Pediatric emergency medicine trisk 2052 2052
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Clinical Recognition
Symptoms of PUD vary with the patient’s age. Stress ulcers account for 80%
of peptic disease in early infancy, and often present as medical emergencies.
Infants may present either with nonspecific feeding difficulties and vomiting,
or with upper GI bleeding or perforation. Nonspecific signs and symptoms
predominate among older infants and preschool-aged children, with boys and
girls affected equally. Preschool-aged children often complain of poorly
localized abdominal pain, vomiting, or GI hemorrhage, which can manifest as
either hematemesis or melena. Among teenagers with ulcer disease, a male
predominance is seen, with boys outnumbering girls nearly 4:1. Older children
and adolescents generally present with abdominal pain, which is classically
described as waxing and waning, sharp or gnawing, and localized to the
epigastrium. It may awaken the child at night or in the early hours of the
morning. Other historical clues include a family history of ulcer disease and
the presence of predisposing factors such as smoking or use of NSAIDs.
Initial Assessment/H&P
History should focus on the presence of hematemesis and whether melanotic
stools have been passed. Identifying if risk factors (e.g., NSAID usage or
personal/family history of H. pylori ) or chronic GI symptoms (e.g., pain with
meals) are present may also help. If a gastrostomy tube is present, determining
the color of any material emanating from the tube when accessed may help.
Physical examination may reveal orthostasis, pallor, as well as abdominal
tenderness, which is poorly localized in young children, but localized to the
epigastrium or to the right of the midline in older children and adolescents.
Stool should be tested for occult blood. The remainder of the physical
examination should include an oral examination looking for dental enamel
erosion, which would suggest chronic gastroesophageal reflux (GER) or
recurrent emesis, and an examination of the lungs for wheezing, which also
might suggest bronchospasm due to or exacerbated by reflux. Weight loss may
be noted.
Management/Diagnostic Testing
A CBC and fecal occult blood test are good screening tests when one is
considering the possibility of significant PUD. If a gastrostomy tube is present
then material can be suctioned from the stomach. If a gastrostomy tube is not
present and there is a high suspicion without overt hematemesis then an NG
