eMedicine Specialties > Pediatrics: Surgery > General Surgery

Peptic Ulcer: Surgical Perspective: Workup

Author: Carlos A Angel, MD, Associate Professor of Pediatrics, Division of Pediatric Surgery, University of Tennessee School of Medicine; Consulting Staff, East Tennessee Children's Hospital, East Tennessee Pediatric Surgery Group
Contributor Information and Disclosures

Updated: Jul 19, 2006

Workup

Laboratory Studies

  • In preparation for surgery, patients should have a complete blood count to test for leukocytosis and assess the degree of anemia.
  • Patients should also have a complete chemistry panel, including serum glucose, blood urea nitrogen, creatinine, and electrolytes (eg, ionized calcium).
  • Blood cultures should be drawn if systemic infection is suspected.
  • Because many of these patients (particularly infants) may be septic, coagulation studies are needed to evaluate for coagulation abnormalities, which should ideally be corrected before laparotomy.
  • Arterial blood gas measurements are helpful to assess and correct the acid-base balance and to adjust oxygenation and ventilation in patients who are receiving mechanical ventilation.
  • The patient's blood should be typed and crossmatched before exploration.

Imaging Studies

  • Plain radiographs are useful to diagnose perforations of gastric or duodenal ulcers.
  • Although single contrast studies with barium and double contrast studies with air and barium are widely available, these tests are grossly inadequate (except for the rare case of gastric outlet obstruction) for use in confirming the diagnosis of peptic ulcer disease in children because of the low sensitivity and specificity of the tests' findings.
  • For cases of massive bleeding that use of an endoscopy cannot control, an angiography can help reveal the bleeding site, thus allowing embolization or injection of vasoconstrictors.

Diagnostic Procedures

  • Endoscopy is the diagnostic procedure of choice in the investigation of peptic ulcer disease, gastrointestinal bleeding, and gastritis in pediatric patients. Often, microscopic gastritis may be present in mucosa that appears normal via endoscopy. Nodularity of the antrum is a frequent finding in children with H pylori gastritis.
  • Routine antral and duodenal biopsies should be performed. Culture of H pylori in mucosal biopsies is cumbersome and may take up to one week. Rapid tests are available that use the high urease content of H pylori. The biopsy sample is placed in media containing urea and a pH-sensitive indicator to detect ammonia. Reactions that are positive for H pylori are observable in as little as one hour. This rapid urease test has more than 95% sensitivity and specificity in adults; sensitivity and specificity are slightly lower in children because of a lower bacterial burden. Silver or Giemsa preparations may demonstrate spiral organisms on the antral mucosa just below the mucus layer.
  • H pylori testing should be reserved for children whose symptoms are severe enough to justify the potential risks of eradication and when peptic ulcer is either proven or a high index of suspicion is present.
  • Biopsy-based tests continue to be the criterion standard, but are invasive and expensive. 13C-urea breath testing (13C-UBT) has both a high sensitivity and specificity for diagnosing H pylori infection in children and is noninvasive. Although 13C-UBT is reliable for children younger than 6 years, it may be difficult to perform in younger children. 13C-UBT with a cutoff value of 3.5% stable isotope enrichment over baseline has sensitivity of 97% and specificity of 98%, compared with standard biopsy results, which are used as the standard.
  • Recently, a stool antigen enzyme-linked H pylori immunosorbent assay has been developed. This noninvasive test detects H pylori antigens excreted in stool using commercial kits with either monoclonal or polyclonal antibodies and has a reported sensitivity and specificity greater than 93%.

Histologic Findings

Gastritis lymphonodular hyperplasia is a characteristic finding of endoscopic biopsies in children infected with H pylori. Lymphonodular hyperplasia alone has been shown to be highly predictive of H pylori infection and seems to resolve with eradication of the infection. Antral nodularity, however, depends more on inflammation than on the presence of lymphoid follicles. Histologically, the antral mucosa may demonstrate a severe chronic inflammatory infiltrate. The combination of chronic antral inflammation and lymphonodular hyperplasia provides further evidence of H pylori infection.

More on Peptic Ulcer: Surgical Perspective

Overview: Peptic Ulcer: Surgical Perspective
Workup: Peptic Ulcer: Surgical Perspective
Treatment: Peptic Ulcer: Surgical Perspective
Follow-up: Peptic Ulcer: Surgical Perspective
References
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References

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Further Reading

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Keywords

peptic ulcer, gastric necrosis, gastric necrosis in neonates, erosive gastritis, chronic gastritis, gastric perforation, peptic stricture with gastric outlet obstruction, duodenal perforation, bleeding duodenal ulcer, Helicobacter pylori, H pylori, Dieulafoy lesion, Dieulafoy disease, Zollinger-Ellison syndrome, peptic ulcer disease, peptic ulcer surgery, gastrointestinal bleeding, vagotomy, pyloroplasty, gastric ulcer, primary peptic ulcer, secondary peptic ulcer, hemorrhagic ulcer

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Contributor Information and Disclosures

Author

Carlos A Angel, MD, Associate Professor of Pediatrics, Division of Pediatric Surgery, University of Tennessee School of Medicine; Consulting Staff, East Tennessee Children's Hospital, East Tennessee Pediatric Surgery Group
Carlos A Angel, MD is a member of the following medical societies: American College of Surgeons, American Pediatric Surgical Association, British Association of Paediatric Surgeons, Children's Oncology Group, International Children's Continence Society, International Pediatric Endosurgery Group, New York Academy of Sciences, Society of Critical Care Medicine, and Texas Pediatric Society
Disclosure: Nothing to disclose.

Medical Editor

Robert K Minkes, MD, PhD, Staff Pediatric Surgeon, Houston Pediatric Surgeons, Texas Children's Hospital
Robert K Minkes, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Andre Hebra, MD, Clinical Associate Professor, Department of Surgery, University of South Florida School of Medicine; Director, Minimally Invasive Pediatric Surgery Program, Chief of Surgery, All Children's Hospital
Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

H Biemann Othersen Jr, MD, Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery, Medical University of South Carolina
H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American Thoracic Society, British Association of Paediatric Surgeons, Pediatric Oncology Group, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

Chief Editor

Harsh Grewal, MD, FACS, FAAP, Professor of Surgery and Pediatrics, Temple University School of Medicine; Chief, Section of Pediatric Surgery, Temple University Children's Medical Center
Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education, Children's Oncology Group, Eastern Association for the Surgery of Trauma, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, and Southwestern Surgical Congress
Disclosure: Nothing to disclose.

 
 
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