What is the evidence‑based approach to evaluating and managing chronic gastritis in a pediatric patient, including indications for upper endoscopy, H. pylori testing, and appropriate treatment regimens?

Chronic Gastritis in Pediatrics: Evidence-Based Evaluation and Management

Initial Clinical Assessment

In pediatric patients with suspected chronic gastritis presenting with recurrent epigastric pain, begin with a 2- to 4-week trial of conservative dietary modifications before considering pharmacologic therapy or invasive testing. 1

Key Clinical Features to Identify

• Epigastric pain influenced by meals, associated with nausea, vomiting, and weight loss are the hallmark symptoms of gastritis in children 2
• Recurrent abdominal pain is the most common presentation (67-67.4% of cases) 3
• Upper gastrointestinal bleeding occurs in approximately 17-19% of pediatric gastritis cases 3
• Iron deficiency anemia without obvious blood loss should raise suspicion for autoimmune gastritis, particularly in adolescents 4

Critical Pitfalls to Avoid Early

• Never dismiss cardiac causes regardless of age—myocardial infarction can present as isolated epigastric pain in adolescents with 10-20% mortality if missed 1
• Check for peritoneal signs suggesting perforated peptic ulcer, which carries 30% mortality if treatment is delayed 1
• Assess vital signs for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation or sepsis 1

Conservative Management Strategy

Dietary and Lifestyle Modifications

• Continue usual diet with emphasis on starches, cereals, yogurt, fruits, and vegetables 1
• Avoid foods high in simple sugars and fats 1
• Implement these changes for 2-4 weeks before escalating to pharmacologic therapy 1

Indications for Upper Endoscopy with Biopsy

Upper endoscopy with gastric biopsies is the gold standard for diagnosing chronic gastritis and should be performed when:

Alarm Features Present

• Unexplained weight loss 5
• Progressive dysphagia 5
• Recurrent vomiting 5
• Evidence of gastrointestinal bleeding 5
• Family history of gastric cancer 5
• Iron deficiency anemia without obvious source 4

Failed Conservative Management

• Symptoms persisting beyond 4 weeks despite dietary modifications 1, 5
• Symptoms requiring diagnostic reassessment after empirical therapy failure 5

Diagnostic Advantages of Endoscopy

• Direct visualization of mucosal injury and histologic grading of inflammation—approximately 25% of infants under 1 year have esophageal inflammation detectable only by biopsy 6
• Allows exclusion of eosinophilic esophagitis, which requires tissue sampling for diagnosis 6
• Enables detection of atrophic gastritis and intestinal metaplasia, which carry malignancy risk 4, 3
• Permits culture and histologic confirmation of H. pylori infection 2

H. pylori Testing Strategy

When to Test

Offer non-invasive H. pylori testing in patients without alarm features who have had symptoms for 4 weeks or longer 1

• When endoscopy is performed for alarm symptoms or failed conservative management, biopsy-based H. pylori testing should be performed 5
• Testing is particularly important when endoscopy reveals antral nodular gastritis or peptic ulcer disease 5

Testing Methods and Preparation

• Stop proton pump inhibitors for at least 2 weeks before testing, as they cause false-negative results in up to 40% of cases 5
• Stop antibiotics and bismuth products for at least 2 weeks to reduce false-negative risk 7
• Stool antigen test has sensitivity and specificity exceeding 90% in untreated patients with proper medication washout 5
• During endoscopy, obtain antral and fundic biopsies for histology, culture, and rapid urease testing 2, 3
• H. pylori infection is considered positive if 2 out of 3 tests are positive (culture, histology, rapid urease test) 3

Important Context on H. pylori in Pediatric Gastritis

• H. pylori infection is detected in 62.3% of children with chronic gastritis 3
• Active, follicular, and atrophic gastritis are significantly associated with H. pylori infection 3
• H. pylori gastritis in children is more severely expressed than in adults, particularly in the antrum, possibly due to child-specific immune response 8
• Chronic gastritis that begins in childhood progresses or persists into adulthood in all H. pylori-positive patients if untreated 9

Treatment Regimens

Pharmacologic Therapy for Symptomatic Gastritis

• Initiate full-dose PPI therapy with omeprazole 20 mg once daily before meals for 2 weeks when epigastric pain is the predominant symptom 1
• If symptoms improve, continue PPI for 8-12 weeks total 1
• Avoid routine PPI use in infants due to increased risk of pneumonia, gastroenteritis, and necrotizing enterocolitis 1

H. pylori Eradication Therapy

Provide eradication therapy if H. pylori testing is positive 1

• Treatment associates proton pump inhibitors and two antibiotics for 7-10 days 2
• In children with H. pylori-positive chronic gastritis, eradication therapy leads to regression or disappearance of gastritis in 86% of cases (6 of 7 re-examined patients) 9
• Diagnostic testing for and treatment of H. pylori should be done in consultation with a gastroenterologist 7

Follow-up After Treatment

• Confirm eradication with non-invasive testing (stool antigen or urea breath test) at least 4 weeks after completing therapy 2
• Endoscopic follow-up should be performed in cases of atrophic gastritis due to risk of malignancy 4

Special Considerations

Autoimmune Gastritis

• Consider autoimmune gastritis in the differential diagnosis of iron deficiency anemia in adolescents, particularly when H. pylori is negative 4
• Diagnosis requires pathological examination showing atrophy of oxyntic glands 4
• Standardized clinico-pathologic work-up is mandatory, and endoscopic follow-up should be performed due to increased risk of malignancy 4

Atrophic Gastritis and Intestinal Metaplasia

• Atrophic gastritis is found in 14.4-14.5% of children with chronic gastritis 3
• Atrophic gastritis is significantly associated with H. pylori infection (93.7% H. pylori-positive) and nodular gastritis 3
• Intestinal metaplasia, though rare in children, represents progression toward malignancy risk 3

Long-term Outcomes Without Treatment

• All 6 patients who had duodenal ulcers in childhood had recurrences of duodenal ulcer when re-examined 11 years later 9
• 31% of patients with persisting chronic gastritis who had no ulcers previously developed duodenal ulcer or erosions 9
• Gastritis progressed or remained unchanged in 90% of patients in the corpus and 75% in the antrum over 11 years in H. pylori-positive patients 9

Common Pitfalls to Avoid

• Do not use empiric PPI therapy as a diagnostic test—lack of response does not rule out gastritis, and response does not confirm it 1, 6
• Do not delay imaging or endoscopy in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis 1
• If PPI therapy is ineffective, reassess the diagnosis before proceeding to more invasive interventions, as conditions like cyclic vomiting, rumination, gastroparesis, and eosinophilic esophagitis will not respond to acid suppression 1
• Do not rely on barium upper GI series for diagnosis—these studies are too brief to capture pathologic reflux, have high false-positive rates, and cannot assess mucosal injury 6
• Recognize that symptoms alone are unreliable for diagnosing gastritis in children, and that comprehensive diagnostic evaluation with endoscopy and biopsy is necessary when conservative management fails 6