Peptic disease and Helicobacter pylori — formative SAQs

SAQ 1 (10)

An 11-year-old girl presents with three months of epigastric pain that sometimes wakes her at night, and one episode of black stool. Her father had a duodenal ulcer. She is growing normally but looks slightly pale. ^{[1] [10]}

1. State which alarm features are present and how they change your investigation plan. (3) ^[1]
2. Explain why you would not use a non-invasive test-and-treat strategy for H. pylori in this child. (3) ^{[1] [2]}
3. Outline how you would diagnose H. pylori at endoscopy and what tissue you would send. (4) ^{[1] [5]}

Model answer

Alarm features and plan. Nocturnal pain, a possible gastrointestinal bleed (melaena), pallor suggesting anaemia, and a first-degree family history of ulcer are all alarm features. Their presence moves this child to prompt upper gastrointestinal endoscopy with biopsy rather than empiric treatment or reassurance, alongside a full blood count and iron studies. ^{[1] [10]}

Why not test-and-treat. In children, unlike adults, a non-invasive test-and-treat strategy is explicitly not recommended. Most infected children never ulcerate, so a positive breath or stool test does not establish that H. pylori is causing the symptoms. Committing a child to antibiotics on a non-invasive test risks over-treatment, misses the true diagnosis, and forgoes susceptibility information. ^{[1] [2]}

Endoscopic diagnosis and tissue. Upper endoscopy allows direct visualisation of an ulcer and gastritis. Take antral and corpus biopsies for histology and a rapid urease test, and send tissue for culture and antibiotic susceptibility testing or molecular resistance testing. A reliable diagnosis needs a positive culture, or positive histology plus a positive rapid urease test, so a single false-positive does not commit the child to treatment. ^{[1] [5]}