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ЕНДОКРИНОЛОГИ, СІМЕЙНІ ЛІКАРІ, ПЕДІАТРИ, КАРДІОЛОГИ ТА ІНШІ СПЕЦІАЛІСТИ

ПЕДІАТРИ ТА СІМЕЙНІ ЛІКАРІ

АНЕСТЕЗІОЛОГИ, ХІРУРГИ

"Child`s Health" Том 12, №8, 2017

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Clinical and endoscopic features of the upper digestive tract pathology in children and adolescents depending on age

Authors: L.K. Parkhomenko(1), L.A. Strashok(1), E.M. Zavelya(1), M.Yu. Isakova(1), A.V. Yeshchenko(1), Zh.V. Polishchuk(2)
(1) — Kharkiv Medical Academy of Postgraduate Education, Kharkiv, Ukraine
(2) — State Institution “Institute for Children and Adolescents Health Care of the NAMS of Ukraine”, Kharkiv, Ukraine

Categories: Pediatrics/Neonatology

Sections: Specialist manual

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Summary

Мета роботи: визначити структуру та вікові особ­ливості клініко-ендоскопічних проявів гастродуоденальної патології в підлітковому віці. Матеріали та методи. Під спостереженням перебували 493 підлітки віком 10–14 років і 444 підлітки віком 15–18 років. Здійснювали клінічні та лабораторно-інструментальні дослідження (езофагофіброгастродуоденоскопія, внутрішньошлункова рН-метрія, ДНК Helicobacter pylori). Результати. Проведені дослідження показали, що в підлітковому віці переважають запальні ураження верхніх відділів травного тракту в обох вікових групах. Частота деструктивних уражень у віці 10–14 років становить усього 8–10 %, але до 15–18 років зростає у 2 рази в хлопців і в 1,5 раза в дівчат. Незалежно від віку в 30 % пацієнтів установлені рухові порушення верхніх відділів травного тракту, що дещо частіше виявляються в дівчат. У хлопчиків пошкодження верхніх відділів травного тракту, як правило, супроводжуються базальною гіперацидністю, а в дівчат частіше визначають базальну нормацидність. Інфікування Helicobacter pylori виявлено у 2/3 підлітків із патологією верхніх відділів травного тракту, дещо частіше — у віці 10–14 років. Висновки. Результати досліджень можуть сфокусувати напрямки етіотропної та патогенетичної терапії захворювань верхніх відділів шлунково-кишкового тракту залежно від віку і статі пацієнтів.

Цель работы: определить структуру и возрастные особенности клинико-эндоскопических проявлений гастродуоденальной патологии в подростковом возрасте. Материалы и методы. Под наблюдением находились 493 подростка в возрасте 10–14 лет и 444 подростка в возрасте 15–18 лет. Осуществляли клинические и лабораторно-инструментальные исследования (эзофагофиброгастродуоденоскопия, внутрижелудочная рН-метрия, ДНК Helicobacter pylori). Результаты. Проведенные исследования показали, что в подростковом возрасте преобладают воспалительные поражения верхних отделов пищеварительного тракта в обеих возрастных группах. Частота деструктивных поражений в возрасте 10–14 лет составляет всего 8–10 %, но к 15–18 годам возрастает в 2 раза у мальчиков и в 1,5 раза у девочек. Независимо от возраста у 30 % пациентов установлены двигательные нарушения верхних отделов пищеварительного тракта, которые несколько чаще выявляются у девочек. У мальчиков повреждения верхних отделов пищеварительного тракта, как правило, сопровождаются базальной гиперацидностью, а у девочек чаще определяется базальная нормацидность. Инфицирование Helicobacter pylori выявлено у 2/3 подростков с патологией верхних отделов пищеварительного тракта, несколько чаще — в возрасте 10–14 лет. Выводы. Результаты исследований могут сфокусировать направления этио­тропной и патогенетической терапии заболеваний верхних отделов желудочно-кишечного тракта в зависимости от возраста и пола больных.

Background. The purpose was to determine the structure and age characteristics of clinical and endoscopic features of gastroduodenal pathology in adolescence. Materials and methods. The study included 493 adolescents between 10 and 14 years of age and 444 adolescents aged 15 to 18 years. Clinical, laboratory and instrumental studies were conducted (esophagogastroduodenoscopy, intragastric pH-metry, Helicobacter pylori DNA). Results. The study showed that in adolescence, the inflammatory lesions of the upper digestive tract predominate in both age groups. Destructive lesions occur in 8–10 % of patients in the 10–14 age group, and their incidence increases 2 times in boys and 1.5 times — in girls in the 15–18 age group. Motility disorders of the upper digestive tract are determined in 30 % of patients regardless of age, more often in girls. Lesions of the upper digestive tract are usually accompanied by basal gastric hyperacidity in boys, while in girls the basal normacidity is more often determined. Helicobacter pylori infection is detected in 2/3 of adolescents with disorders of the upper digestive tract, slightly more often in the 10–14 age group. Conclusions. The results obtained in the course of the study can focus the directions of etiotropic and pathogenetic therapy for the upper digestive tract diseases depending on the age and gender of the patients.


Keywords

запальні захворювання верхніх відділів травного тракту; виразкова хвороба; діти; підлітки; езофагогастродуоденоскопія; Helicobacter pylori

воспалительные заболевания верхних отделов пищеварительного тракта; язвенная болезнь; дети; подростки; эзофагогастродуоденоскопия; Helicobacter pylori

inflammatory diseases of the upper digestive tract; peptic ulcer disease; children; adolescents; eso­phagogastroduodenoscopy; Helicobacter pylori

Introduction

The frequency of gastrointestinal tract pathology in the structure of somatic pathology is increasing all over the world. Diseases of the digestive system currently occupy the second place in the prevalence among noncommunicable diseases in children and adolescents [3, 9]. It should be mentioned that lesions of the upper digestive tract predominate in the gastroenterological patho–logy structure of the last ten years (functional dyspepsia, chronic gastritis and duodenitis, peptic ulcer disease). The share of chronic gastroduodenitis and functional dyspepsia accounts for 70–75 % of all gastrointestinal diseases in children. Functional pathology of the upper digestive tract is formed in early childhood and is one of the frequent reasons for visiting a pediatrician [2]. The prevalence of chronic gastritis and duodenitis increased from 614 per 10 000 adolescents in 2010 to 1346 in 2016, the prevalence of peptic ulcer disease increased from 47.5 per 10 000 adolescents in 2010 to 54 in 2016. 
Functional and inflammatory diseases of the upper digestive tract are more often detected in prepubertal and pubertal age, at that more often in girls. In adolescence, determined by neurohormonal restructuring and maturation of regulatory systems, conditions are formed which lead to reducing the resistance of the mucosa of the digestive tract for the effects of both exogenous and endogenous aggressive influences. Studies of the peptic ulcer in childhood indicate that the disease is equally common in children and adolescents of both sexes, but at the age of 15 years in boys this disease occurs 1.7–2 times more often, and up to 30 years — 5–13 times more often than in members of another gender [1, 5, 10, 13]. Some authors note that the frequency of complicated forms of peptic ulcer disease is higher among young people than in older age groups, and varies according to different data from 10–15 to 45–50 %. At the same time, other authors indicate that ulcer bleedings predominate in the elderly and are caused by the intake of NSAIDs [4, 11, 12]. 
There has been a clear trend towards a significant rejuvenation of gastroduodenal pathology in children, an increase in the frequency of destructive processes, a prolonged course with relapses in recent years.
Diseases of the digestive system in children due to their high prevalence, clinical course, high risk of early manifestation and recurrent course represent a serious medical and social problem. 
The purpose of the study: to determine the structure and age characteristics of clinical and endoscopic manifestations of gastroduodenal pathology in adolescents. 

Materials and methods

The study took place from 2013 to 2016 and involved 937 adolescents (504 boys and 433 girls) with diseases of the upper digestive tract aged from 10 to 18 (table 1). Clinical, laboratory and instrumental studies were conducted at the SI “Institute of Children and Adolescents Health Care of the NAMS of Ukraine”.
Diagnoses of diseases were verified on the basis of anamnestic information, clinical, laboratory and instrumental examination (esophagogastroduodenoscopy, intragastric pH-metry, H. pylori DNA by the PCR method in feces). Statistical analysis of the results was performed with the help of Microsoft Excel 2000 and software packa–ges Statistica 8.0. The statistical analysis was carried out using the paired and unpaired t-test.
All patients with diseases of the upper digestive tract were divided into groups that were comparable in terms of gender and age, depending on the nosological form (table 1). The group of inflammatory lesions of the upper digestive tract included patients with functional gastro–pathy*, chronic gastritis, chronic gastroduodenitis and gastroesophageal reflux disease. Adolescents with erosive gastritis, erosive duodenitis, erosive esophagitis, gastric and duodenum ulcer were included in the group of patients with destructive lesions of the upper digestive tract.
Note: * — morphological studies of many gastroente–rologists have identified the signs of inflammation in children and adults with so-called “functional dyspepsia” [2, 4–8, 13].

Results and discussion

There are a number of similar clinical symptoms in adolescents with pathology of the upper digestive tract. The analysis of complaints, anamnesis and indicators of physical examination of adolescents with gastroduodenal pathology did not reveal significant differences depen–ding on the age of patients, as this is largely determined by the nature of the lesion. In this regard, we have conducted an analysis of clinical and anamnestic indicators depending on gender. The results of clinical and anamnestic examination of patients with destructive and inflammatory lesions (IL) are given in table 2.
The analysis of clinical and anamnestic examination revealed that a positive family history of gastroduodenal pathology in patients with destructive lesions of the upper digestive tract is determined significantly more often than in patients with inflammatory lesions (р < 0.05).
The pain syndrome in half of the patients with erosive and ulcerative lesions arose in the evening and at night and was characterized by the “classic” symptoms: hunger — pain — food — relief — hunger — pain etc.; nocturnal pain was significantly more prevalent in patients with destructive lesions (65 %) than in patients with inflammatory changes (33 %) (р < 0.05). An abdominal pain in patients with erosive-ulcerative lesions was limited and localized in 94 % of patients in the epigastrium. If dyskinetic and inflammatory disorders of the biliary system added, 48 % of patients complained about pain in the right hypochondrium. A pain syndrome that occurs after eating or independently of it was determined significantly more often in patients with inflammatory lesions of the upper digestive tract (р < 0.05). A heartburn was significantly more prevalent in patients with erosive-ulcerative lesions (≈ 50 %) than in one third of patients with inflammatory chan–ges (р < 0.05).
A physical examination revealed that a painfulness during palpation in the epigastric region was noted more often (96 %) in patients with destructive lesions, half of these adolescents had local muscular tension. A painfulness during palpation in the epigastric region was also leading symptom in patients with inflammatory dise–ases of the upper digestive tract (85 %), however, local muscular tension was not detected in any patient. Painful sensations during palpation in the right and left hypochondrium were determined with equal frequency in boys and girls, regardless of the nature of the pathology of the upper digestive tract. 
Thus, the nature of pain and dyspeptic syndromes and the physical examination don't allow to assess the nature of pathological changes in digestive organs objectively in adolescents. Therefore, it is assumed to use available and adequate method of research — esophagogastroduodenoscopy, which results are shown in table 3. 
The analysis of endoscopic signs of lesions of the upper digestive tract in adolescents allowed to draw a conclusion about the absolute predominance of nondestructive inflammatory injuries of the upper digestive tract. Erythematous gastropathy and gastroduodenopathy were detected in 56–57 % of girls, regardless of age. Erythematous changes in the gastric and duodenum in boys were less common and detected in 44 % in the 10–14 age group and in 34 % in the 15–18 age group. 
Congestive gastroduodenopathy and lymphoid hyperplasia of the gastric mucosa were 2 times more common in girls (p < 0.05), regardless of age.
Erosive lesions of the mucous membrane of the gastric and duodenum were detected in 5.6 ± 2.0 % of girls in the 10–14 age group and in 8.5 ± 2.0 % of girls in the 15–18 age group. Erosive lesions of the mucous membrane of the gastric and duodenum were more common in boys: in 9 ± 2 % of boys in the 10–14 age group and in 12 ± 2 % of boys in the 15–18 age group. Ulcer and/or deformity of duodenal bulb were detected in both age groups among girls with the same frequency 3.0–5.6 %, in 2 ± 2 % of boys in the 10–14 age group and in 7 ± 2 % of boys in the 15–18 age group (р < 0.05).
Gastric polyp was found in 5 girls and 2 boys in the 15–18 age group. Atrophic changes of the mucous membrane of the gastric were identified in 1 girl and 1 boy in the older age group. 
Erythema in the lower third of the esophagus was identified in 21 ± 3 % of girls in the 10–14 age group and was identified significantly less frequent in the 15–18 age group 15 ± 3 %, р < 0.05. Esophagitis in girls was extremely rare (1.7–1.5 %), regardless of age. Erythema in the lower third of the esophagus was determined significantly less frequent in boys 13 ± 2 % than in girls in the 10–14 age group, but its frequency increased 2 times to 15–18 years. Inflammatory changes in the esophagus among boys in the 10–14 age group were identified only in 2 patients 0.8 ± 2.0 % and their frequency increased 10 times to 15–18 years. Erosive lesions of the esophagus were detected in 4 girls, the Barrett’s esophagus was diagnosed in 1 boy. Insufficiency of the gastric cardia was detected in 4 boys. 
Such form of motility disorders of the upper gastrointestinal tract as duodenogastric reflux (DGR) was more often observed in girls in both age groups — 37–42 %, than in boys — 23–37 %, p < 0.05. Isolated gastroesopha–geal reflux (GER) was determined extremely rarely, regardless of gender, its frequency decreased with age. The combination of DGR and GER was found in 4–6 % of patients, regardless of gender and age.
The analysis of the acid-forming function showed that, regardless of age, the basal gastric hyperacidity was more often determined in boys (in 75 ± 3 % of patients with erosive and ulcerative lesions and in 62 ± 3 % of patients with inflammatory lesions, p > 0.05). Gastric normacidity was determined significantly more often in girls — 60 ± 3 %, regardless of the age and nature of the lesions of the upper digestive tract.
The presence of Helicobacter pylori in feces was determined by PCR method. A positive reaction was determined in 2/3 of the patients: in 70 ± 3 % of boys and in 64 ± 3 % of girls. These figures were higher among adolescents in the younger age group (boys — 74 ± 3 %, girls — 70 ± 3 %). This was confirmed by the presence of lymphoid hyperplasia of the gastric mucosa in a larger number of patients in younger age group. 

Conclusions

The analysis of clinical and endoscopic studies of the pathology of the upper digestive tract in children and adolescents has led to the following conclusions:
1. An objective differential diagnosis between inflammatory and destructive lesions of the upper digestive tract in childhood and adolescence is only possible with the use of esophagogastroduodenoscopy.
2. Inflammatory lesions predominate among lesions of the upper digestive tract in childhood and adolescence. Erosive-ulcerative lesions occur in 8–10 % of patients in the 10–14 age group, and their frequency increases 2 times in boys and 1.5 times in girls in the 15–18 age group. 
3. Motility disorders of the upper digestive tract are determined in 1/3 of the patients in prepubertal and pubertal age, more often in girls. 
4. Regardless of age, in boys the basal gastric hyperacidity is determined significantly more often and basal gastric normacidity is more common in girls with the pathology of the upper digestive tract.
5. Helicobacter pylori infection is detected in 2/3 of adolescents with pathology of the upper digestive tract, more often in the 10–14 age group.
The analysis of clinical and endoscopic features of the pathology of the upper digestive tract revealed that inflammatory lesions predominate among lesions of the upper digestive tract in prepubertal and pubertal age. Destructive lesions of the upper digestive tract in the 10–14 age group make up about 10 % of the entire gastroduodenal pathology, and up to the age of 18 years their frequency increases 1.5–2 times. The dominance of hyperacidity in boys and motility disorders of the upper digestive tract in girls allows us to assume that they are leading factors in the progression of gastroduodenal pathology. It should also be taken into account for carrying out etiotropic treatment and primary prevention, that Helicobacter pylori infection more often starts in the prepubertal age group. The results obtained in the course of the study can provide a basis for choosing the priority directions in pathogenetic therapy of diseases of the upper digestive tract.
Conflict of interests. Authors declare the absence of conflict of interests.

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