Management of Worsening Gastroenteritis in a 14-Year-Old with H. pylori-Positive Gastric Ulcer
This patient requires immediate reassessment of hydration status with continued IV fluid resuscitation, initiation of H. pylori eradication therapy after 72-96 hours of IV PPI therapy, and close monitoring for complications, as the worsening symptoms on day 4 suggest either inadequate initial management or a complicated course requiring more aggressive intervention. 1, 2
Immediate Fluid Management
Administer isotonic IV fluids (0.9% normal saline or lactated Ringer's) at 20 mL/kg bolus over 1-2 hours, then reassess hydration status, as this patient has recurrent moderate dehydration despite initial IV therapy 2, 3
Continue maintenance IV fluids at approximately 30 mL/kg/day for adolescents until the patient can consistently tolerate oral intake without vomiting 2
Replace ongoing losses by administering additional 10 mL/kg of 0.9% normal saline for each episode of emesis or significant diarrheal output 2
Monitor vital signs every 4 hours including heart rate, blood pressure, capillary refill time, and urine output (target >1 mL/kg/hour) 2
Acid Suppression and H. pylori Eradication
Start high-dose IV PPI therapy immediately (omeprazole 40 mg IV twice daily or equivalent) for 72-96 hours before initiating H. pylori eradication therapy, as this approach optimizes conditions for successful eradication in the setting of active gastric ulcer 1
After 72-96 hours of IV PPI, transition to standard triple therapy for 14 days: amoxicillin 1000 mg twice daily, clarithromycin 500 mg twice daily, and PPI (omeprazole 20 mg or equivalent) twice daily if local clarithromycin resistance is low 1, 4
The rapid urease test is reliable for H. pylori diagnosis in this patient, with sensitivity of 89.6% in bleeding peptic ulcer disease, though body biopsies are more accurate than antral biopsies 5, 6, 7
Do NOT use empirical antibiotics for the gastroenteritis itself, as antimicrobial therapy is not recommended for bleeding or complicated peptic ulcer unless there are signs of sepsis or perforation 1
Antiemetic Support
Administer ondansetron only after adequate initial IV hydration to facilitate tolerance of oral rehydration, not as a substitute for fluid therapy 2
This medication should only be given once clinical hydration status improves, as it helps transition to oral intake but does not address the underlying fluid deficit 2
Dietary Management and Transition to Oral Intake
Keep the patient NPO initially until vomiting resolves and clinical hydration improves 2
Once vomiting resolves and the patient tolerates 1-3 ounces of clear fluid without emesis, transition to oral rehydration solution (ORS) to replace remaining deficit 2
Resume normal age-appropriate diet during or immediately after rehydration is complete; avoid restrictive diets or prolonged fasting 2
Provide dietary counseling to eliminate spicy foods, soda, coffee, and highly acidic foods that exacerbate gastric ulcer symptoms 2
Critical Monitoring Parameters
Reassess hydration status after initial bolus and every 4-6 hours: evaluate skin turgor, mucous membranes, mental status, and urine output 2
Obtain complete blood count to assess for anemia (given gastric ulcer history), comprehensive metabolic panel to evaluate electrolytes and renal function 2
If serum bicarbonate is ≤13 mEq/L, the patient is at significantly higher risk for treatment failure and may require hospital admission for prolonged IV therapy 3
Monitor for resolution of vomiting and ability to tolerate oral intake as criteria for transitioning from IV to oral fluids 2
Important Clinical Caveats
Do NOT administer antimotility agents (loperamide) as this patient is under 18 years old and such agents are contraindicated in pediatric patients 2
The worsening symptoms on day 4 despite initial IV fluids suggest either: (1) inadequate initial resuscitation, (2) ongoing losses exceeding replacement, or (3) complicated gastroenteritis requiring more aggressive management 1
Classify this patient as "complicated" given grade 2 symptoms (vomiting and diarrhea) with added risk factors of known gastric ulcer disease and recurrent dehydration requiring close monitoring and potentially hospital admission 1
Do not delay rehydration while awaiting diagnostic testing or H. pylori eradication therapy results 2
The combination of active gastric ulcer with acute gastroenteritis increases risk for complications; ensure stool workup is performed if symptoms persist beyond 48 hours on appropriate therapy to rule out infectious colitis 1