Запальні захворювання шлунка та ДПК. Автор: к.мед.н.доцент Салтикова Г.В.

Inflammatory Diseases of the Stomach and Duodenum in Children

Overview of Lecture Topics

• The lecture focuses on inflammatory diseases of the stomach and duodenum in children, emphasizing unique aspects related to diagnosis and treatment.

• It aims to highlight differences from adult cases, particularly regarding gastritis and duodenitis.

Definitions and Characteristics

• Gastritis is defined as inflammation of the stomach, while duodenitis refers to inflammation of the duodenum. These definitions seem straightforward but involve complex processes when examined closely.

• Chronic gastritis can manifest as recurrent, focal, or diffuse inflammation affecting gastric mucosa with potential for atrophy and secretory insufficiency over time. This leads to digestive disturbances.

Progression and Types of Gastritis

• Regardless of initial type (e.g., hyperacidic or erosive), chronic gastritis often progresses towards atrophic gastritis due to prolonged inflammation. The longer the condition persists, the higher the likelihood of developing atrophy.

• Chronic duodenitis typically presents with structural changes in both gastric and duodenal mucosa, leading to secretory, motor, and evacuation disorders. Gastritis tends to be more persistent in children compared to adults.

Epidemiology

• The prevalence rate for chronic gastritis among children is approximately 300-400 per 1,000 pediatric population; it predominantly affects children aged 10 years and older with a slight male predominance during adolescence.

• Among upper gastrointestinal inflammatory diseases, chronic duodenitis is most common (over 50%), followed by chronic gastritis (16%) and isolated duodenitis (1%). Other pathologies include esophagitis and peptic ulcers.

Etiological Factors

• Various etiological factors contribute to these conditions:

• Infectious agents like Helicobacter pylori.

• Dietary factors such as excessive consumption of irritants or preservatives.

• Genetic predisposition plays a significant role; family history increases susceptibility to gastric issues.

Allergic Factors

• Attention is drawn towards allergic factors contributing to eosinophilic gastroenteropathy; its global prevalence stands at about 3.8 per 100,000 residents.

• As societal allergen levels rise, these conditions are becoming more prevalent; diagnosing them has become feasible but treatment remains challenging—sometimes involving corticosteroids used for asthma management repurposed for treating allergic esophagitis.

Understanding Chronic Gastritis in Children

Prevalence and Age Factors

• The treatment of chronic gastritis in children is complex due to limited medication options for younger patients.

• The prevalence of Helicobacter pylori-related chronic gastritis is lower in children compared to adults, influenced by the duration of infection and age.

• Among children over 15 years old, about 50% are affected; this drops to 20% for ages 4-9 and rises to 40% for those under 14.

Clinical Classification of Gastritis

• A clinical classification based on the Sydney morphological classification from the '90s allows for a comprehensive description of mucosal changes. This aids communication among healthcare providers.

• Accurate diagnosis according to this classification helps other doctors understand the severity and specific changes present in the gastric mucosa.

Endoscopic vs Morphological Assessment

• The first part of the classification focuses on endoscopic findings, while morphological assessment relies on histology results. This distinction is crucial for evaluating disease progression.

• Chronic gastritis typically arises as a primary condition, whereas acute gastritis often results from infections like viral gastroenteritis or foodborne illnesses. Acute cases usually do not transition into chronic forms.

Factors Influencing Chronic Inflammation

• Chronic inflammation can stem from various factors including autoimmune diseases (e.g., Crohn's disease) that affect gastrointestinal structures, leading to significant mucosal changes.

• Autoimmune processes can cause diverse topographical lesions visible during endoscopy, which may be localized or widespread across different stomach regions (e.g., antrum or fundus).

Histological Evaluation and Remission States

• Morphological evaluation through histology assesses inflammation levels, activity degree, atrophy, and potential metaplasia—important indicators for cancer risk assessment later on.

• Remission states can vary; complete remission indicates no signs of chronic gastritis after several years despite previous diagnoses, although such periods are rarely diagnosed without ongoing monitoring or endoscopic evaluations.

Understanding the Variability of Gastric Acidity

Daily Fluctuations in Gastric Acidity

• Gastric acidity varies throughout the day, with different levels observed in the morning, afternoon, and evening.

• It is challenging to provide a 100% accurate assessment of gastric acid production due to individual variability.

• The absence of clear signs of atrophy suggests normal acid production; treatment often focuses on reducing acidity.

Introduction to Helicobacter Pylori

• Helicobacter pylori was first described in 875 AD as a spiral-shaped gram-negative bacterium that can change form under adverse conditions.

• There are three primary transmission routes for H. pylori: oral-oral, fecal-oral, and contact transmission.

Transmission Routes of Helicobacter Pylori

Understanding Contact Transmission

• A question arises regarding what constitutes contact transmission for H. pylori.

• Possible contact transmission could occur through contaminated surfaces or microtraumas on skin that come into contact with infected materials.

Limitations of Transmission

• H. pylori does not transmit through blood; it resides only in mucosal layers and is related strictly to gastrointestinal tract interactions.

• Poorly sterilized endoscopes can facilitate the transfer of H. pylori between patients during procedures.

Pathogenic Mechanisms of Helicobacter Pylori

Factors Contributing to Pathogenicity

• H. pylori possesses both exotoxins and endogenous factors contributing to its pathogenicity.

• Exotoxins include vacuolating cytotoxin (VacA), which damages mucosal membranes and promotes inflammation.

Genetic Factors Influencing Virulence

• Different strains contain varying virulence genes that affect their pathogenic potential; some strains express specific toxins while others do not.

Impact on Gastric Environment

Neutralization Mechanism

• To survive, H. pylori produces urease, creating a neutral environment around itself by converting urea into ammonia.

Consequences for Host Health

• This neutralization leads to increased acid secretion from the host's stomach lining, potentially causing damage over time.

Clinical Implications and Genetic Interactions

Inflammation and Disease Development

• The interaction between H. pylori and host genetics influences disease outcomes; certain genetic predispositions may lead to more severe inflammatory responses.

Microbiome Considerations

• The presence of other microorganisms within the human microbiome can also impact how H. pylori affects gastric health, highlighting the complexity of these interactions.

Understanding Microbiocenosis and Gastrointestinal Syndromes

Importance of Microbiocenosis

• The significance of microbiocenosis in the organism, particularly in the stomach, is widely acknowledged today. This understanding is crucial when discussing clinical manifestations of gastritis and duodenitis.

Clinical Manifestations of Gastritis and Duodenitis

• Three primary syndromes are associated with gastrointestinal tract damage:

• Pain syndrome

• Dyspeptic syndrome

• Asthenic syndrome or chronic syndrome due to prolonged illness.

Characteristics of Pain Syndrome

• Pain can be early or late, depending on the location of inflammation:

• Early pain occurs within 10-20 minutes after eating, often seen in fundal gastritis.

• Late pain arises about an hour to an hour and a half post-meal, typically associated with duodenitis.

Localization and Symptoms

• Pain localization may vary but is commonly found in:

• Epigastric region or pyloric-duodenal area.

• Can also radiate to the left upper quadrant or left arm.

• Dyspeptic symptoms include:

• Nausea, vomiting, loss of appetite, and non-specific upper dyspepsia signs like belching and heartburn.

Diagnostic Approaches

• Diagnosis involves physical examination for vitamin deficiencies and other signs such as skin dryness.

• Laboratory tests typically include:

• Complete blood count (CBC), urinalysis, stool analysis for hidden blood, chemical blood analysis.

• Endoscopy with targeted biopsy is essential for assessing inflammation nature accurately.

Endoscopic Evaluation and Helicobacter Pylori Testing

Role of Endoscopy in Diagnosis

• Fibroesophagogastroduodenoscopy (EGD) allows direct visualization and biopsy collection to determine inflammation type accurately.

• Without biopsy results from endoscopy, diagnoses like gastritis cannot be considered legitimate.

Identifying Helicobacter Pylori Infection

• Two main groups exist for testing H. pylori: invasive and non-invasive methods.

• Invasive methods involve taking biopsies during endoscopy; non-invasive methods include breath tests or serological tests.

• Biopsy samples can be cultured to grow H. pylori for further analysis.

Limitations of Non-Invasive Tests

• While rapid tests can indicate H. pylori presence quickly, they do not quantify bacterial load effectively compared to histological evaluations from biopsies.

This structured approach provides a comprehensive overview while ensuring clarity through timestamps linked directly to relevant sections for easy reference during study sessions.

Diagnosis and Treatment of Functional Disorders in Children

Diagnostic Challenges in Identifying Functional Disorders

• The gold standard for diagnosing Green syndrome involves biopsy, but the bacteriological assessment is complex due to the microaerophilic nature of the bacteria, making it difficult to grow in specific environments. This complicates antibiotic resistance evaluation.

• Distinguishing between organic disorders and functional disorders is crucial; endoscopy may be necessary if symptoms align with organic issues. For instance, functional dyspepsia criteria focus solely on pain or discomfort in the epigastric area post-meal without other gastrointestinal symptoms.

Symptoms and Their Implications

• In cases of functional dyspepsia, symptoms are limited to epigastric pain that is poorly localized and typically lasts less than an hour, often resolving spontaneously. Stress or eating can exacerbate these symptoms. Between episodes, children generally feel well.

• Anxiety or depressive symptoms may accompany abdominal pain in children; recognizing these signs is essential for accurate diagnosis. A family history of functional disorders can also provide valuable context during assessment. If organic issues are present, they usually exhibit more consistent localization and worsening over time compared to functional disorders.

Treatment Principles for Gastrointestinal Disorders

• The primary treatment approach for peptic ulcers and gastritis includes dietary modifications aimed at protecting the gastric mucosa through mechanical, chemical, and thermal means—food should be soft, warm (not hot or cold), and devoid of spices or additives like salt or sugar.

• Medication therapy should encompass etiological (addressing H.pylori infection), pathogenetic (normalizing acid production), and symptomatic treatments (managing dyspeptic manifestations). Effective management requires a comprehensive understanding of underlying causes such as allergies or infections like giardiasis.

Specific Considerations for Helicobacter Pylori Testing

• It’s critical not to conduct Helicobacter pylori testing in children with suspected functional abdominal pain unless there are indications of organic disease requiring further investigation through endoscopy; this aligns with guidelines established by Maastricht consensus recommendations from 2018 regarding pediatric care across Europe and North America.

• If H.pylori is suspected due to conditions like gastritis or ulcers confirmed via endoscopy, appropriate testing must follow before initiating treatment; otherwise, unnecessary interventions could occur without clear evidence linking H.pylori to observed gastrointestinal inflammation in children.

Treatment Protocols for Helicobacter Pylori Infections

Diagnosis and Initial Considerations

• When treating patients with iron supplements, if there is no effect, FDS (Fibro-Optic Diagnostic Study) is conducted to identify potential issues such as autoimmune conditions or the presence of H. pylori.

• It is crucial to stop using acid-reducing medications four weeks prior to testing for H. pylori; otherwise, test results may be misleadingly negative.

Treatment Duration and Medication Guidelines

• Current treatment regimens should last at least 14 days to ensure effective eradication rates of around 90%.

• If a child is allergic to clarithromycin or metronidazole, alternative antibiotics like amoxicillin can be used in combination with proton pump inhibitors (PPIs).

Antibiotic Resistance and Alternatives

• There are restrictions on certain antibiotics; tetracycline should only be used in children over eight years old.

• In cases of unknown sensitivity to clarithromycin, bismuth compounds may be included in the treatment regimen alongside PPIs and amoxicillin.

Advanced Treatment Strategies

• For patients with penicillin allergies, metronidazole or tetracyclines (for older children) can serve as alternatives.

• Quadruple therapy involving bismuth is preferred when available due to its effectiveness compared to high doses of amoxicillin.

Current Protocol Recommendations

• The Ministry of Health's protocol from 2023 outlines treatment strategies for peptic ulcers in both adults and children, emphasizing pathogenetic therapy through antisecretory medications.

• Three main groups of antisecretory drugs include antacids, alginates, and histamine receptor blockers that reduce gastric acid production.

Proton Pump Inhibitors: Efficacy and Usage

• PPIs like omeprazole are essential for reducing gastric acidity effectively; newer options like pantoprazole show improved efficacy over older medications.

• Achieving a less acidic environment enhances the effectiveness of antibacterial treatments against H. pylori while promoting mucosal healing.

Understanding Peptic Ulcers vs. Gastritis

• A peptic ulcer involves damage extending into the muscular layer of the stomach lining; this distinguishes it from erosive gastritis which affects only superficial layers.

• Diagnosing peptic ulcers requires endoscopic examination confirming ulcerative defects; chronic conditions with recurrent lesions indicate peptic ulcer disease.

Understanding Recurrence in Peptic Ulcer Disease

Causes of Recurrence

• The search for causes of recurrence includes factors like Helicobacter pylori, Zollinger-Ellison syndrome, and hyperparathyroidism. Despite these considerations, the diagnosis remains peptic ulcer disease.

• In children, the incidence of ulcers is noted as 2.7 per 1000 in school-age populations and 0.4 per 1000 in preschoolers.

Clinical Presentation and Diagnosis

• The localization of ulcers primarily occurs in the duodenum (99%), with a minimal presence in the stomach (0.5%) and esophagus (0.3%). This highlights different clinical presentations between adults and children.

• Complications from ulcers can include bleeding, perforation, or stenosis due to frequent recurrences. Staging via FGDS is crucial for assessing ulcer healing stages.

Etiology and Pathogenesis

• Key etiological factors include medications, neuropsychological stressors, family conflicts, and Helicobacter pylori infection—these are considered primary despite other potential causes.

• The pathogenesis involves a balance between aggressive factors (like H. pylori) and protective mechanisms influenced by the central nervous system.

Treatment Considerations

• Treatment strategies must be tailored based on underlying causes; this may involve addressing both psychological components and H. pylori eradication.

• Distinguishing between peptic ulcer disease and gastritis is essential; symptoms such as nocturnal pain or hunger-related pain are indicative of duodenal ulcers.

This structured summary provides an overview of key concepts related to peptic ulcer disease discussed within the provided timestamps while maintaining clarity for study purposes.