Pediatric Helicobacter Pylori Infection Workup

  • Author: Mutaz I Sultan, MBChB; Chief Editor: Carmen Cuffari, MD   more...
 
Updated: May 17, 2012
 

Laboratory Studies

The indications of testing for H pylori as recommended by the recent guidelines from North European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and North American Society for Paediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) for H pylori infection in children are as follows[21] :

  • The primary goal of clinical investigation of gastrointestinal symptoms is to determine the underlying cause of the symptoms and not solely the presence of H pylori infection.
  • Diagnostic testing for H pylori infection is not recommended in children with functional abdominal pain. At present, there is inadequate evidence supporting a causal relation between H pylori gastritis and abdominal symptoms in the absence of ulcer disease. Therefore, cases of abdominal pain consistent with the diagnostic criteria of functional pain should not be investigated for H pylori, unless upper endoscopy is performed during the diagnostic workup in search for organic disease.
  • In children with first-degree relatives with gastric cancer, testing for H pylori may be considered.
  • In children with refractory iron-deficiency anemia in which other causes have been ruled out, testing for H pylori infection may be considered.
  • There is insufficient evidence that H pylori infection is causally related to otitis media, upper respiratory tract infections, periodontal disease, food allergy, sudden infant death syndrome, idiopathic thrombocytopenic purpura, and short stature.
  • To confirm eradication of infection in selected children with complicated peptic ulcer disease or lymphoma and in children who remain symptomatic.

The recommendations for diagnostic tests that should be applied are as follows[21] :

  • For the diagnosis of H pylori infection during esophagogastroduodenoscopy(EGD), it is recommended that gastric biopsy samples (antrum and corpus) for histopathology be obtained.
  • It is recommended that the initial diagnosis of H pylori infection be based on either a positive histopathology plus a positive rapid urease test or a positive culture.
  • The 13C-urea breath test (UBT) is a reliable noninvasive test to determine whether H pylori has been eradicated.
  • A validated enzyme-linked immunosorbent assay (ELISA) test for detection of H pylori antigen in stool is a reliable noninvasive test to determine whether H pylori has been eradicated. Several methods are available for the detection of H pylori antigen in stool, such as enzyme immunoassay (EIA) based on polyclonal or monoclonal antibodies, and immunochromatographic tests (so-called rapid or quick tests). Stool tests are generally more convenient in pediatric patients than the UBT. Neither keeping the samples at room temperature for up to 5 days nor freezing for months or even years seems to influence the accuracy of the stool tests. So far, only the EIA based on monoclonal antibodies has achieved the accuracy of the UBT.
  • Tests based on the detection of antibodies (IgG, IgA) against H pylori in serum, whole blood, urine, and saliva are not reliable for use in the clinical setting.
  • It is recommended that clinicians wait at least 2 weeks after stopping proton pump inhibitor (PPI) therapy and 4 weeks after stopping antibiotics to perform biopsy-based and noninvasive tests (UBT, stool test) for H pylori.

Of note, these guidelines apply only to children living in Europe and North America, but not to those living in other continents, particularly in developing countries with a high H pylori infection rate in children and adolescents and with limited resources for health care.

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Imaging Studies

  • Imaging studies are not helpful in the diagnosis of H pylori infection. They may be useful in patients with complicated disease (eg, ulcer disease, gastric cancer, MALToma).
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Other Tests

  • Urea breath test: The patient ingests a test meal that contains urea labeled with carbon-13 (13 C), which is a nonradioactive isotope. H pylori urease activity produces labeled13 C dioxide that can be detected in exhaled air. A positive result confirms urease activity and H pylori infection. This test is very specific and sensitive in patients older than 6 years. Its most useful application is to verify H pylori eradication after treatment. Experience in children 5 years or younger, particularly in infants, is relatively limited and needs further validation.
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Procedures

  • Upper endoscopy (EGD) is the procedure of choice for detecting gastritis, duodenitis, and PUD in the pediatric population.
    • EGD allows for direct visualization of the mucosa; for localization of the source of bleeding; for the detection of H pylori by means of biopsy, culture, and cytology analysis; and for DNA testing by using PCR.
    • In addition, a quick test based on detection of urease activity (a highly specific marker of H pylori) can be performed. The test, termed the Campylobacter -like organism (CLO) test allows for a diagnosis of H pylori infection within 24 hours.
    • Two modified, rapid urease test kits are now commercially available and are reported to have better accuracy, a shorter reaction time, and better cost-effectiveness than those of the CLO test.
    • In children, endoscopy may reveal a nodular appearance in the gastric antrum resulting from lymphoid hyperplasia.[22] However, only approximately 50% of affected children have endoscopic evidence of changes of H pylori gastritis.
    • The gross appearance of an active ulcer is a round or oval, punched-out lesion with a smooth, white base and with surrounding mucosa that is red and edematous. In H pylori infection, the most common location for ulceration is the duodenal bulb.
    • Biopsy specimens obtained in the prepyloric antrum have the highest yield in H pylori infection. Tissue specimens are often also obtained from the body and the transition zones of the stomach, particularly if the patient has recently taken acid-suppressing medication.
  • Endoscopic biopsy is indicated for the following reasons:
    • Histologic examination of gastric tissue
    • Rapid urease testing (eg, CLO test)
    • Culture of organisms
    • PCR testing to identify H pylori DNA
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Histologic Findings

  • Histologic findings include a superficial infiltrate with substantial numbers of plasma cells and lymphocytes within the gastric mucosa and organisms visible on Giemsa, Diff-Quick, or hematoxylin and eosin staining. Sensitive staining for small numbers of bacteria is possible using silver stains such as Genta or Warthin-Starry.
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Staging

  • Although a staging system for the H pylori infection has not been established, several steps in disease progression are well described.
  • The first step is chronic gastritis, which is followed by the second step, atrophic gastritis. The third step is intestinal metaplasia, which may evolve into dysplasia. The last step in this process is gastric adenocarcinoma.
  • This process is very slow (ie, decades) and may stop at any step because gastric cancers probably require several other factors to develop, not only an H pylori infection.
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Contributor Information and Disclosures
Author

Mutaz I Sultan, MBChB  Instructor and Fellow, Department of Pediatrics, Division of Gastroenterology and Nutrition, Medical College of Wisconsin, Children's Hospital

Mutaz I Sultan, MBChB is a member of the following medical societies: American Gastroenterological Association and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Coauthor(s)

B UK Li, MD  Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Maria Triantafyllopoulou Greene, MD  Assistant Professor of Pediatrics, Northwestern University Feinberg School of Medicine; Attending Physician, Division of Gastroenterology, Hepatology, and Nutrition, Children's Memorial Hospital

Maria Triantafyllopoulou Greene, MD is a member of the following medical societies: American Gastroenterological Association and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Specialty Editor Board

Hisham Nazer, MB, BCh, FRCP, DCh, DTM&H  Professor of Pediatrics, Consultant in Pediatric Gastroenterology, Hepatology and Clinical Nutrition, Bushnaq Medical Centre, University of Jordan Faculty of Medicine, Jordan

Hisham Nazer, MB, BCh, FRCP, DCh, DTM&H is a member of the following medical societies: Royal College of Paediatrics and Child Health, Royal College of Physicians, Royal College of Surgeons in Ireland, Royal College of Surgeons of Edinburgh, and Royal Society of Tropical Medicine and Hygiene

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Stefano Guandalini, MD  Director, Celiac Disease Center, Chief, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Chicago Medical Center; Professor, Department of Pediatrics, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Stefano Guandalini, MD is a member of the following medical societies: American Gastroenterological Association, European Society for Paediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Steven M Schwarz, MD, FAAP, FACN, AGAF  Professor of Pediatrics, Children's Hospital at Downstate, State University of New York Downstate Medical Center

Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research

Disclosure: Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor; Johnson & Johnson, Inc. Grant/research funds Independent contractor

Chief Editor

Carmen Cuffari, MD  Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Meta Carroll, MD, to the development and writing of this article.

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Helicobacter pylori infection revealed by endoscopy (nodular gastropathy).
Helicobacter pylori–associated peptic ulcer in the duodenal bulb.
 
 
 
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