the prevalence of peptic ulcer disease which is unrelated to non-steroidal anti-inflammatory drugs (NSAIDs) or Helicobacter pylori infection. Although initially recognized in the West, this disease is being increasingly recognized in the Asian population. The higher risk of bleeding and ulcer recurrence in this subgroup of patients highlights the clinical importance of analyzing the changing trends of peptic ulcer disease in developing countries.

AIMS

To assess the proportion of non-NSAID, non-H. pylori peptic ulcer disease in an Indian cohort of patients with peptic ulcer disease managed at a tertiary care center; and to compare the gastric and duodenal ulcer subgroups in these patients.

METHODS

Patients diagnosed with peptic ulcer disease were screened for a history of NSAID use and those with a negative history were tested for H. pylori using a combination of rapid urease test (RUT) and (14)C-urea breath test (UBT). Only those cases which tested negative for both the tests were considered 'H. pylori-negative'. Serum gastrin was measured in all patients included in the study.

RESULTS

Seventy-four gastric ulcer (GU) and 54 duodenal ulcer (DU) patients with no history of NSAID use were enrolled. Of these, 36 GU (45.9%) and 16 DU (29.6%) patients were H. pylori-negative. The proportion of non-NSAID non-H. pylori gastric ulcers was significantly higher than duodenal ulcers (p < 0.05). However, patients who tested negative for H. pylori did not differ significantly from those who tested positive with regard to age, gender, serum gastrin level, and presence of risk factors, like smoking and alcoholism.

CONCLUSION

The current study indicates existence of high proportion of non-NSAID, non-H. pylori peptic ulcer disease in Indian patients.

The survey of Helicobacter pylori infection in infant

This present study was designed to determine the prevalence of H. pylori in infants and correlation of this infection with age. In a prospective descriptive study in Tabriz children hospital, we conducted analysis of children within age 2 year or younger who had H. pylori infection that were diagnosed with endoscopies and biopsy. Prevalence of infection was higher in the infants whose mothers had a low education level (p = 0.045). The H. pylori prevalence didn't differ between exclusively breastfeeding to six months and infants who had never breast fed (26.6% vs. 13.3%) (p = 0.2). We could not find any correlation between rate of infection and age of patients which used by regression model for analysis and t test (p = 0.5). Based on our study the prevalence of H. pylori infection in infants living in North West of Iran was low. We could not find any correlation between rate of infection and age of patients.

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.

Helicobacter pylori infection and childhood

Pediatric-based Helicobacter pylori research continues to contribute significantly to our understanding of both clinical and pathophysiological aspects of this infection. Here, we review the published pediatric H. pylori literature from April 2009-March 2010. Analysis of pediatric H. pylori strains continues to suggest that cagA(+) and cagPAI competent strains are less prevalent than in adult isolates. Studies from the Middle East report a high H. pylori prevalence and intrafamilial transmission. Data continue to show a lack of association between H. pylori and recurrent abdominal pain of childhood, gastroesophageal reflux disease, and growth retardation. Recent probiotic trials have not shown a benefit on H. pylori eradication in children, while sequential therapy remains an attractive therapeutic eradication strategy in children, which requires validation in different geographic regions.

Time trends of Helicobacter pylori resistance to antibiotics in children living in Vienna, Austria

BACKGROUND

Increase of antibiotic resistance is a worldwide problem. Within the 4 years before the turn of the millennium Helicobacter pylori strains isolated in children living in Vienna, Austria, showed a primary clarithromycin and metronidazole resistance of 20% and 16%, respectively. The aim of this retrospective follow-up survey was to assess the further development and current antimicrobial resistance status.

METHODS

Children having undergone upper endoscopy between March 2002 and March 2008 at the same two co-operating pediatric gastroenterology units which had also been collaborating on the prior assessment were included. H. pylori infection was diagnosed by rapid urease test, histology, and culture. If the latter was positive, susceptibility testing to amoxicillin, clarithromycin and metronidazole by E-test followed. From March 2004 onwards, susceptibility to levofloxacin, tetracycline and rifampin was additionally assessed.

RESULTS

Out of 897 children, 153 had a proven infection with H. pylori and no history of prior eradication treatment. Their median age was 11.5 years (range 0.5-20.9 years). Primary resistance to clarithromycin and metronidazole were 34% and 22.9%, respectively; dual resistance was found in 9.8% of the strains; 0.9% was resistant to tetracycline and rifampin, respectively. No case of amoxicillin resistance was detected. The only independent risk factor for clarithromycin resistance turned out to be the origin of a child from Austrian parents.

CONCLUSIONS

In the last decade, the rate of primary resistance of H. pylori to clarithromycin continued to rise. No significant change was found regarding primary resistance to metronidazole or dual resistance to metronidazole and clarithromycin, respectively.