eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology
Peptic Ulcer Disease: Differential Diagnoses & Workup
Updated: Nov 5, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Other Problems to Be Considered
Autoimmune gastritis
Chronic recurrent abdominal pain
Eosinophilic gastritis
Workup
Laboratory Studies
- A minimum of laboratory studies may be indicated in children with mild peptic ulcer disease (PUD) symptoms and normal examination findings. The following laboratory data may be needed in children who are in unstable condition, in those who have severe or chronic or recurrent symptoms, or in those with serious complications of peptic ulcer disease.
- Hemoglobin and hematocrit tests: These may be indicated to diagnose anemia in the setting of chronic blood loss from the GI tract, to determine the severity of anemia in the setting of acute or massive GI bleeding, and to guide and monitor transfusion or iron therapy.
- Iron studies (peripheral smears and test of serum iron, total iron-binding capacity [TIBC], ferritin, reticulocyte count): These tests are used to determine the presence of IDA.
- H pylori serology: This analysis help to detect H pylori infection not previously diagnosed or treated. The evaluation can be used to identify infection in teenagers, but it is not recommended in children because of its false-positive rate and inability to distinguish colonization from inflammation or previous infection. It can be useful in children if results are negative. Stool studies for H pylori appear to be more sensitive and specific than serology testing in children.
- Measurement of the prothrombin time (PT) and the activated partial thromboplastin time (aPTT): These values are used to identify coagulopathy in patients with sepsis, multiple injuries, or massive GI bleeding. They are also used to identify those at risk for diffuse intravascular coagulation (DIC).
- Typing and cross-matching of blood: This is done in preparation for transfusion in patients in unstable condition or in critically ill patients.
- Determination of electrolyte, BUN, and creatinine levels: These levels aid in assessing patients with volume depletion or those who require fluid resuscitation.
- Arterial blood gas analysis: The values are used to assess the degree of acidosis in a patient with systemic illness, respiratory failure, or severe hypovolemia, or severe burns or trauma.
- Urinalysis: Urinalysis is performed to assess the patient's hydration status and to screen for infection or stones.
- WBC count and differential: These are used to detect peripheral eosinophilia in children with eosinophilic gastritis.
- Measurement of serum gastrin and gastrin-releasing peptide levels: These data are used to exclude Zollinger-Ellison syndrome (ZES) in patients with refractory ulcers.
- Examine and perform guaiac testing on the stool to confirm GI bleeding. Melena is usually the result of an upper-GI bleed, though blood from a duodenal ulcer that quickly transits the intestinal tract may be visible as red or maroon blood in the stool.
Imaging Studies
- Abdominal and/or chest radiography assist in the diagnosis of perforation.
- Upper-GI series
- An upper-GI series helps in detecting peptic ulcer disease in approximately 70% of children who are examined. A double-contrast study increases the detection rate, but the child should be older and cooperative, and the study increases the radiation exposure. The false-positive rate may be 30%.
- The sensitivity is higher for duodenal ulcers than for gastric ulcers.
- Radiologic findings of duodenal ulcers include filling defects or deformities of the duodenal bulb.
- A fibrinous clot in the ulcer may lead to false-negative findings. Rates of false-positive findings on barium studies are especially high, as high as 30-40%, in pediatric patients.
- Gastric-outlet obstruction, the result of pyloric lesions, can be detected on upper-GI imaging.
- Angiography may be necessary in patients with a massive GI bleed in whom endoscopy cannot be performed. An ongoing bleeding rate of 0.5 mL/min or more is needed for the angiography to be able to accurately identify the bleeding source. Angiography can depict the source of the bleeding and can help in providing needed therapy in the form of a direct injection of vasoconstrictive agents in adults.
Procedures
- Esophagogastroduodenoscopy
- Esophagogastroduodenoscopy (EGD) is the procedure of choice for detecting peptic ulcer disease in the pediatric population.
- EGD allows for direct visualization of the mucosa; for localization of the source of bleeding; and for the diagnosis of H pylori infection by analyzing biopsy specimens, performing cultures or detecting urease activity.
- Therapeutic endoscopy for acute bleeding (coagulation of a bleeding ulcer with a heater probe or injection with vasoconstricting agents) is another important indication for EGD.
the gross appearance of an active ulcer is a round or oval, punched-out lesion with a smooth, white base and surrounding mucosa that is red and edematous.
Most gastric ulcers are located in the lesser curvature of the stomach.
- More than 90% of duodenal ulcers are found in the duodenal bulb. An erosion is small (<3 mm) and superficial defect in the mucosa.
- Consider nasogastric (NG) lavage in a child who is ill and in whom upper-GI hemorrhage is suspected because of hematemesis or melena.
Histologic Findings
- Histologic analysis of an active ulcer reveals 4 zones. From superficial to deep, the zone are (1) a thin layer of necrotic fibrinoid material at the base and margins of the ulcer, (2) a region of mostly polymorphonuclear neutrophil (PMN) leukocytes, (3) active granulation tissue with mononuclear leukocytes, and (4) a solid fibrous or collagenous scar. Ulcers extend through the mucosa and penetrate the muscularis mucosa layer into the submucosa or deeper layers.
- Antral mucosal nodularity and lymphocytic inflammation may be found in association with H pylori gastritis. Hematoxylin and eosin staining reveals the degree of inflammation and ulceration. Giemsa, Diff-Quick, or Warthin-Starry silver staining demonstrates the spiral organisms in the mucous layer overlying the gastric mucosa. With long-standing chronic gastritis, dysplastic changes may be found in the epithelial cells with variation in size, shape, and orientation. These changes support the finding of an increased incidence of gastric cancer in patients with chronic H pylori infection.
- Secondary gastritis, or acute inflammation associated with serious underlying illness or injury, results in a predominance of PMN leukocytes. With the mucosal damage caused by corrosive agents, histologic examination reveals edema, submucosal hemorrhage, and a mild inflammatory cell infiltrate. In children with eosinophilic gastritis, eosinophilic infiltration of the gastric mucosa is the prominent histologic feature.
More on Peptic Ulcer Disease |
| Overview: Peptic Ulcer Disease |
 Differential Diagnoses & Workup: Peptic Ulcer Disease |
| Treatment & Medication: Peptic Ulcer Disease |
| Follow-up: Peptic Ulcer Disease |
| Multimedia: Peptic Ulcer Disease |
| References |
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References
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Further Reading
Keywords
peptic ulcer disease, PUD, primary ulcer, secondary ulcer, stress ulcer, peptic ulcer, gastric disease, stomach ulcer, intestinal ulcer, ulceration, infection, mucosal ischemia, treatment, diagnosis
