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Duodenal Ulcers in a child

Ulcers of the duodenum and stomach are called peptic ulcers. H.pylori causes most ulcers; other causes are aspirin and arthritis type drugs (NSAIDS). Ulcers can also be in the oesophagus but these are not caused by H.pylori.

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MelP_mum
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Duodenal Ulcers in a child

Post by MelP_mum » Wed Feb 17, 2016 12:55 pm

Hi,

I have a son, who is 6 years old, who has been suffering from Gastro Oesophageal Reflux Disease for years. He had reflux from birth but it got worse at about 7 months old when weaning. He is very underweight, has struggled to eat for several years and has been taking a PPI, Omeprazole, since 18 months old.
His sister also has milder reflux. I have had reflux/indigestion since a childhood and have had severe morning sickness during both pregnancies (just in case it is relevant).
Last year they suggested he had CMPI and we have eliminated cows milk from his diet but he still struggles.

Our health system in the UK, the NHS, performed an Endoscopy on him in January and found shallow ulcers and inflammation on his Duodenum.
We stopped PPI’s 7 days before the Endoscopy. He took Mebendazole for thread worms approximately 4 weeks before the Endoscopy and was on Movicol when he had the Endoscopy done.
The paediatric gastroenterologist performing the Endoscopy really thought it looked like H Pylori.
However, the H Pylori Rapid Urease Test came back negative. The histology results came back negative.
The other test results (blood/stool) suggested no other reason why he would have duodenal ulcers. They did not test for H Pylori in stool test.
So I have been asked to increase his PPI and give him an iron supplement. No further medical advice or investigation suggested.

I found a paper ‘Evidence-based Guidelines From ESPGHAN and NASPGHAN for Helicobacter pylori Infection in Children’ which suggests PPI’s be ceased 14 days prior to testing.
Can I ask if this is correct or if 7 days is sufficient ?
From my research it seems that the guidelines regarding how long to stop the PPI for is unclear. Especially for children as the test is less reliable for children.

Secondly, is there any other bacteria other than H Pylori that can cause the same symptoms ?

Many thanks.

Helico_expert
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Re: Duodenal Ulcers in a child

Post by Helico_expert » Thu Feb 18, 2016 5:32 am

Thank you for sharing your story. I am so sorry to hear what happened to your very young child.

It is difficult to diagnose for H. pylori in children. reason:
1. the immune system is not fully developed. So, the blood test can be false negative.
2. the stomach may not be as acidic as adult. So the CLOtest or Breath test can give false negative.
3. because the stomach is not as acidic, other bacteria may be able to grow and H. pylori number will be low. Another factor for false negative in CLOtest or Breath test.

Nevertheless, if the doctor really want a diagnosis, he should consider stool antigen test and DNA testing.

Stool antigen test can be affected by the low bacteria count, but it is not affected by the higher pH in the stomach.
DNA testing has high rate of false positive. but if it is negative, it is most likely true.

has your son taken any antibiotics in the past 2-3 years? if no, can consider blood test.

PPI should stopped for at least 2 weeks before stool or breath test. here is our guideline.
http://www.helico.com/PYtest_guide_2013.pdf

MelP_mum
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Re: Duodenal Ulcers in a child

Post by MelP_mum » Thu Feb 18, 2016 2:33 pm

Many thanks for your reply and for your help. I will pass this information on to our doctor.

My son has had antibiotics within the last 2-3 years so I think a stool test and DNA test is the way to go.

We are going to see a different private Paediatric Gastroenterologist at a different hospital to speed the process up.

If the new doctor decides to redo the Endoscopy should our son stop his PPI 7 days or 14 days prior to the Endoscopy for a CLO test and Histology ?

Helico_expert
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Re: Duodenal Ulcers in a child

Post by Helico_expert » Fri Feb 19, 2016 5:11 am

you can use H2 blockers such as Ranitidine if you plan to get another endoscopy done. H2 blockers are not as strong as PPI and you can stop it at the night before endoscopy.

if your specialist did decide to get another endoscopy, try ask him to get the gastric juice to measure pH and a good brush of the mucous for bacteria culture. The bacteria culture can then be further used for antibiotic sensitivity testing.

MelP_mum
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Re: Duodenal Ulcers in a child

Post by MelP_mum » Tue Feb 23, 2016 11:47 am

Thank you Helico Expert for all your help.

Is it possible that the following medications could result in a false negative CLO or histology result ? :-
1) Mebendazole (for threadworms)
or
2) Movicol (contains macrogol [polyethylene glycol] 3350, an iso-osmotic laxative, along with sodium bicarbonate, sodium chloride and potassium chloride).

Helico_expert
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Re: Duodenal Ulcers in a child

Post by Helico_expert » Wed Feb 24, 2016 2:40 am

Mebendazole is the same class as metronidazole used for killing H. pylori. So yes, it may give false negative CLO and histology test.

Movicol is a lexative. So i dont think it will affect the CLO or histology result.

MelP_mum
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Re: Duodenal Ulcers in a child

Post by MelP_mum » Sun Feb 28, 2016 10:23 pm

Hi Helico Expert,

Thank you for the info.

If my other child (who also has had reflux for years) has a stool antigen test for H Pylori how long should she stopping taking for Ranitidine before the test ?

Helico_expert
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Re: Duodenal Ulcers in a child

Post by Helico_expert » Tue Mar 01, 2016 1:28 am

Hi,

you can continue ranitidine until the day before stool antigen test.

This is a guideline for UBT. But it will be the same for stool antigen test.
http://www.helico.com/PYtest_guide_2013.pdf

MelP_mum
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Re: Duodenal Ulcers in a child

Post by MelP_mum » Mon Mar 07, 2016 2:50 pm

Hi Helico Expert,

Is there a time limit from passing stool within which the stool sample has to be tested to ensure a valid result ?
Our hospital has said that it make take 3 weeks before they can test it :(

Thanks for your help.

Helico_expert
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Re: Duodenal Ulcers in a child

Post by Helico_expert » Tue Mar 08, 2016 4:50 am

Some hospital is more careful than others. However, if you get a stool test now and it turns positive, it is very likely it is positive. You only need to worry about false negative. So what do you feel now? do you still feel all the symptoms?

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