William Spivak, M.D.
Symptoms of GASTRITIS
Epigastria or Supraumbilical Pain
Heartburn (if secondary GER is present)
Poor Weight Gain/Growth
Causes of Gastritis
Stress and Genetics
H. pylori infection
Fundic Gastritis with cyclical
GI food Allergy
vomiting and fundic prolapse
Evaluation of Possible Gastritis
Therapeutic trial for mild symptoms
Upper GI with small bowel series if anatomic abnormalities suspected
Medication history (e.g. NSAID's)
Crohn' s gastritis a consideration
History of allergic disease, stress or family history
Endoscopy if therapeutic trial fails
Upper GI in infants to exclude
CBC, Diff, ESR
H. pylori antibodies
Gastritis: It's more common than you might think
Gastritis in children usually involves a superficial inflammatory reaction of the mucosa and submucosa of the antrum of the stomach. In severe cases, the body and fundus of the stomach are also involved. Frank ulceration is rare, but when it does occur, it may be associated with GI bleeding. If one eliminates benign causes of abdominal pain such as lactose intolerance and constipation, gastritis becomes a major cause of abdominal pain in children, especially during adolescence.
Gastritis as a spectrum of disease
Gastritis is often associated with other upper GI tract abnormalities such as esophagitis or duodenitis. If gastritis is the primary problem (such as in H. pylori), the esophagus may be secondarily affected because of GER from delay in gastric emptying. Duodenal ulcer disease may be associated with H. pylori antral gastritis or associated with peptic erosion of the stomach. Occasionaly bile reflux into the stomach may cause an alkaline gastritis.
Most gastritis in children is idiopathic, with acid-pepsin, stress and genetics probably playing a major role in "idiopathic" gastritis. Although H. pylori infection plays a major role in gastritis and duodenal ulcer disease in adults, it has a relatively minor role in children. In my experience, less than 5% of children of middle or upper socioeconomic class who undergo endoscopy are infected with H. pylori, whereas the infection rate in children of lower socioeconomic status is approximately 20% of those undergoing endoscopy. Infection is also a function of age, with serologic evidence of infection increasing to 50% by the sixth decade of life.
Serologic tests for H. pylori
Serologic tests for H. pylori currently measure the IgG antibody. Values do not necessarily indicate recent infection, and therefore must be interpreted in light of symptoms. In patients with symptoms and positive antibodies, treatment with antibiotics and H2 blockers is indicated. Asymptomatic individuals with serologic evidence of infection do not warrant treatment. With successful treatment, levels of IgG antibody decrease over several months. IgM antibody tests are available and appear to be more sensitive to acute infection. The IgM test is awaiting FDA approval.
Other causes of gastritis in children are NSAID's, Crohn's disease with gastric involvement, GI food allergy (e.g. cow milk allergy), eosinophilic gastroenteritis or bile reflux gastritis. Bile reflux gastritis may be associated with motility disorders, Giardia, or peptic inflammatory involvement of the duodenum.
Evaluation of Possible Gastritis
We recently reported 6 children with recurrent vomiting that had isolated fundic gastritis. This is an unusual form of gastritis in which the antrum appears normal or is only minimally inflamed, while the fundus of the stomach is hemorrhagic. These hemorrhages are a result of prolapse of the fundus into the esophagus during retching with subsequent ischemia of the fundus. Since the fundus of the stomach contains the "gastric pacemaker," recurrent and prolonged retching may occur.
Treatment of Gastritis
In the child with mild symptoms of gastritis, antacids or H2 antagonists are indicated. Antacids are usually as effective as H2 antagonists (e.g. Tagamet or Zantac) in these mild cases, although the frequent need for administration makes antacids less convenient. In children less than 12 years of age, antacids should be tried first, since H2 antagonists have an added potential for side effects in young children(e.g. hyperactivity, restlessness, headache). In this age group, failure of antacids will often portend failure of standard doses of H2 blockers. Thus, endoscopy is indicated if antacids fail, since high doses of H2 antagonists may be necessary to effectively treat gastritis in this age group.
On the other hand, adolescents with symptoms of gastritis may benefit from the empiric use of H2 blockers based on symptoms alone. Their active lifestyle makes them less likely to be compliant with frequent antacid use. Except for headache, side effects are very uncommon in this age group. If improvement does not take place within 7 days, these drugs should be discontinued and endoscopy scheduled.
Upper GI (UGI) Series vs. Endoscopy
For the most part, the UGI is insensitive for the detection of gastritis which is often a subtle mucosal abnormality. Therefore, in most patients, endoscopy is the procedure of choice. However, for example, if anatomical abnormalities are suspected in an infant with vomiting, a UGI is warranted as the first and often the only procedure.
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