3.  Step 1: ABCs!! Assess hemodynamic status of the patient › Orthostatic changes- best indicator of significant blood loss  Step 2: Establish severity of bleeding › Coffee ground emesis, melena: lower rate of bleeding › Bright red blood: ?higher rate of bleeding

4.  Step 3: Determine the location of the bleeding › UGI: bleeding above the ligament of Treitz  Hematemesis › LGI: bleeding distal to the ligament of Treitz  Bloody diarrhea  Bright red blood mixed with or coating stool › Hematochezia, melena, or occult blood loss can be due to both UGI or LGI bleeds  Passing NGT can determine if the blood is originating from the UGI tract or LGI tract

5.  Simulates bright red blood › Food coloring › Colored gelatin or children’s drinks › Red candy › Beets › Tomato skins › Antibiotic syrups  Simulates melena › Bismuth or iron preparations › Spinach › Blueberries › Grapes › Licorice

7. Cytotoxic factors: 1.Acid 2.Pepsin 3.Medications 4.Bile acids 5.Infection with H.Pylori Cytoprotective factors: 1.Mucous layer 2.Local bicarb secretion 3.Mucosal blood flow

8.  Epigastric abdominal pain  Recurrent vomiting (at least 3x/mo)  Symptoms associated with eating (anorexia/ wt loss)  Pain awakening the child at night  Heartburn  Oral regurgitation  Chronic nausea  Excessive belching/ hiccuping  FHx of PUD, dyspepsia, or IBS

9.  Symptoms?  Dietary history? › Specific foods that worsen pain?  Medications?  Alcohol or tobacco use?  Doses of acid-suppressive meds?

10.  Height, weight and BMI  PLOT!  HEENT › Funduscopic exam › OP: aphthous ulcers  Crohn’s dz, dental enamel erosion  GER, Eating d/o  Lungs › Wheezing  GER  Abdomen › Splenomegaly  portal HTN  Rectum › Perianal disease  Crohn’s dz  Extremities › Clubbing  Crohn’s dz, Russell sign  Eating d/o

11.  Screening labs › CBC with diff › ESR › LFTs › Electrolytes › Stool for O&P › UA  Endoscopy › Indications  Evidence of GI bleeding  Abnormality on UGI  Odynophagia  Refusal to eat  Persistant unexplained vomiting  Lack of response to medications

13.  Gram negative bacillus  Transmission fecal-oral, gastric-oral, or oral- oral  *Organism associated with a significant proportion of duodenal ulcers & chronic active gastritis › To a lesser extent, gastric ulcers  Also linked to the development of gastric adenocarcinoma and lymphoma

14.  50 % of the world’s population is infected › Most are asymptomatic  Infection most common in developing countries › Incidence 3-10% in developing countries › Incidence 0.5% in industrialized countries  Asian Americans, African Americans and Hispanic individuals living in North America have a prevalence of infection similar to that of a developing country › Ethnic or genetic predisposition?

15.  Poor socioeconomic status  Family overcrowding  Child care attendance  Poor hygiene  Living with an infected family member

16.  The ideal test does not yet exist! › Endoscopy with biopsies from the prepyloric antrum= gold standard  Histologic identification  Culture  Immunologic detection of H.Pylori urease  PCR › Urease breath test › Anti-H. Pylori IgG › Stool antigen testing

17.  Stool antigen testing › Sensitivity and specificity> 98% › Sample easy to obtain › Less expensive than the urease breath test  The AAP says…don’t test for it if you are not going to treat it!! › Active peptic ulcer disease › History of ulcers › MALT lymphoma or gastric cancer

18.  Goals › Eradicate the organism › Heal the ulcer › Prevent recurrence of infection and the emergence of resistant organisms  Two antimicrobials + PPI › First line: clarithromycin+ Amoxicillin OR metronidazole+ PPI › Alternative (age>8): tetracycline+ metronidazole+ bismuth subsalicylate+ H2 blocker

19.  Length of treatment: 14days  Cure rates 75-90%  To check for eradication, wait 6 weeks-3 months after the completion of therapy › Urease breath test › Stool antigen test

20. AA 12 yo boy who has a h/o recurrent abdominal pain presents to your office for an annual health supervision visit. The boy complains of periumbilical pain, unrelated to meals, occuring twice a month and lasting 15 minutes. PE is normal. FOBT is negative. His father, who is a physician, asks if the boy should undergo testing for H. Pylori. Of the following, a TRUE statement about H. Pylori infection is: ›A›A. All children who have positive H. Pylori serologies should undergo endoscopy ›B›B. Antibiotic therapy for H. Pylori is most effective when combined with a PPI ›C›C. H. Pylori is difficult to detect on gastric histology without special immunofluorescent staining ›D›D. H. Pylori infection is less prevalent in children from the developing world ›E›E. H. Pylori organisms rarely develop antibiotic resistance

21. Noon Conference: Pseudoasthma, Dr. Pepiak