1 response to each discussion with one reference,
Discussion one- PEPTIC ULCER DISEASE IN PEDIATRICS
Pathophysiology
Peptic ulcer disease (PUD) is a sore or sores in the lining of the stomach and the duodenum as a result of the weakening of normal repairing mechanism of the linings. There are two types. They are primary and secondary. The cause of primary ulcers are unknown and tend to be chronic. Primary ulcers are recurring and are usually duodenal ulcers. There is also a familial predisposition of PUD in children with duodenal ulcers. Secondary ulcers are acute and is the most common in adolescents than children. The use of corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDS) is the cause of secondary pelvic ulcers (Maaks, et al., 2020). The incidence of peptic ulcer disease in the general population is about 5% of the global population and not specifically for children. “ About 70-90% of patients with gastric ulcer and 80-95% with duodenal ulcers are infected with H. pylori”… almost 20% – 40% of north American that has peptic ulcers is as a result of NSAIDs (Chaudhari, et al., 2016).
Physical exam findings
Physical exam findings can be seen in different age groups. Infants will present with weight loss and poor feeding history, poor skin turgor, GI bleeding, vomiting, slow growth, and history of NICU care. Toddlers, preschoolers, school-age, and adolescents present with abdominal pain, weight loss, dry mucous membranes, poor skin turgor, may have enamel erosion (recurrent vomiting), abdominal tenderness on palpitation and may find hepatosplenomegaly, and sores in oral cavity (Maaks, et al., 2020). An esophagogastroduodenoscopy (EGD) is usually the diagnostic test done for PUD in children (Maaks, et al., 2020. A complete blood count would show anemia and blood loss. A positive H-pylori test would indicate chronic infection.
Differential diagnoses and rationale
Differentials diagnoses may include gastroesophageal reflux disease (GERD), GI bleeding, pancreatitis, and irritable bowel syndrome (IBS). These have similar symptoms such as abdominal pain, pain after eating, weight loss, nausea, and vomiting, except for IBS which includes frequent bowel movements.
Management plan
Pharmacotherapy treatment is based upon evidence-based practice guidelines is to heal the ulcers, relief of symptoms, and eliminating the cause (Maaks, et al., 2020). Pharmacological agents are first line therapy and these consists of H2RAs or PPIs. This include two kinds of antibiotics and an acid suppressor. For example: Antibiotics include amoxicillin at 50mg/kg/day up to 1 g BID, Clarithromycin 15mg/kg/day up to 500mg BID or Metronidazole 20mg/kg/day up to 500mg BID, in addition to omeprazole 1mg/kg/day up to 20 mg BID for 5 days. There is an option for 8 -12 years old also include Bismuth sub- salicylate at 8mg/kg/day x 1 day (Maaks, et al., 2020), (Kamada, et al., 2021).
Non-pharmacological intervention includes education and symptoms that needs reporting. The parents need to report sudden and lasting abdominal pain, black tarry stool, deep pain in abdomen (perforation), and vomiting blood.
How quickly a person will have a good outcome is dependent on the severity of symptoms and diagnostic findings.
References
Chaudhari Priyanka, R., Rana Jenish, H., Gajera, V., Lambole, V., & Shah, D. P. (2016). Peptic Ulcer: A Review on Epidemiology, Etiology, Pathogenesis and Management Strategies. Pharma Science Monitor, 7(2), 139–147.
Kamada, T., Satoh, K., Itoh, T., Ito, M., Iwamoto, J., Okimoto, T., Kanno, T., Sugimoto, M., Chiba, T., Nomura, S., Mieda, M., Hiraishi, H., Yoshino, J., Takagi, A., Watanabe, S., Koike, K. (2021). Evidence-based clinical practice guidelines for peptic ulcer disease. Journal of Gastroenterology. 56(4):303-322. doi: 10.1007/s00535-021-01769-0. Epub 2021 Feb 23. PMID: 33620586; PMCID: PMC8005399.
Maaks, D., Starr, N., Brady, M., Gaylord, N., Driessnack, M., Duderstadt, K. (2020). Burn’s Pediatric Primary Care 7th Edition Elsevier Publishing.
Nimish, B., Feldman, M. & Grover, S. (2022). Peptic Ulcers: epidemiology, etiology, and pathogenesis. Up-To-Date
Discussion 2-Failure to thrive (FTT) in the United States takes a prevalence of 5 to 10 percent of pediatrics. The causes include inadequate caloric intake or absorption and excessive caloric expenditure (Willer & James-Petersen, 2019, p.796). In a primary care setting, the diagnosis is based on the child’s weight gain compared to their age.
During the examination, the physical findings include the individual’s weight according to the standard growth chart falling below the third percentile or the ideal weight for their height is below 20 percent. Other common findings associated with poor weight gain include vomiting, food refusal, lack of food, tiredness, and lack of age-appropriate social response. With each wellness visit obtaining and reviewing the child’s growth curves will help with how they plotted on the standardized growth percentiles. A feeding and development assessment should be done to help rule out causes.
Differentials include inadequate caloric intake due to poor food intake, inadequate absorption, abnormal GI assessment, increased metabolism due to a history of adequate feeding with delayed weight gain, or growth failure due to genetics or hormones.
Once FTT has been diagnosed, a multidisciplinary team approach will be needed for management. The involvement with the care includes a nutritionist, a social worker, a specialist such as OT, speech or PT, and a pediatric gastroenterologist depending on the underlying cause. In addition, NPs can give parents an appropriate nutritional goal to follow when no abnormal medical conditions are found.
The patient can follow up every 1 to 3 weeks for weight evaluation to achieve symmetry of weight and height.
Reference
Willer E.E., James-Petersen B. (2019). Gastrointestinal disorders. In D.L.G. Maaks, N.B. Starr, M.A. Brady, N.M. Gaylord, M. Driessnack & K.G. Duderstadt, (Eds.), Burns’ pediatric primary care (7th ed, p.796). Elsevier.
