Overview
Definition:
Helicobacter pylori (H
pylori) is a gram-negative bacterium that infects the gastric mucosa, commonly causing gastritis and peptic ulcer disease
In children, infection can be asymptomatic or manifest with various gastrointestinal symptoms
It is a significant cause of chronic gastritis and is associated with an increased risk of peptic ulcer disease and gastric adenocarcinoma in adults, though the latter is rare in children.
Epidemiology:
The prevalence of H
pylori infection in children varies significantly worldwide, generally being lower in developed countries and higher in developing nations, often acquired in childhood through fecal-oral or oral-oral transmission
In India, seroprevalence studies show varying rates, with some indicating a significant burden of infection even in younger age groups, influenced by socioeconomic factors and hygiene practices.
Clinical Significance:
Prompt diagnosis and effective eradication of H
pylori in symptomatic children are crucial to prevent long-term complications such as peptic ulcer disease, growth retardation, and iron deficiency anemia
Understanding current diagnostic strategies and evidence-based treatment regimens is essential for pediatricians preparing for DNB and NEET SS examinations, impacting patient outcomes and preventing recurrence.
Clinical Presentation
Symptoms:
Many children with H
pylori are asymptomatic
Symptomatic children may present with: Epigastric pain, often described as burning or gnawing, which may be worse on an empty stomach or at night
Nausea and vomiting
Early satiety
Loss of appetite
Abdominal distension
Unexplained weight loss or failure to thrive
Vomiting of blood (hematemesis) or passing black, tarry stools (melena) are alarming signs of upper GI bleeding.
Signs:
Physical examination may reveal: Epigastric tenderness on palpation
In cases of significant bleeding, pallor may be present
Signs of malnutrition or growth failure in chronic, symptomatic infections
In most cases, the physical examination is non-specific.
Diagnostic Criteria:
There are no strict diagnostic criteria for H
pylori infection itself in children, but rather guidelines for when to test based on symptoms and risk factors
The diagnosis is confirmed by detecting the bacteria or its products using validated methods
Current international guidelines (e.g., ESPGHAN) provide recommendations for testing and management.
Diagnostic Approach
History Taking:
Key history points include: Duration, character, and timing of abdominal pain
Association with meals, time of day, or nocturnal symptoms
Presence of nausea, vomiting, early satiety, or anorexia
History of weight loss or failure to thrive
Previous diagnoses of PUD, gastritis, or H
pylori infection
Family history of H
pylori, peptic ulcers, or gastric cancer
Medications, especially NSAIDs
Red flags: Hematemesis, melena, unexplained weight loss, severe persistent vomiting, dysphagia, or iron deficiency anemia unresponsive to iron supplementation.
Physical Examination:
A thorough abdominal examination is essential, focusing on: Inspection for distension or scars
Palpation for tenderness (especially epigastric), masses, or organomegaly
Auscultation for bowel sounds
Assessment of growth parameters (height, weight, BMI) and signs of anemia or malnutrition.
Investigations:
Non-invasive testing is preferred in children when indicated
Invasive testing (biopsy) is usually reserved for children undergoing endoscopy for other reasons: Non-invasive: Urea Breath Test (UBT) - highly sensitive and specific, involves ingesting a labeled urea compound and measuring labeled CO2 in exhaled breath
Stool Antigen Test (SAT) - detects H
pylori antigen in stool, good sensitivity and specificity
Serology (IgG antibodies) - less reliable for active infection diagnosis, as antibodies can persist for months after eradication
more useful for epidemiological studies or historical infection status
Invasive: Endoscopic biopsy with rapid urease testing (RUT), histology, or PCR - gold standard but requires endoscopy
Culture is rarely used due to low sensitivity and difficulty in rapid results.
Differential Diagnosis:
Conditions to consider in children with abdominal pain or dyspepsia include: Functional dyspepsia (most common)
Gastroesophageal reflux disease (GERD)
Peptic ulcer disease (if H
pylori positive or other causes)
Esophagitis
Gastritis (non-H
pylori)
Irritable bowel syndrome
Lactose intolerance
Constipation
Pancreatitis
Malabsorption syndromes.
When To Test
Indications For Testing:
Testing for H
pylori in children is generally recommended in the presence of: Documented peptic ulcer disease (gastric or duodenal ulcer)
Unexplained iron deficiency anemia unresponsive to iron therapy, particularly in older children and adolescents
Chronic or recurrent abdominal pain with alarm symptoms (as listed in history taking)
A strong family history of gastric cancer
Children with certain conditions like Henoch-Schönlein purpura or chronic urticaria have also been considered, but indications are evolving.
Timing Of Test:
Testing should ideally be performed when the child is not on proton pump inhibitors (PPIs) or antibiotics for at least 2 weeks, as these can lead to false-negative results
Bismuth compounds should be avoided for at least 4 weeks prior to testing
For UBT and stool antigen tests, the absence of PPIs and antibiotics is crucial.
Management
Eradication Therapy Regimens:
Treatment aims to eradicate H
pylori and heal any associated pathology
Standard triple therapy (Omeprazole, Clarithromycin, Amoxicillin/Metronidazole) is often used, but resistance is increasing
Recommended first-line therapies often include a PPI, Amoxicillin, and Clarithromycin or Metronidazole, or a PPI with bismuth, Amoxicillin, and Metronidazole
High-dose dual therapy (PPI + Amoxicillin) or sequential therapy are alternatives
Recommended regimens for DNB/NEET SS preparation: 1
Standard Triple Therapy: PPI (e.g., Omeprazole 1mg/kg/day divided BID) + Clarithromycin (15mg/kg/day divided BID) + Amoxicillin (25-50mg/kg/day divided BID) OR Metronidazole (20mg/kg/day divided BID) for 10-14 days
2
Bismuth-based Quadruple Therapy: PPI + Bismuth subsalicylate (e.g., 15mg/kg/day divided QID) + Amoxicillin (25-50mg/kg/day divided BID) + Metronidazole (20mg/kg/day divided BID) for 10-14 days
Clarithromycin resistance rates influence choice
if >20%, non-Clarithromycin regimens are preferred.
Duration And Doses:
Therapy typically lasts for 10-14 days
Doses are weight-based and may vary slightly between guidelines
For Amoxicillin, doses up to 50mg/kg/day are common
For Clarithromycin, up to 15mg/kg/day
For Metronidazole, up to 20mg/kg/day
PPI doses are usually 0.5-1mg/kg/day
Bismuth doses are around 15mg/kg/day.
Follow Up Testing:
Test-of-cure is recommended 4-8 weeks after completion of therapy, using UBT or stool antigen test, to confirm eradication
Repeat testing is crucial as eradication rates can be suboptimal
If initial therapy fails, salvage therapy with a different regimen, often guided by susceptibility testing if possible, is indicated
Re-testing for H
pylori is essential after failed treatment.
Complications
Peptic Ulcer Disease:
Gastric or duodenal ulcers are the most common complication, leading to pain, bleeding, perforation, or obstruction.
Iron Deficiency Anemia:
Chronic blood loss from gastritis or ulcers can cause or exacerbate iron deficiency anemia, especially in children.
Growth Retardation:
In severe, chronic infections, malabsorption and poor nutritional intake can lead to impaired growth and failure to thrive.
Gastric Adenocarcinoma:
While extremely rare in children, chronic H
pylori infection is a known risk factor for gastric cancer in adults, highlighting the importance of eradication.
Prevention Strategies:
Good hygiene practices, including hand washing and safe food and water, are key to preventing transmission
Early diagnosis and treatment of symptomatic children are vital to prevent long-term complications.
Prognosis
Factors Affecting Prognosis:
Prognosis is generally good with successful eradication of H
pylori and resolution of associated complications
Factors influencing outcome include the severity of initial infection, presence of complications (e.g., perforation), adherence to treatment, and bacterial resistance patterns.
Outcomes With Treatment:
Successful eradication leads to symptom resolution, healing of ulcers, and improvement in anemia and growth parameters
Eradication significantly reduces the risk of ulcer recurrence.
Long Term Follow Up:
Children with a history of peptic ulcer disease or complications may require periodic follow-up to monitor for recurrence and ensure adequate growth
Those with H
pylori-related anemia usually show improvement after successful eradication and iron supplementation
Long-term monitoring for gastric cancer risk is not generally recommended in children unless they have specific risk factors for other reasons.
Key Points
Exam Focus:
DNB/NEET SS exam focus: Indications for testing in children (ulcers, IDA, chronic pain with alarm symptoms)
Preferred non-invasive tests (UBT, stool antigen)
Contraindications for testing (recent antibiotics/PPIs)
First-line and alternative eradication regimens (PPI-based triple/quadruple therapy)
Importance of test-of-cure
Complications like PUD, IDA, growth failure.
Clinical Pearls:
Always consider H
pylori in children with unexplained iron deficiency anemia or persistent dyspeptic symptoms
Eradication therapy requires strict adherence to the full course
Always re-test for H
pylori after treatment to confirm eradication
Be aware of local antibiotic resistance patterns when selecting therapy.
Common Mistakes:
Not testing for H
pylori in indicated children
Using serology for active infection diagnosis
Failing to stop PPIs/antibiotics before testing
Incomplete treatment courses or non-adherence
Not performing test-of-cure
Treating symptoms without confirming eradication.