What is the treatment for children with peptic ulcers?

Treatment of Peptic Ulcers in Children

Children with peptic ulcers should be treated with a combination of proton pump inhibitors (PPIs) and H. pylori eradication therapy when infection is present, with PPI therapy for 4-8 weeks being the cornerstone of treatment regardless of etiology. 1

Diagnostic Approach

• All children with suspected peptic ulcers should undergo:
  • Endoscopy to confirm diagnosis
  • H. pylori testing (urea breath test, stool antigen testing, or endoscopic tissue biopsy)
  • Basic laboratory tests (CBC, liver function, renal function) 1

Treatment Algorithm

First-Line Treatment

1. PPI Therapy:

   • Standard dose PPI once or twice daily for 4-8 weeks (longer for gastric ulcers) 1

   • Options include:

     • Omeprazole 20 mg daily
     • Lansoprazole 30 mg daily
     • Pantoprazole 40 mg daily
     • Rabeprazole 20 mg daily
     • Esomeprazole 20 mg daily 1

   • Pediatric PPI Dosing:

     • For treatment of duodenal/gastric ulcers: 2-4 mg/kg twice daily (maximum 300 mg/day) 1

2. For H. pylori Positive Ulcers:

   • Standard Triple Therapy (in areas with low clarithromycin resistance):

     • PPI standard dose twice daily
     • Clarithromycin 500 mg twice daily
     • Amoxicillin 1000 mg twice daily (or Metronidazole 500 mg twice daily) 2
     • Duration: 14 days 2, 1

   • Sequential Therapy (in areas with high clarithromycin resistance):

     • Days 1-5: PPI + Amoxicillin
     • Days 6-10: PPI + Clarithromycin + Metronidazole 2

Second-Line Treatment

• If first-line therapy fails:

  • 10-day levofloxacin-amoxicillin triple therapy:
    • PPI standard dose twice daily
    • Levofloxacin 500 mg once daily or 250 mg twice daily
    • Amoxicillin 1000 mg twice daily 2

• For H2-receptor antagonist option (alternative to PPIs):

  • Ranitidine:
    • Pediatric dosing: 2-4 mg/kg twice daily (maximum 300 mg/day) for active ulcers
    • Maintenance: 2-4 mg/kg once daily (maximum 150 mg/day) 3

Special Considerations

Bleeding Peptic Ulcers

• High-dose PPI therapy:
  • Initial IV therapy: 80 mg bolus followed by 8 mg/h continuous infusion for 72 hours
  • Then oral therapy: 40 mg twice daily for 6-8 weeks 1
• Start standard triple therapy for H. pylori after 72-96 hours of IV PPI administration 2

Follow-up and Monitoring

• Confirm H. pylori eradication 4 weeks after completing therapy 1
• Consider endoscopic follow-up in 8-12 weeks to confirm healing, especially for gastric ulcers 1
• Monitor for potential PPI adverse effects with long-term use 1

Important Clinical Pearls

• Ulcers in young children are typically secondary to systemic illnesses or drugs and do not recur 4
• Duodenal ulcers in older children and adolescents often have a relapsing course related to H. pylori infection 4
• H. pylori eradication significantly reduces ulcer recurrence rates from 50-60% to 0-2% 5
• Not all primary duodenal or gastric ulcers in children are related to H. pylori; some have unknown causes 4
• Avoid prescribing anti-H. pylori therapy without a firm diagnosis 6
• The [13C]urea breath test is the preferred non-invasive method to determine H. pylori status in children 6

By following this treatment approach, most pediatric peptic ulcers can be effectively managed, preventing complications and recurrence.