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

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.


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 UDK 616.33/.342-053.6-055.12-055.25 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 gastropathy*, 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.

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 depending 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 changes (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 diseases 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 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 gastroesophageal reflux (GER) was determined extremely rarely, regardless of gender, its frequency decreased with age.The

Notes: * -the significant differences between boys and girls (р < 0.05); ** -the significant differences between patients with inflammatory and destructive lesions of gastroduodenal zone (р < 0.05).
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.

Clinical and endoscopic features of the upper digestive tract pathology in children and adolescents depending on age
[1,5,tute for Children and Adolescents Health Care of the NAMS of Ukraine", Kharkiv, Ukraine 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].
For cite: Zdorov'yeRebenka.2017;12(8):895-899. doi: 10.22141/2224-0551.12.8.2017.119245Abstract.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: inflammatory diseases of the upper digestive tract; peptic ulcer disease; children; adolescents; esophagogastroduodenoscopy; Helicobacter pylori endogenous aggressive influences.