Clinical and demographical characteristics of the patients.
The current gold standard for the detection of Helicobacter pylori in children remains upper endoscopy plus mucosal biopsies. Endoscopy has the advantage of being able to detect complications of Helicobacter pylori infection and to rule out other upper gastro-intestinal pathologies. An additional advantage of endoscopy with gastric biopsy is that it allows physicians to obtain mucosa for urease testing, histological examination and bacterial culture. In children, there is a high correlation between antral nodularity at endoscopy and the presence of Helicobacter pylori infection. The authors have proposed to investigate the correlations between macroscopic aspects during endoscopy and histological findings, in order to identify those endoscopic and histopathological features that can help the clinician in clinical practice.
- Helicobacter pylori
- endoscopic aspects
It is now well accepted that PUD, the most common stomach disease, is an infectious disease, and all consensus conferences agree that the causative agent,
The public health importance of
Numerous diagnostic tests are available for detecting
The same diagnostic methods used for adults can be used for children. However,
2. Material and methods
This was a prospective, single center study (in Maria Sklodowska Curie Children’s Emergency Hospital Bucharest, Romania) that evaluated consecutive children referred by their physicians for upper endoscopy because of dyspepsia. They were all screened for
Demographic characteristics and family history of each patient were collected through a questionnaire, which was completed by parents or by patients depending on the age of the child. Demographic data included patients’ age, gender, and residency (urban or country area). Information on patient’s history of
Excluding criteria were: use of proton pump inhibitors or H2 receptors antagonists and antibiotics as well as non steroidal anti inflammatory drugs or steroidal therapy 2 weeks before the beginning of the study, history of intestinal surgery (except for polypectomy and appendectomy), concomitant severe disease (heart, lungs, kidneys and endocrine diseases), and smoking and alcohol consumption.
The study was approved by Ethics Committee.
All patients underwent endoscopy with biopsy specimens for histology (one for the antrum, one for the corpus). One sample from the antrum was used for rapid urease test. Two additional biopsies were taken from the antrum for bacterial culture. The samples were placed in separates vials, previously identified, containing the appropriate medium for each test.
This procedure was performed in patients with a minimum of 10 hours of fasting, under general anesthesia or conscious sedation. Vital signs were continuously monitored for the entire procedure.
Written informed consent was obtained from the parent or tutor of each child included in the study.
A biopsy of gastric body and antrum were fixed in a solution of formaldehyde 10%. Subsequently, the gastric mucosa samples were processed, following the usual steps of dehydration and paraffin embedding.
Two stains were used for histological study: hematoxylin eosin and Giemsa. Hematoxylin eosin stain was used to evaluate inflammatory cells and
Gastritis was graded according to the Sydney System  that assesses the severity of inflammation, the level of activity (the degree of polymorph neutrophil inflammation), and the presence of atrophy and of intestinal metaplasia on a scale from 0 to 3.
In accordance with the Sydney System, the density of
2.4. Bacterial culture
The biopsy specimens collected for bacterial culture were transported in commercial selective transport
2.5. Statistical analysis
The data was collected and analyzed with Microsoft Excel 2013 and PSPP version 1.0.1. Continuous variables with a normal distribution were expressed as a mean with standard derivation (SD) and continuous variables with a non-normal distribution as median with interquartile range (IQR). Differences between groups were analyzed using Student t-test and Mann-Whitney U test for continuous variables, and Fisher’s exact test for categorical variables. A p value <0.05 was considered statistically significant for all the analyzed parameters.
Of the 38 patients who underwent upper endoscopy with biopsies by protocol (Figure 1), nine were excluded because of negative results in both culture and histology.
In the study, the culture and histology examination findings were accepted as “gold standard”. The detection of
Twenty-nine cases (76.31%) were included in the final analyses, 19 females (65.51%) and the 10 males (34.49%). The ages were between 3 years and 7 months and 17 years and 8 months (mean age 13.5 ± 4.53 years).
Four patients had a family history of peptic ulcer disease. In 15 children the duration of symptoms was more than 6 months and 12 patients were previously treated for
|Mean age ± SD, years||13.5 ± 4.47|
|Familial history for ||4/29|
|Peptic ulcer/non ulcer dyspepsia||1/28|
The mean duration of the period between the onset of symptoms and the effective diagnosis in patients with a family history of upper gastrointestinal diseases was 3.75 ± 3.69 and 8.66 ± 5.42 months in those with negative family history (p = 0.17). A family history of gastric or duodenal ulcer did not significantly alter the length of time between the onset of symptoms and the diagnosis according to our statistical results, which, however, may have been influenced by the restricted number of patients in our study population.
Twelve patients had previous therapies. The median age of patients who were previously treated was 14.5 ± 3.74 and 13 ± 4.71 years old of those without any anterior therapy (p = 0.2).
The most common finding identified at endoscopy was macroscopic nodular antral gastritis, which was present in 22 patients (75.86%) (Figure 2). Among these, 10 had additional associated macroscopic lesions: 8 presented with nodular gastritis of gastric body, 1 with bulbitis, and one with esophagitis. Endoscopy showed antral hyperemia in 4 cases and a normal mucosal aspect in other 3 cases (Table 2).
|Endoscopic features||n (%)|
|Macroscopic nodular antral gastritis||22 (75.86%)|
|Nodular antral gastritis (only)||12|
|Nodular gastritis of corpus (with)||8|
|Erosive bulbitis (with)||1|
|Antral hyperemia without macroscopic nodularity||4 (13.79%)|
We tried to find out if there was a significant difference in the severity of endoscopic findings between patients who received previous therapy and those who did not. Among the 12 previously treated patients, 7 (58.33%) presented with macroscopic nodular antral gastritis, 2 (16.67%) with antral hyperemia and 3 (25%) showed a normal mucosal aspect. In patients who were not previously treated, we observed macroscopic nodular antral gastritis in 15 cases (88.24%), antral hyperemia in 2 cases (11.76%) while a normal appearance of gastric mucosa was never detected (Table 3). There was not a statistically significant association between the severity of mucosal damage at endoscopy and the existence of a previous therapy against the infection (p = 0.06).
|Macroscopic nodular antral gastritis||15 (88.24)||7 (58.33%)|
|Nodular antral gastritis (only)||8||4|
|Nodular gastritis of corpus (with)||6||2|
|Erosive bulbitis (with)||0||1|
|Esophagitis (with)||1||2 (16.67%)|
|Antral hyperemia without macroscopic nodularity||2 (11.76)||3 (25.0%)|
In our study, bleeding was the presenting symptom in 4 children; three of them had pan gastritis, and one had nodular gastritis and esophagitis.
There is a clear association between
The finding of
In our study, the most frequent lesion identified by endoscopy was macroscopic antral nodular gastritis, which was present in 22 patients (78.86%). This high frequency is in accordance with a retrospective study from Japan that also found out a marked prevalence of nodular antral gastritis associated with
Although the mechanisms underlying nodular gastritis in children is not clear yet, it is thought that lymphoid follicles with germinal center form nodules on gastric mucosa or that inflammatory reaction generated by
In a 14-year-old boy we observed erosions at endoscopy. The frequency of these lesions in our study (3.45%) is similar to the one measured by another study conducted in Italy (3.40%) .
A prospective study, carried out during 1-month simultaneously in 19 centers among 14 European countries, showed a frequency of 8.1% of ulcers and/or erosions in children, occurring mainly in the second decade of life, but
For years, reports have noted an association between peptic ulcer disease and families with a strong history of upper gastrointestinal tract disease, in particular between gastric and duodenal ulcers. Family history of gastric cancer is an important component in the diagnosis and management of
In countries with an elevated risk for gastric cancer, however, eradicating
Recently, a decreasing proportion of
In our study, four patients had a family history of
The sex difference between the
Studies have unanimously shown a male preponderance for peptic ulcer disease in children. It is still not known why primary peptic ulcers predominantly develop in infected male children. Epidemiological studies do not suggest any sex predilection in
Median age for patients with previous therapies was 14.5 ± 3.74 years, comparative with 13 ± 4.71 years for patients without previous therapies, results or else expected. We do not have data to express if it is failure of antimicrobial therapy or reinfection. 1/12 patient with previous therapies had family history of peptic ulcer disease. We do not investigate all the family member of each child, and therefore we do not know the real status of
In patients with anterior therapies, the endoscopic features were less serious than in those without any previous treatment. All three patients with normal endoscopic mucosa were anteriorly treated. These results suggest that children might become “tolerant” to the bacterium or that the growing child is more resistant to
The ability of
The main endoscopic feature found in our study was macroscopic nodular antral gastritis, in 75.86%. In 10.34% of cases the endoscopic aspect of mucosa was normal. All patients with normal endoscopic mucosa were previously treated. These results suggest that children might become “tolerant” to the bacterium or that the growing child is more resistant to
The authors thank Dr. Augustina Enculescu for her histological support.
Conflict of interest