Medication Summary
Histamine-2 blockers or proton-pump inhibitors (PPI) are used to inhibit gastric acid production in peptic ulcer disease, gastroesophageal reflux disease (GERD), and duodenal ulcer disease. Alkaline suspensions are used to directly neutralize gastric acid secretions. Bleeding from esophageal varices may be prevented with vasoconstrictors, such as octreotide. Those with the etiology of infectious diarrhea should not be given antimotility agents, though some may benefit from antibiotics.
Somatostatin is not currently available in the United States for pediatric use. It is a hormone produced by the body that inhibits adenylate cyclase and therefore the production of cyclic AMP. Although it decreases pituitary secretion of growth hormone and thyrotropin, it also has physiologic effects of inhibiting secretion of serotonin, gastrin, vasoactive intestinal peptide (VIP), and many other hormones (eg, insulin, glucagon). It decreases intestinal motility and gastric emptying, but it is not recommended for use. Octreotide, a somatostatin analog, has been more widely adopted for the indication of variceal bleeding as secondary prophylaxis and, in some, primary prophylaxis.
Histamine H2 Antagonists
Class Summary
H2 blockers are reversible competitive blockers of histamine at H2 receptors, particularly those in the gastric parietal cells (where they inhibit acid secretion). The H2 antagonists are highly selective, they do not affect the H1 receptors, and they are not anticholinergic agents.
Some gastroenterologists recommend PPIs as being more effective than H2 blockers in promoting lesion cicatrization for hemorrhagic esophagitis and gastroesophageal reflux. Studies with omeprazole (Prilosec) and pantoprazole (Protonix) in intravenous (IV) forms have been encouraging, but they are not yet approved by the US Food and Drug Administration (FDA) for use in children.
Ranitidine (Zantac)
This agent inhibits histamine stimulation of H2 receptors in gastric parietal cells, which reduces gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Famotidine (Pepcid)
Famotidine competitively inhibits histamine at the H2 receptors in gastric parietal cells, reducing gastric acid secretion, gastric volume, and hydrogen concentrations.
Nizatidine (Axid, Axid AR)
This agent competitively inhibits histamine at the H2 receptor of the gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and hydrogen concentrations.
Cimetidine (Tagamet HB 200)
This agent inhibits histamine at H2 receptors of gastric parietal cells, which results in reduced gastric acid secretion, gastric volume, and hydrogen concentrations.
Antacids-Alkaline Suspensions
Class Summary
These agents are used to neutralize gastric acidity.
Aluminum and magnesium hydroxide (Maalox, Alamag, Mag-AL, Mag-Al Ultimate)
This is a drug combination that neutralizes gastric acidity and increases the pH of the stomach and duodenal bulb. Aluminum ions inhibit smooth muscle contraction and gastric emptying. Magnesium-aluminum antacid mixtures are used to avoid changes in bowel function.
Hormones/Hormone Analogs
Class Summary
Pharmacologic treatment to reduce portal pressure is important for the treatment of bleeding from esophageal varices. Propranolol has been studied for primary and secondary prophylaxis of esophageal varices; although it is helpful for adults, studies in children are limited. Therefore, these drugs are not currently considered the standard of care for this population.
In addition, vasopressin had been used as a splanchnic vasoconstrictor, but its many adverse effects (eg, bowel-wall or cutaneous ischemia, hypertension, abdominal pain) have made it less desirable than other options are, even when tempered with the vasodilatory effects of nitroglycerin. As a result, octreotide has emerged as the recommended treatment, especially in conjunction with sclerotherapy for patients with variceal bleeding, because it blunts sudden increases in pressure due to postprandial hyperemia.
Octreotide (Sandostatin, Sandostatin LAR)
A synthetic polypeptide, octreotide acts as natural somatostatin but is more resistant to enzymatic degradation and has a longer half-life in circulation than somatostatin. These factors make octreotide easier to use clinically.
Vasopressin (Pitressin)
At high doses, vasopressin can cause vasoconstriction, with many other effects (eg, promoting water resorption, increasing peristaltic activity). It is effective in reducing portal pressure.
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Intraoperative view of a bleeding juvenile polyp.
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Radioactive tracer in stomach, bladder, and the Meckel diverticulum in a 5-year-boy brought in for lower gastrointestinal bleeding.
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Intraoperative view of the bleeding Meckel diverticulum. Note the ulceration at the base.
Tables
Age Group |
Upper Gastrointestinal Bleeding |
Lower Gastrointestinal Bleeding |
Neonates |
Hemorrhagic disease of the newborn Swallowed maternal blood Stress gastritis Coagulopathy |
Anal fissure Necrotizing enterocolitis Malrotation with volvulus |
Infants aged 1 month to 1 year |
Esophagitis Gastritis |
Anal fissure Intussusception Gangrenous bowel Milk protein allergy |
Infants aged 1-2 years |
Peptic ulcer disease Gastritis |
Polyps Meckel diverticulum |
Children older than 2 years |
Esophageal varices Gastric varices |
Polyps Inflammatory bowel disease Infectious diarrhea Vascular lesions |
