What is the next step in diagnosing a child with a 2-month history of nocturnal epigastric pain and a family history of Peptic Ulcer Disease (PUD)?

Next Step in Diagnosis: Upper GI Endoscopy with Biopsy

Upper GI endoscopy with biopsy is the next step for this child with 2 months of nocturnal epigastric pain and a family history of peptic ulcer disease. 1

Why Endoscopy is the Definitive Next Step

Endoscopy is the only test that simultaneously visualizes ulcers directly, obtains tissue for histopathology to diagnose gastritis, and performs H. pylori testing from biopsy samples. 1 This is critical because:

• Nocturnal pain that awakens the patient is a classic symptom of peptic ulcer disease, particularly duodenal ulcers 2
• The 2-month duration represents chronic symptoms requiring definitive diagnosis 1
• Family history of PUD increases pre-test probability significantly 3
• In children aged 10 years and older, primary peptic ulcer disease becomes more common with high recurrence rates 1

Why Other Options Are Inadequate

H. Pylori Stool Antigen Alone (Option D) - Insufficient

While H. pylori testing is important, stool antigen testing alone cannot:

• Visualize the ulcer or assess its severity 1
• Rule out complications like bleeding or perforation 2
• Exclude other serious conditions including eosinophilic esophagitis or Crohn's disease 1
• Provide histopathological confirmation of gastritis 1

In pediatric PUD, 62-87% of duodenal ulcers are H. pylori-positive, but this means 13-38% are not, requiring alternative diagnosis and management 3, 4

CBC (Option A) - Non-Diagnostic

CBC may detect anemia from chronic bleeding but does not diagnose the underlying ulcer or guide specific treatment 5

Abdominal Ultrasound (Option B) - Cannot Visualize Mucosal Disease

Ultrasound cannot visualize mucosal ulcers or gastritis and is not the test of choice when peptic ulcer disease is strongly suspected 1, 6

Critical Endoscopic Biopsy Protocol

When performing endoscopy, obtain at least two biopsy samples from both antrum and body to improve H. pylori detection sensitivity, as colonization density varies 1

Warning Signs Requiring Urgent Endoscopy

This child already meets criteria for endoscopy based on:

• Chronic symptoms (>2 months) 5
• Nocturnal awakening (classic for PUD) 2
• Family history of PUD (alarm feature in pediatric context) 1

Additional alarm features that would mandate immediate endoscopy include:

• Hematemesis or melena 3
• Weight loss 5
• Persistent vomiting 5
• Dysphagia 6
• Anemia on CBC 5

Common Pitfall to Avoid

Do not delay endoscopy by empirically treating with proton pump inhibitors or performing non-invasive H. pylori testing first in children with chronic symptoms and alarm features. 1, 5 While a test-and-treat strategy may be appropriate for adults with uncomplicated dyspepsia, children with 2 months of nocturnal pain and family history require definitive diagnosis to guide appropriate management and assess for complications. 1

The answer is C: Upper GI endoscopy with biopsy.