Upper abdominal pain

1. • F.M.S 6 years old female presented to rapareen hospital with
upper abdominal pain for one week duration, which was
started gradually radiated to umbilical region aggravated by
stress and relieved a little by taking rest, sometimes awaken
the patient from sleep. Associated with nausea and some
dizziness, there was no vomiting, no change in bowel habit,
no change in stool color, no abdominal distension, no any
constitutional sympoms. This patient has had many previous
similar attacks like this with so many investigations done.

2. Systemic review
• Respiratory: no dyspnea, no chest pain, no cough.
• Cardiovascular: no dyspnea, no cyanosis, no palpitation.
• CNS: no headache, no vertigo, no LOC.
• Genitourinary: no dysuria, no frequency, no nocturia, no
enuresis.
• Musculoskeletal: no joint/muscle pain or swelling, no any skin
rash

3. Physical examination
• 6 y.o female looking in pain but not distressed.
• Vital signs: BP 110/70, PR 99, RR 16, Temp 36.1
• Abdominal examination: flat, not distended, no any scar, soft
with epigastric tenderness with superficial and deep palpation,
no mass, no organomegally.

4. Peptic ulcer disease
• A peptic ulcer is a round or oval sore in the lining of the stomach
or duodenum where it has been eroded by stomach acid and
digestive enzymes.
•

5. These things may play a role in stomach or
duodenal ulcers:
• H. pylori: These bacteria make substances that weaken the
protective mucus in the stomach, makes it more likely to get
damaged from acid and pepsin.
• Caffeine: cause the stomach to release acid, make the pain of an
existing ulcer worse. However, it does not cause ulcers.
• Stress: Emotional stress is no longer thought to cause ulcers. But
people with ulcers often say that their stress increases ulcer pain.
Acid and pepsin: The stomach can’t always fully defend itself against
strong digestive fluids. These include hydrochloric acid and
Nonsteroidal anti-inflammatory drugs (NSAIDs).

6. Which children are at risk for stomach and
duodenal ulcers?
• The greatest risk factor for gastric and duodenal ulcers is an H.
pylori infection.
• Living in overcrowded conditions
• Sharing a bed
• Genetics (children with Hispanic and African-American
backgrounds have a higher risk)
• Children who regularly take aspirin or NSAID pain relievers are also
at risk for ulcers.

7. Symptoms
• Ulcers don’t always cause symptoms.
• The most common symptom is a gnawing or feeling of burning pain in the stomach. This is
often felt between the breastbone and the belly button (navel), may feel the pain more
between meals, in the early morning, or at night. It may last from a few minutes to a few
hours.
• Less common ulcer symptoms include:
• Anemia
• Bloating
• Belching
• Nausea and vomiting
• Vomit with blood in it
• Poor appetite
• Weight loss
• Tiredness and weakness
• Red or maroon stool or black, tarry stool

8. Diagnosis
• A thorough history , physical examination
• Upper GI (gastrointestinal) series
• Blood, stool, breath, and stomach tissue tests
• These tests are done to look for H. pylori.
• Endoscopy

9. Treatment
• Treatment will depend on your child’s symptoms, age, and general
health. It will also depend on how severe the condition is.
• Your child's treatment will also depend on what’s causing the ulcer.
For instance, ulcers caused by H. pylori need different treatment
from ulcers caused by using NSAIDs.
• Lifestyle changes
• H. pylori is typically treated with a combination of antibiotics plus a
proton pump inhibitor. Patients should be asked about previous
antibiotic exposure to help guide the treatment regimen. There is no
regimen with a 100% cure rate for H. pylori infection, and there are
few, if any, regimens with a 90% cure rate

10. • RECOMMENDED
• Clarithromycin triple therapy: consists of a PPI, clarithromycin
(Biaxin), and amoxicillin or metronidazole (Flagyl) for 14 days
• Bismuth quadruple therapy: consists of a PPI, bismuth,
tetracycline, and a mitroimidazole for 10 to 14 days (It may be a
particularly good option in patients with macrolide exposure or
who are allergic to penicillin).
• Concomitant therapy: consists of a PPI, clarithromycin,
amoxicillin, and a nitroimidazole (tinidazole or metronidazole) for
10 to 14 days.

11. • Sequential therapy: consists of a PPI and amoxicillin for five to
seven days followed by a PPI, clarithromycin, and a
nitroimidazole for five to seven days. Although 10 days of
sequential therapy appears to be a viable alternative to 14 days
of clarithromycin triple therapy, 10 days of sequential therapy
has not been shown to be superior to 14 days of clarithromycin
triple therapy.
• Hybrid therapy: consists of a PPI & amoxicillin for 7days followed
by a PPI, amoxicillin, clarithromycin, and a nitroimidazole for
7days. This regimen is a promising option that has been shown in
international studies to be at least as effective as clarithromycin
triple therapy with similar tolerability.
• (the complexity of hybrid and sequential therapy may limit its
use).

12. • Levofloxacin triple therapy: PPI, levofloxacin & amoxicillin for 10 -
14 days. Levofloxacin is a fluoroquinolone with in vitro
antimicrobial activity against gram-positive and gram-negative
bacteria, including H. pylori.
• The best options appear to be fluoroquinolone-containing
sequential therapy (a PPI and amoxicillin for 5-7days followed by
a PPI, a fluoroquinolone, and nitroimidazole for 5-7days) or
• LOAD therapy (levofloxacin, omeprazole, nitazoxanide &
doxycycline for 7-10days).

13. What Factors Predict Successful Eradication When
Treating H. pylori Infection?
• Determinants of success can be related to patient factors or to the
infection. The main determinants are choice of regimen, patient
adherence to a multidrug regimen with frequent adverse effects, and
the sensitivity of the H. pylori strain to the combination of antibiotics
used. The number of doses per day and the severity of adverse
effects influence treatment adherence

14. Should We Test for Treatment Success After H. pylori
Eradication Therapy?
• Because of the declining success rate of H. pylori eradication therapy,
persistent infection is not uncommon. A urea breath test, fecal antigen
testing, or biopsy-based testing should be used to determine treatment
success. Testing should be performed at least 4weeks after completion of
antibiotic therapy and after PPI therapy has been withheld for 1-2weeks.
• If infection persists after treatment, the same antibiotics should be
avoided when retreating the patient. Bismuth quadruple therapy or
levofloxacin regimens are preferred for patients who initially received a
regimen containing clarithromycin. A regimen containing clarithromycin
or levofloxacin is preferred for patients who initially received bismuth
quadruple therapy.