How should acute gastritis be diagnosed and managed in a child presenting with acute epigastric pain, nausea, vomiting (with possible coffee‑ground or frank blood) and low‑grade fever?

Acute Gastritis in Pediatrics: Diagnosis and Management

Initial Clinical Assessment

For a child presenting with acute epigastric pain, nausea, vomiting (especially coffee-ground or bloody emesis), and low-grade fever, immediately assess hydration status through specific clinical signs rather than waiting for laboratory confirmation. 1, 2

Evaluate the following clinical parameters to categorize dehydration severity:

• Skin turgor and capillary refill time (prolonged skin retraction >2 seconds indicates severe dehydration) 1, 3
• Mental status (lethargy or altered consciousness signals severe dehydration) 1, 3
• Mucous membrane moisture 1, 2
• Vital signs including heart rate and blood pressure 1, 2
• Urine output (decreased frequency or volume) 1, 2

Categorize dehydration as:

• Mild (3-5% fluid deficit) 1, 2
• Moderate (6-9% fluid deficit) 1, 2
• Severe (≥10% fluid deficit) 1, 2

Red Flags Requiring Immediate Intervention

Watch for these critical warning signs that mandate urgent escalation:

• Severe lethargy or altered consciousness 1, 3
• Prolonged skin tenting >2 seconds 1, 3
• Cool extremities with poor perfusion 1
• Rapid, deep breathing (indicating metabolic acidosis) 1
• Bloody stools with fever and systemic toxicity (suggests bacterial infection requiring cultures) 1, 3
• Absent bowel sounds (absolute contraindication to oral rehydration) 1, 3
• Persistent vomiting despite small-volume oral rehydration attempts 1, 3

Diagnostic Workup

Upper gastrointestinal endoscopy is the gold standard for diagnosing gastritis in children, allowing direct visualization of gastric lesions and obtaining antral and fundic biopsies for histopathology and culture. 4

Endoscopy is indicated when:

• Symptoms persist despite appropriate rehydration and supportive care 4
• There is coffee-ground emesis or frank hematemesis 4
• Severe epigastric pain is disproportionate to examination findings 1

Endoscopic findings typically include gastric edema, erythema, mucosal friability, and gastric antral erosions. 5 In some cases, nodularity of gastric mucosa may be present. 6

Obtain biopsies for:

• Histopathologic examination (to assess degree of inflammation) 4
• H. pylori testing (culture and histology) 4, 7

Stool tests should not be used to make the diagnosis of acute gastritis. 5 However, if bloody diarrhea is present, obtain stool cultures to rule out bacterial pathogens like Salmonella, Shigella, or enterohemorrhagic E. coli. 1, 2

Primary Management: Rehydration

Mild to Moderate Dehydration (3-9% fluid deficit)

Oral rehydration solution (ORS) is the first-line treatment and successfully rehydrates >90% of children with vomiting without antiemetic medication. 1

Administer ORS using this specific technique:

• Start with 5-10 mL every 1-2 minutes using a spoon or syringe 1, 3
• Gradually increase volume as tolerated without triggering more vomiting 1, 3
• Target 50-100 mL/kg over 2-4 hours for moderate dehydration 1, 3, 2
• Replace ongoing losses continuously: 10 mL/kg ORS for each watery stool and 2 mL/kg for each vomiting episode 1

Use low-osmolarity ORS formulations rather than sports drinks, apple juice, or other high-sugar beverages, which can worsen diarrhea through osmotic effects. 1

Severe Dehydration (≥10% fluid deficit)

Severe dehydration constitutes a medical emergency requiring immediate intravenous rehydration. 1, 3

• Administer isotonic IV fluids (lactated Ringer's or normal saline) at 20 mL/kg over 30 minutes 3, 2
• Continue IV rehydration until pulse, perfusion, and mental status normalize 1, 2
• Transition to ORS once the patient improves to replace remaining deficit 1

Pharmacological Management

Antiemetics

Ondansetron (0.15 mg/kg orally dissolving tablet) may be given to children >4 years with significant vomiting to facilitate oral rehydration. 3, 2 This can prevent the need for IV therapy in many cases. 2

Acid Suppression

Proton pump inhibitors have no established pediatric indication for children under 12 years with acute gastritis. 3 The primary focus should remain on rehydration and nutritional management rather than acid suppression. 3

For confirmed H. pylori-associated gastritis, treatment consists of:

• Proton pump inhibitor plus two antibiotics for 7-10 days 4

Medications to AVOID

Never administer loperamide to children <18 years with acute diarrhea due to serious adverse events including ileus, drowsiness, and potentially fatal abdominal distention. 3, 2

Do not use metoclopramide as it has no role in gastroenteritis management and may worsen outcomes. 1

Avoid antimotility agents, adsorbents, antisecretory drugs, and toxin binders as they do not reduce diarrhea volume or duration. 1

Nutritional Management

Resume age-appropriate diet immediately during or after rehydration rather than prolonging fasting. 1, 3 Early refeeding reduces severity and duration of illness. 1, 3

Offer these foods:

• Starches, cereals, soup, yogurt, vegetables, and fresh fruits 3
• Continue breastfeeding on demand if applicable 1

Avoid these items during acute illness:

• Foods high in simple sugars (soft drinks, undiluted apple juice) 1
• High-fat foods 1
• Caffeinated beverages (coffee, tea, energy drinks) as they worsen symptoms through stimulation of intestinal motility 1

Antimicrobial Therapy

Antimicrobial agents have limited usefulness since viral agents cause most acute gastroenteritis. 1

Consider antibiotics only in these specific circumstances:

• Infants <3 months with suspected bacterial etiology: third-generation cephalosporin 2
• Bloody diarrhea with fever and systemic toxicity: empiric fluoroquinolone (ciprofloxacin) or azithromycin depending on local resistance patterns 2
• Confirmed H. pylori infection: dual antibiotic therapy with PPI 4

Hospitalization Criteria

Admit children who meet any of these criteria:

• Severe dehydration (≥10% fluid deficit) or signs of shock 1, 3
• Failure of oral rehydration therapy after ondansetron trial 3
• Altered mental status or ileus 3
• Persistent vomiting preventing adequate oral intake 3
• Infants <3 months (lower threshold due to higher risk) 1
• Bloody stools with fever requiring monitoring for hemolytic uremic syndrome 1

Infection Control

Implement strict infection control measures to prevent transmission:

• Hand hygiene after toilet use, diaper changes, before food preparation and eating 1, 2
• Use gloves and gowns when caring for the child 1, 2
• Clean and disinfect contaminated surfaces promptly 1
• Separate ill child from well siblings until at least 2 days after symptom resolution 1

Common Pitfalls to Avoid

• Do not delay rehydration while awaiting diagnostic testing – begin ORS immediately 1
• Do not use inappropriate fluids (sports drinks, apple juice) as primary rehydration for moderate-severe dehydration 1
• Do not unnecessarily restrict diet during or after rehydration 1
• Do not underestimate dehydration severity – use objective clinical signs rather than subjective assessment 1, 3
• Do not prescribe pantoprazole for children <12 years as first-line therapy 3

Monitoring and Reassessment

Reassess hydration status after 2-4 hours of ORS administration. 1 If still dehydrated, reestimate deficit and restart rehydration protocol. 1

Monitor these parameters every 2-4 hours:

• Vital signs 1
• Capillary refill 1
• Skin turgor 1
• Mental status 1
• Mucous membrane moisture 1

Daily weights provide the most accurate tracking of rehydration progress. 1

Discharge Planning

Discharge when the child meets all these criteria:

• Tolerating oral intake 1
• Producing urine 1
• Clinically rehydrated 1
• Afebrile for 24 hours (if bacterial infection confirmed) 1

Provide caregivers with:

• ORS supply 1
• Clear instructions on small-volume, frequent administration technique (5-10 mL every 1-2 minutes) 1, 3
• Warning signs requiring return to medical care (decreased urine output, lethargy, high fever, bloody stools) 1