STRESS, DRUGS, AND H. PYLORI: GASTRIC/DUODENAL ULCERS LEADING TO PERFORATION IN PEDIATRICS Laurie Sands, RN, MSN, CPNP- PC/AC Ann & Robert H. Lurie Children’s Hospital of Chicago BACKGROUND IMPLICATIONS FOR SURGERY AND NURSING CARE CONCLUSIONS • Abdominal pain is a common complaint in pediatrics • Research is limited: • Surgical intervention indicated as a result of indirect signs of bowel perforation, peritoneal signs, acute abdomen, • Gastric/duodenal (peptic) ulcers leading to perforation is rare and is o May be more common in adolescent males (often previously healthy) bleeding or obstruction often low on the healthcare providers’ differential o Perforated ulcer often not associated with chronic abdominal pain and • Surgical intervention: • Delay in diagnosis of peptic ulcers may lead to complications and presents as acute abdominal pain with peritoneal signs o Classic surgery: Vagotomy with pyloroplasty increased morbidity o Radiography is important, free air or pneumoperitoneum seen in the Ulcer excision with Graham patch and simple suture o majority of patients • Nursing care o Current evidence suggests: diet does not necessarily predispose Diet: Strict bowel rest, NG tube may be placed (consider no manipulation of NG tube), TPN may be indicated with OBJECTIVES o patients to peptic ulcer disease, there may be a genetic component, prolonged NPO status, UGI may be considered prior to initiating diet to assess for leak emotional stress alone unlikely to cause ulceration, smoking may lead o Pain management: IV pain medications until transition to oral pain medications, consider avoiding NSAIDS • Describe the potential causes of peptic ulcers leading to perforation to ulceration, and alcohol unlikely to cause ulceration. o Medications: • Describe signs and symptoms of peptic ulcers • Perforated peptic ulcer should be considered in the differential diagnosis for Ø IV antibiotics • Discuss implications for surgical management of peptic ulcers leading to the patient that presents with acute abdominal pain with peritoneal signs for Ø Proton Pump Inhibitor perforation and review key components of nursing care early identification and treatment. Ø Treatment of H. Pylori if indicated: [Current Redbook recommendations for treatment of H. Pylori may include: 2 antimicrobials (clarithromycin and amoxicillin/metronidazole) + Proton Pump Inhibitor]; alternate therapies available CAUSES o Nursing interventions: OOB and IS, child life • Primary: o Helicobacter Pylori (H. Pylori) CASE STUDIES o H. Pylori negative or idiopathic • Secondary: o Stress (organic, not emotional): Sepsis, shock, trauma, intracranial lesion (Cushing ulcer), or in response to severe burn injury (Curling ulcer) J. H., 14 y/o male S. C., 13 m/o male o Drugs: Use of NSAIDS, corticosteroids, and aspirin o Hypersecretory states: Zollinger-Ellison syndrome, short bowel REFERENCES syndrome, cystic fibrosis, and systemic mastocytosis • PMH: Asthma and ADHD, otherwise healthy • PMH: Otherwise healthy male with newly diagnosed brain tumor • Symptoms: Diffusely tender abdominal pain, non bilious emesis s/p craniotomy and placement of right external ventricular drain Blanchard, S. S. & Czinn, S. J. (2011). Peptic ulcer disease in • Workup: CXR with pneumoperitoneum, VS on admission: BP within tumor resection cavity children. In Kliegman, R. M., Stanon, B. F., Gemell, J. W. 152/86 | Pulse 121 | Temp 37.4 °C (99.3 °F) | Resp 32 • Symptoms: Abdominal distention post operative from craniotomy SIGNS AND SYMPTOMS J. W. Schor, N. F. & Behrman, R. E. (Eds.), Kleigman: Nelson • Surgical Course: Diagnostic laparoscopy converted to open • Workup: Abdominal X-ray with pneumoperitoneum textbook of pediatrics. (pp. 1291-1294). Philadelphia, PA: exploratory laparotomy with Graham patch repair of perforated • Surgical course: Exploratory laparotomy, abdominal washout, Elsevier Saunders. • Pain: Often epigastric, may awaken patient from sleep, may be referred duodenal ulcer, appendectomy kocherization of the duodenum, primary repair of prepyloric gastric Hua, M.C., Kong, M. S., Lai, M. W., & Luo, C. C. to shoulder (diaphragmatic irritation), may be alleviated by meals • Post operative course: NPO with NG on TPN, IV antibiotics and perforation with omental patch and biopsy (2007) Perforated peptic ulcer in children: a 20-year • Decreased appetite, weight stagnation or weight loss Proton Pump Inhibitor, PCA for pain. UGI prior to initiation of diet • Post operative course: NPO with NG on TPN, IV antibiotics and experience. Journal of Pediatric Gastroenterology, 45, 71-74. • Hematemesis, melena and anemia may be present with no evidence of leak. Transitioned to full oral diet. Proton Pump Inhibitor, PCA for pain. UGI prior to initiation of diet Schwartz, S., Edden, Y., Orkin, B., & Erlichman, M. (2012). • Late signs (indicating potential perforation): Severe abdominal pain, • Presumed Cause: H. Pylori (+) – started on clarithromycin and with no evidence of leak. Transitioned to full oral diet. Perforated peptic ulcer in an adolescent girl. Pediatric rigid abdomen, peritoneal signs, ill appearing child, and/or signs of metronidazole + Prilosec • Presumed cause: Ulcer biopsy: inflammation, negative for H. Emergency Care, 28, 709-711. shock • Follow up: Completed treatment for H. Pylori. He tolerates a Pylori, ulcer likely related to stress Wyllie, R., Hyams, J. S. & Kay, M. (2011). Gastritis, § Laboratory: Electrolyte panel may show signs of dehydration, H. Pylori normal diet and has returned to track and weight lifting. • Follow up: Continues on Prilosec for 6 months. He is eating well, gastropathy, and ulcer disease. In Dimock, K. & Ball, T. may be present acting normally, and regaining milestones. § Radiological Imaging: Pneumoperitoneum (free air) likely present (Eds.), Pediatric gastrointestinal and liver disease (pp. 288-308). Philadelphia, PA: Elsevier Saunders. .