Helicobacter pylori causes ulcers in children

March 2003

MIAMI BEACH, Fla. — Although ulcers used to be blamed on excess stomach acid, they are really caused by Helicobacter pylori. Excess stomach acid only aggravates ulcers that are already present.

“Ulcer disease is an infectious disease, and the infection is due to H. pylori, which is a bacterium that lives in the stomach,” said William F. Balistreri, MD, at the 38th Annual Postgraduate course “Perspectives in Pediatrics” at Miami Children’s Hospital here.

H. pylori can be a long-term inhabitant of the human stomach, and it can persist for the lifetime of the host.

There are several goals in the treatment of ulcers. The first goal is to relieve symptoms. To do this, acid suppression is necessary, because acid causes irritation. Acid suppression will also help the ulcer to heal. The second treatment goal is to prevent recurrence. “To do this, you need to avoid inciting factors such as nonsteroidal anti-inflammatory agents. Most importantly, you want to eradicate H. pylori,” he said.

Demographics

H. pylori infection is associated with childhood socioeconomic status, suboptimal sanitary conditions and crowded living conditions. Of children with low socioeconomic status, 85% will be infected, compared with 52% of those with middle socioeconomic status and 11% with a high socioeconomic status. Additionally, if the household includes many children, there is a high incidence (65%) of infection, compared with 55% with middle crowding and 30% with low crowding.

H. pylori transmission is by stomach-to-mouth, mouth-to-mouth or fecal-oral routes, and it is most often transmitted to children by their parents or siblings. “If a child has a sibling who is infected, he or she has an 82% chance of being infected,” said Balistreri, who is director of pediatric gastroenterology, hepatology and nutrition at Children’s Hospital Medical Center and professor of pediatrics at the University of Cincinnati Medical Center.

H. pylori infection has several clinical manifestations. Patients with acute infection will have nausea and vomiting, epigastric pain and bad breath. Patients with chronic infection will have gastritis, gastric ulcer disease or possibly no symptoms.

Diagnosis

H. pylori infection in children is strongly associated with antral gastritis, nodularity and duodenal ulcer. “There is a little bit weaker association with gastric ulcers and there is no association with chronic abdominal pain,” he said.

There are several ways to make a diagnosis of H. pylori infection. It can be done using invasive or noninvasive techniques. “The only problem with a noninvasive test is that you can’t identify whether the patient has an ulcer,” he said.

Invasive tests are based on endoscopy. Physicians can do a biopsy and then look at histology. There are tests to detect urease activity, which is a characteristic of this microbe in tissue. Of the invasive tests, Balistreri prefers the rapid urease test.

Noninvasive tests include blood and breath tests. Balistreri said that he does not think that blood tests work well in children. “I like breath tests. It is a very simple measurement of urease activity,” he said.

After treatment, a breath test can be done to see if the infection has been eradicated.

Guidelines for diagnosis, treatment

According to Balistreri, the North American Society for Pediatric Gastroenterology (NASPGN) has published evidence-based guidelines to help with the diagnosis and treatment of H. pylori infection. For diagnosis, it recommends endoscopy to determine whether the child has an ulcer. The society said that serologic tests are unreliable for screening children.

According to the guidelines, any child with a duodenal ulcer or gastric ulcer should be tested for H. pylori. Do not test children with chronic recurrent abdominal pain or children with a family history of gastric cancer. “If you have treated someone, you probably ought to test to document that you have eradicated the disease,” Balistreri said.

Treatment is indicated if a child has a documented duodenal ulcer or gastric ulcer and is H. pylori-positive. However, do not treat children with chronic recurrent abdominal pain or other functional diseases, even if H. pylori is detected.

First-line therapy for eradication is based on the triple-drug regimen used for adults. Use two antibiotics (amoxicillin, clarithromycin or metronidazole) and an acid-blocking agent. Balistreri said that a vaccine may be available in the next few years.

For Your Information:

• Balistreri WF. Helicobacter pylori. Presented at the 38th annual postgraduate course “Perspectives in Pediatrics” at Miami Children’s Hospital. Jan. 24-31, 2003. Miami.