P - ISSN : 2349-6592    |    E - ISSN : 2455-7099
Year : 2019 | Volume : 6 | Issue : 3 | Page : 56 - 57
Source of Funding:None Conflict of Interest:None
Peptic ulcer disease (PUD) in children remains rare and diffi cult to diagnose before the onset of complications. We describe a 3-year-old child with perforated duodenal ulcer, associated with lower respiratory tract infection and hyperthyroidism. Upper GI endoscopy revealed three clean based ulcers in the fi rst part of duodenum, erect chest x-ray showed bilateral gas under diaphragm and CT scan confi rmed massive pneumoperitoneum. Emergency exploratory laparotomy detected perforation in the anterior wall of duodenum, managed with simple sutural closure. PUD in children is rare and high index of suspicion is required to prevent complications.
Duodenal ulcer, perforation, laparotomy, hyperthyroidism, H. pylori.
Peptic ulcer disease, the result of infl ammation caused by an imbalance between cytoprotective and cytotoxic factors in the stomach and duodenum, manifests with varying degrees of gastritis or frank ulceration. Deep mucosal lesions that disrupt the muscularis mucosa of the gastric or duodenal wall is referred to as peptic ulcers1.
A previously healthy 3-year-old girl was referred to our pediatric outpatient department with a history suggestive of lower respiratory tract infection. She was treated with intravenous antibiotics, non-steroidal anti-infl ammatory drugs and other supportive medications. On day 5, when child was about to be discharged from the hospital, she had sudden onset of tachypnoea, tachycardia, had multiple episodes of vomiting which was clear initially later became coffee–coloured and was brought to our hospital. There was no past history suggestive of peptic ulcer disease in her or in the family. The child was apparently healthy, was not on any medication before the onset of the illness. From history she was born at full term with no signifi cant prenatal or postnatal complications. There was no previous history of hospitalization or a medical problem. Immunization was up-to date. On examination child was irritable, no demonstrable guarding or rigidity, bowel sounds normal. She was taken up for upper gastrointestinal endoscopy, which revealed three clean based ulcers in the fi rst part of duodenum and biopsy was obtained. Erect chest x-ray showed bilateral gas under diaphragm, CT scan confi rmed massive pneumoperitoneum. Urgent exploratory laparotomy done showed a small perforation in the anterior wall of 1st part of duodenum. It was managed with simple sutural closure and was put on iv antibiotics, proton pump inhibitors and other supportive measures. In view of proptosis noted on subsequent examination, thyroid function was evaluated. It showed TSH <0.005, Free T3 -13.90, Free T4 - 40.61. Thyroid uptake and scintigraphy showed features suggestive of Graves thyrotoxicosis. Tc 99m uptake was 12.5% high and showed increased vascularity to the thyroid gland. Postoperative period was uneventful. Biopsy was suggestive of mild chronic gastritis and H. Pylori was detected, hence child was started on H. Pylori eradication measures and antithyroid medication.
Duodenal ulcer is an uncommonly diagnosed entity in children with an incidence of 1.55 cases per year in an Indian series2. Large pediatric centers anecdotally report an incidence of 5-7 children with gastric or duodenal ulcers per 2,500 hospital admissions each year1. Some present with recurrent abdominal pain and anemia where as others have hematemesis or melena with or without perforation.3-5
Peptic ulcer disease in children is classifi ed as primary or secondary depending up on the aetiology. Primary PUD is commonly associated with H pylori infection. Secondary PUD is associated with physiological stress, systemic illness and drugs, including non-steroidal anti-infl ammatory drugs and steroids. It can also be idiopathic or associated with conditions causing increased acid secretion.6,7 The usual causes are non-steroidal anti-infl ammatory drug treatment, head injury, overwhelming sepsis, burns, major surgery, steroid therapy, H pylori infection, the presence of blood group ‘O’, acting alone or in combination.1 PUD is more commonly secondary in children under ten years of age and primary in over ten years. Secondary PUD occurs in the stomach or duodenum and is more likely to present with complications including perforation and hemorrhage. Primary PUD predominantly occurs in the duodenum and rarely presents with perforation.8
94% of children with perforated PUD present with acute abdominal signs and some even have soft abdomen and normal bowel sounds as in our case. Free air under the diaphragm is found in 82.7%.9 Surgery is the recommended treatment for perforation. Medical management of secondary PUD includes histamine receptor blockers and elimination of physiological stress. If treated secondary PUD rarely recurs.
There are few studies showing correlation between hyperthyroidism and peptic ulcer. In a Japanese study conducted in the 1980s, the mean value of gastric acid output was found to be higher in hyperthyroid patients, and an extremely high gastric acid output was noted in the hyperthyroid patients10.
To conclude, PUD remains diffi cult to be diagnosed in children before devoloping complications hence a lower threshold for considering PUD in children helps to prevent complications and a possibility of high gastric output have to be thought in hyperthyroid patients, which is a more frequently diagnosed entity.
1. Blanchard SS, Cezanne SJ. Peptic Ulcer Disease in Children. In: Kleigman RM, Stanton BF, St.Geme iii JW, Schor NF, editors. Nelson Textbook of Pediatrics. 20th edition. vol.3. New Delhi: Elsevier; 2015. p 1816-7.
2. Maudar KK, Dutta J, Mitra S. Duodenal ulcer disease in children. World J Surg1980;4:261-5.
3. Drumm B, Rhoads JM, Stringer DA, Sherman PM, Ellis LE, Durie PR. Peptic ulcer disease in children: etiology, clinical fi ndings, and clinical course. Pediatrics 1988: 82: 410-4.
4. Johnstone JMS,Rintoul RF. Perforated duodenal ulcer in childhood. British J Surg 1972; 59: 288-9.
5. Moon D, Weeks D, Burgess B, O’Connor R. Perforated duodenal ulcer presenting with shock in a child. Am J Emerg Med1997; 15: 167-9.
6. Sullivan PB. Peptic ulcer disease in children. PaediatrChild Health.2010;20(10): 462–464.
7. Dohil R, Hassall E. Peptic ulcer disease in children. Baillieres Best Pract Res Clin Gastroenterol 2000; 14(1): 53-73.
8. Lee NM, Yun SW, Chae SA, Yoo BH, Cha SJ, Kwak BK. Perforated duodenal ulcer presenting with massive hematochezia in a 30-month-old child. World J Gastroenterol 2009; 15(38): 4853-5.
9. Hua MC, Kong MS, Lai MW, Luo CC. Perforated peptic ulcer in children: a 20-year experience. J Pediatr Gastroenterol Nutr. 2007; 45(1): 71-4.
10. Aoyagi K, Uehara K, Ito K. Jpn J Surg1982; 12 (3); 198-202.