Pediatric emergency medicine trisk 2053 2053
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tube with normal saline lavage can be diagnostic. If physical examination
findings reveal significant abdominal tenderness with guarding or rebound
tenderness, plain radiographs of the abdomen including an upright view
should be obtained to evaluate for perforation or secondary bowel obstruction.
IV access should be obtained in all patients who have significant emesis,
dehydration, weight loss, or concerning abdominal examination findings. An
initial bolus of isotonic fluid (20 mL/kg) should be given and vital signs
monitored frequently, with additional boluses given as needed to achieve
hemodynamic stability.
An upper GI series is not recommended for the routine evaluation of PUD
given its relatively poor sensitivity. However, it may be useful in diagnosing
children with gastric outlet obstruction secondary to PUD. Practice guidelines
by the North American Society for Pediatric Gastroenterology, Hepatology,
and Nutrition (NASPGHAN) recommend initial diagnostic H. pylori testing
with positive histopathology on EGD plus a positive rapid urease test or a
positive culture. Culture of the organism may assist in the determination of
appropriate antibiotic therapy, particularly in communities where antibiotic
resistance is high. Serologic tests based on the detection of antibodies (IgG,
IgA) against H. pylori in serum, whole blood, urine, and saliva are not reliable
for use in the clinical setting. These noninvasive H. pylori tests are not
recommended for initial H. pylori diagnosis; however stool antigen testing or
13C-urea breath testing can be used to assess the outcome of H. pylori
treatment 4 weeks after completion therapy.
A number of approaches are available for the treatment of PUD. Therapies
can be categorized as those that neutralize acid (i.e., antacids); those that block
acid secretion; those that are cytoprotective; and the anti-infective treatments
(e.g., H. pylori regimen). Antacids are a low-cost, safe, primarily short-term
means of treating PUD in children. They can be prescribed for patients of any
age. Adverse effects of antacids are related to the metal ion present in the
preparation: Magnesium-containing products may cause diarrhea, whereas
aluminum-containing products may cause constipation. Some products are
available as a combination of the two to minimize these effects. The usual
dosage for children is 0.5 mL/kg, given 1 hour after eating and before going to
the bed. Patients with food-related or nocturnal abdominal pain without
associated signs of serious illness can be started on empirical therapy with
antacids, and followed by a primary care physician.
