Diagnosis: Peptic Ulcer Disease with Gastritis
In a 10-year-old girl presenting with 6 months of recurrent epigastric pain, vomiting, retrosternal pain, fever, tachycardia, and occult blood in stool, peptic ulcer disease (PUD) with gastritis is the most likely diagnosis. 1, 2
Clinical Reasoning
Key Diagnostic Features Supporting PUD
The constellation of symptoms strongly points toward peptic ulcer disease:
- Recurrent epigastric pain is the hallmark presenting symptom of PUD, occurring in the vast majority of symptomatic patients 3
- Occult blood in stool indicates gastrointestinal bleeding, which is the most common complication of duodenal ulcers and can manifest as hematemesis or melena 4, 1
- Vomiting is a common associated symptom in children with PUD 5
- Retrosternal pain can occur with gastritis and esophagitis, which frequently coexist with PUD 6, 1
- Fever and tachycardia suggest active inflammation or potential complications such as perforation 4
Why PUD Over Other Diagnoses
IBD (Inflammatory Bowel Disease): While IBD can cause abdominal pain and occult blood, the predominant epigastric location and retrosternal pain are more consistent with upper GI pathology rather than the colonic/terminal ileal involvement typical of IBD 1
IBS (Irritable Bowel Syndrome): IBS does not cause occult blood in stool, fever, or systemic signs—these findings indicate organic disease requiring investigation 1
Abdominal Migraine: This diagnosis would not explain occult blood in stool or fever, and typically presents with periumbilical rather than epigastric pain 1
Pediatric Considerations
In children presenting with chronic gastritis and peptic ulcers, the majority have either secondary ulceration (from systemic conditions, sepsis, or NSAID use) or primary disease caused by Helicobacter pylori infection 5. The chronic nature (6 months) and presence of bleeding make PUD the primary concern requiring urgent evaluation 5
Critical Next Steps
Immediate evaluation should include:
- Upper endoscopy (EGD) to directly visualize mucosal inflammation, ulceration, and rule out complications such as active bleeding or perforation 2, 3
- Testing for H. pylori via biopsy during endoscopy, as this organism is present in 100% of pediatric patients with duodenal ulcer and causes chronic active gastritis in the vast majority of children with PUD 5, 7
- Assessment for NSAID use or other secondary causes of ulceration 2, 5
Warning Signs Requiring Urgent Intervention
The presence of fever and tachycardia raises concern for potential perforation, which presents with sudden severe epigastric pain, fever, and abdominal rigidity, and carries mortality rates up to 30% 4, 1. If peritoneal signs develop, immediate surgical consultation is mandatory 4.