Overview
Definition:
Functional dyspepsia (FD) is characterized by persistent or recurrent dyspeptic symptoms (postprandial fullness, early satiety, epigastric pain, or epigastric burning) in the absence of structural disease that fully explains the symptoms
Peptic ulcer disease (PUD) is defined as a break in the gastric or duodenal mucosa, typically caused by Helicobacter pylori infection or NSAID use, leading to symptoms like epigastric pain, bloating, and nausea
In pediatrics, differentiating these common entities is crucial for appropriate management.
Epidemiology:
Dyspepsia is a common complaint in children, with reported prevalence rates varying from 10% to 30% in primary care settings
Functional dyspepsia accounts for a significant proportion of these cases, estimated at 50-70%
Peptic ulcer disease in children is less common than in adults, with an incidence of approximately 0.1-2.1% annually, and is more frequently associated with secondary causes like H
pylori, NSAIDs, stress, or underlying medical conditions such as Zollinger-Ellison syndrome or Crohn's disease.
Clinical Significance:
Accurate differentiation is essential as it dictates the diagnostic pathway and management strategy
Unnecessary investigations can lead to increased healthcare costs and patient anxiety, while delayed diagnosis of PUD can result in serious complications like perforation or bleeding
For DNB and NEET SS preparation, understanding the diagnostic nuances and management differences between these two common upper GI disorders in children is a high-yield area.
Clinical Presentation
Symptoms:
Functional dyspepsia typically presents with postprandial fullness
Early satiety
Epigastric pain
Epigastric burning
Bloating
Nausea
Vomiting (less common)
Symptoms must be present for at least 3 months, with onset at least 6 months prior to diagnosis
Peptic ulcer disease often presents with similar symptoms: epigastric pain, often described as burning or gnawing
Pain may be relieved by food or antacids (duodenal ulcer) or worsened by food (gastric ulcer)
Nocturnal pain is more characteristic of duodenal ulcers
Nausea
Vomiting
Loss of appetite
Weight loss (more common with malignancy or severe PUD).
Signs:
Physical examination in both conditions is often unremarkable
Mild epigastric tenderness may be elicited
No specific physical signs reliably differentiate FD from PUD
Red flag signs warranting urgent investigation for PUD or other organic pathology include: dysphagia
odynophagia
persistent vomiting
hematemesis
melena
hematochezia
unexplained weight loss
palpable abdominal mass
pallor suggesting anemia
jaundice.
Diagnostic Criteria:
Rome IV criteria are used for diagnosing Functional Dyspepsia: Postprandial Fullness, Early Satiety, Epigastric Pain, or Epigastric Burning, occurring at least 3 days per week in the past 3 months, with symptom onset at least 6 months prior to diagnosis, and no evidence of structural disease on endoscopy to explain the symptoms
For PUD, diagnosis is confirmed by endoscopic visualization of an ulcer crater and histology confirming inflammation and/or presence of H
pylori.
Diagnostic Approach
History Taking:
A detailed history is paramount
Inquire about symptom characteristics (onset, duration, frequency, severity, triggers, relievers)
Associated symptoms: vomiting, diarrhea, constipation, weight changes, bleeding
Dietary habits
Use of NSAIDs or other medications
Family history of GI disorders, PUD, or H
pylori
Red flag symptoms: dysphagia, odynophagia, vomiting (especially hematemesis), melena, unexplained weight loss, anemia
Previous GI investigations or treatments
Stressors in the child's life.
Physical Examination:
Perform a thorough physical examination
Assess vital signs
Inspect the abdomen for distension or scars
Palpate for tenderness, masses, or organomegaly
Auscultate bowel sounds
Perform a digital rectal examination if there is any suspicion of bleeding
Assess for signs of anemia (pallor) or malnutrition.
Investigations:
For children with alarm symptoms or those aged <15 years with persistent symptoms despite empirical treatment, upper GI endoscopy is recommended
Biopsies for H
pylori rapid urease test, histology, and culture are essential
For children without alarm features, H
pylori stool antigen testing or urea breath test (UBT) can be considered for presumptive diagnosis of H
pylori-related PUD or to rule out H
pylori in FD
If H
pylori is positive and symptoms persist, endoscopy is warranted
Imaging like abdominal ultrasound or barium studies are generally not indicated for initial evaluation of dyspepsia/PUD in children unless specific complications are suspected.
Differential Diagnosis:
Functional Dyspepsia
Peptic Ulcer Disease (gastric or duodenal)
Gastroesophageal Reflux Disease (GERD)
Gastritis
Esophagitis
Celiac disease
Lactose intolerance
Irritable Bowel Syndrome (IBS)
Gallbladder disease
Pancreatitis (less common in children)
Appendicitis (atypical presentation)
Malignancy (rare but important to exclude with alarm symptoms)
Functional abdominal pain syndromes.
Management
Initial Management:
If alarm symptoms are present, proceed directly to endoscopy
If no alarm symptoms, a stepwise approach can be used
Lifestyle and dietary modifications: avoid trigger foods (spicy, fatty, caffeine, carbonated drinks), eat smaller meals, avoid eating close to bedtime
Stress management
Empirical trial of acid suppression therapy (Proton Pump Inhibitors - PPIs) for 2-4 weeks may be considered for symptom relief in presumed FD.
Medical Management:
For confirmed H
pylori-related PUD or if H
pylori is suspected/positive in FD: Triple therapy is standard, e.g., Omeprazole 1 mg/kg/day (max 40 mg/day) divided BID + Amoxicillin 50 mg/kg/day (max 1g BID) + Clarithromycin 15 mg/kg/day (max 500 mg BID) for 10-14 days
Alternatively, quadruple therapy: Omeprazole + Bismuth subsalicylate + Metronidazole + Tetracycline
For symptom relief in FD without H
pylori or after H
pylori eradication: PPIs (e.g., Omeprazole 0.5-1 mg/kg/day) for 4-8 weeks
Prokinetics (e.g., Domperidone - use with caution due to cardiac risks, or Metoclopramide - short-term) may be considered
Antacids or H2-receptor antagonists (e.g., Ranitidine - availability varies) for milder symptoms.
Surgical Management:
Surgical intervention is rarely required for PUD in children and is typically reserved for management of life-threatening complications such as perforation, uncontrollable bleeding, or obstruction not amenable to endoscopic or medical therapy
Surgical options may include vagotomy, antrectomy, or gastrostomy.
Supportive Care:
Nutritional assessment and support if weight loss or poor intake is present
Psychological support and counseling if stress or anxiety are contributing factors
Education of the child and family about the condition, treatment, and prognosis
Regular follow-up to assess symptom resolution and monitor for complications.
Complications
Early Complications:
Perforation of the ulcer
Acute bleeding (hematemesis, melena, anemia)
Gastric outlet obstruction
Penetration into adjacent organs (e.g., pancreas).
Late Complications:
Chronic anemia due to recurrent bleeding
Scarring and stricture formation (gastric outlet obstruction)
Increased risk of gastric adenocarcinoma (rare, primarily associated with H
pylori-induced chronic gastritis)
Chronic abdominal pain and impact on quality of life.
Prevention Strategies:
Judicious use of NSAIDs and prompt treatment of H
pylori infection are key preventive measures
Early identification and management of red flag symptoms to prevent progression to complications
Education on risk factors and avoidance of triggers.
Prognosis
Factors Affecting Prognosis:
For FD, prognosis is generally good with appropriate management, though symptoms can be chronic and relapsing
For PUD, prognosis depends on the severity of the ulcer, presence of complications, adherence to treatment, and eradication of H
pylori
Underlying secondary causes can affect long-term prognosis.
Outcomes:
Most children with FD experience significant symptom improvement with lifestyle changes, PPIs, or prokinetics
Recurrence is common
Children with PUD treated effectively have good outcomes, with complete healing of ulcers and symptom resolution
Complications significantly worsen prognosis.
Follow Up:
Follow-up is essential for both conditions
For FD, assess symptom response to treatment and consider de-escalation of therapy
For PUD, confirm H
pylori eradication via UBT or stool antigen test 4-6 weeks post-treatment
Regular review for symptom recurrence or complications
Endoscopic follow-up may be needed in complex or complicated cases.
Key Points
Exam Focus:
Differentiating FD from PUD in pediatric patients
Recognizing red flag symptoms that necessitate urgent endoscopy
Understanding H
pylori eradication regimens for children
Rome IV criteria for FD
Common complications of PUD.
Clinical Pearls:
Always consider H
pylori as a treatable cause in pediatric dyspepsia
Endoscopy is the gold standard for diagnosing PUD, but empirical treatment can be considered in select cases without alarm features
Don't forget to confirm H
pylori eradication post-treatment
Stress and psychosocial factors play a significant role in pediatric GI symptoms.
Common Mistakes:
Over-reliance on empirical treatment without considering alarm features
Inadequate history taking leading to missed red flags
Failure to confirm H
pylori eradication
Misinterpreting NSAID-induced gastritis as true PUD without confirmation
Diagnosing FD without ruling out organic causes.