To the Editors:
In a recent issue of your journal, Hyams et al. (1) described their results of a prospective study on childhood dyspepsia. According to their study, 127 children and adolescents, 5 to 19 years of age, fulfilled the criteria of dyspepsia. Before laboratory evaluation, 33 patients (26%) fit the diagnostic criteria of ulcer like dyspepsia, 19 (15%) fit the criteria of dysmotility-like dyspepsia, 9 (7%) fit the criteria for both, and 66 (52%) did not fit the criteria for either condition. After esophagogastroduodenoscopy and biopsy, which was performed in 56 patients, the authors finally found 21 patients (38%) with mucosal inflammation (Helicobacter pylori in 5 patients). The remaining 35 patients (62%) were considered to have functional dyspepsia. Although they did not use a standard protocol of therapy, they noted that 70% of children with functional dyspepsia were either asymptomatic or much improved (only occasional symptoms) after some treatment.
We would like to report our results of a prospective study on childhood dyspepsia and to stress the similarities and differences of our study with that by Hyams et al. (1). During the last 4 years (June 1996–September 2000), we studied 476 children (242 male, 234 female) between 4 and 14 years of age (mean age, 9.7 years) with recurrent abdominal pain that met the criteria of Apley and Naish (2). After clinical and laboratory evaluation (3,4), we found 293 children who met the criteria of dyspepsia (3–5). Children with symptoms of or suspected of having gastroesophageal reflux disease or irritable bowel syndrome were excluded from the study. The most frequent symptoms of dyspepsia in our patients were epigastric or periumbilical pain; nausea, vomiting, or both; early satiety; postprandial fullness; and increased belching. In agreement with Hyams et al. (1), we found it difficult to divide our patients in strictly separated subgroups (ulcer-like, dysmotility-like dyspepsia) because they had too many symptoms in common. Endoscopy and biopsy was performed in 143 children, with 99 having normal findings (68%), and these patients were considered to have functional dyspepsia. Furthermore, we found 18 additional patients (12.5%) having superficial or interstitial inflammation of the gastrointestinal tract, and these children could also be considered to have functional dyspepsia (6,7). We did not note any difference in the prevalence of Helicobacter pylori in children with recurrent abdominal pain compared with control participants (13% vs. 11%). In contrast to Hyams et al. (1), in our study we used a standard protocol for treatment of functional dyspepsia (cisapride when we thought the predominant symptoms were of dysmotility-like dyspepsia, but ranitidine or omeprazole when we thought the predominant symptoms were of ulcer-like dyspepsia). We noted a better outcome in the group given cisapride, with children becoming either asymptomatic or much improved (76%–83%) than in the group given ranitidine (66%–67%).
Notably, children and their parents did not mention any symptoms of dyspepsia (e.g., bloating, belching, early satiety, postprandial fullness, etc.) unless they were directly asked during history taking. Thus, an explicit inquiry should be made about these symptoms. We believe that pediatricians must be familiar with this condition to ask such questions.
Although the references regarding dyspepsia in children are limited, it appears that dyspepsia represents a common situation (60%–80%) under the broad spectrum of recurrent abdominal pain. Until more data are available regarding clinical manifestations, evaluation, and therapy of functional dyspepsia, pediatricians must be familiar with this condition and carefully look for it in children with recurrent abdominal pain. Recognition is quite easy with only gross laboratory evaluation to exclude other pathologic conditions (e.g., renal or pancreas diseases). Therapy with promotility or gastric acid-reducing agents has a good response in these children. We also believe (5) that upper gastrointestinal endoscopy is not necessary as a first-level evaluation in most cases of recurrent abdominal pain, because the more severe organic reasons of dyspepsia in adults (gastroesophageal reflux disease, ulcer disease, and tumor) are rather rare (ulcer, gastroesophageal reflux disease) or nonexistent (tumors) in childhood. Our suggestion is based on the low prevalence of these diseases seen also in our population and is in accordance with the opinion of Hyams et al. Children with functional dyspepsia can be treated empirically according to the prominent symptoms using either promotility or acid-reducing drugs and be reevaluated after 4 weeks. We suggest that esophagogastroduodenoscopy should be reserved only as a second-level evaluation in case of a treatment failure or existence of an organic disease suggestive symptoms such as persistent vomiting or hematemesis.
1. Hyams JS, Davis P, Sylvester FA, et al. Dyspepsia in children and adolescents: A prospective study. J Pediatr Gastroenterol Nutr. 2000; 30: 413–8.
2. Apley J, Naish N. Recurrent abdominal pains: A field survey of 1000 schoolchildren. Arch Dis Child. 1958; 33: 165–70.
3. Spiroglou K, Paroutoglou G. Dyspepsia in children. A real problem. Hell J Gastroenterol. 1999; 12: 87–95.
4. Czinn SJ. Dyspepsia in children. J Pediatr Gastroenterol Nutr. 1993; 17: 237–8.
5. Spiroglou K, Paroutoglou G, Nikolaides N, et al. Management and treatment of children with dyspepsia. Initial endoscopy or empirical therapy with or without testing for Helicobacter pylori? Hell J Gastroenterol. 1998; 11: 36–41.
6. Whitehead R, Treulove SC, Gear MWL. The histologic diagnosis of chronic gastritis in fiberoptic gastroscopy biopsy specimens. J Clin Pathol. 1972; 25: 1–11.
7. Black DB, Haggitt RC, Whitington PFQ. Gastroduodenal endoscopic-histologic correlation in pediatric patients. J Pediatr Gastroenterol Nutr. 1988; 7: 353–8.