Introduction Gastric outlet obstruction (GOO) is a common entity in infancy, caused primarily by idiopathic hypertrophic pyloric stenosis. In the paediatric/adolescent population GOO is rare, however the exact figures are unknown. While H. pylori is well documented as a cause of GOO in the adult population, only two paediatric cases have been published in the literature to date.

Aim The aim of this case report is to raise awareness that insufficiently treated peptic ulcer disease secondary to H. pylori can lead to GOO in paediatric patients.

Subject and Methods We present the case of a 13-year-old girl who attended A&E with a 12-hour history of sudden onset and progressive upper abdominal pain associated with severe nausea and vomiting. On examination she had a rigid, distended abdomen, generalised tenderness and guarding in the epigastric region.

She had recently moved to the UK from Nigeria, where she had been diagnosed with peptic ulcer disease secondary to H. pylori infection following a three year history of extreme weight loss, reduced oral intake and post-prandial vomiting. She underwent a series of psychological interventions due to concerns she was suffering from an eating disorder, until she tested positive for H. pylori in June 2021. She was prescribed a two-week course of omeprazole and an unknown antibiotic, which she completed. Following this treatment her symptoms resolved and she started to regain weight, however she experienced gradually increasing abdominal distension in the months leading up to her presentation to A&E.

Results An abdominal X-ray in A&E showed possible bowel obstruction. This was followed by a contrast study which illustrated almost complete GOO. On upper GI endoscopy the stomach was found to be very dilated with inflamed erythematous mucosa, and the pylorus was almost completely obstructed by a very hypertrophied, friable mucosa. Attempts to cannulate the pylorus were unsuccessful. The CLO test was positive. The diagnosis made was of GOO secondary to H. pylori peptic ulcer disease.

The patient was kept nil-by-mouth, receiving parental nutrition (PN) via PICC line and was prescribed triple therapy for H. pylori eradication.

A repeated barium study nine days after the first showed some improvement, with the stomach emptying small amounts of contrast. A repeated endoscopy revealed a small opening through the pylorus and the endoscope was passed into duodenum, which had a normal appearance. Unfortunately a guided wire NJ placement was unsuccessful and she continues to receive PN with minimal oral fluids.

Summary The case study describes one of the very few paediatric cases of GOO secondary to H. pylori infection.

Conclusion Although rare, GOO should be included in the differential diagnosis of older children with non-bilious vomiting and failure to thrive.¹ Radiological tests are important tools in the diagnosis but, in the case of H. pylori infection, endoscopy and CLO testing are essential² as can lead to medical treatment and resolution of symptoms without the need for surgical intervention.

References

1. Yen JB, Kong MS. Gastric outlet obstruction in pediatric patients. Chang Gung Med J 2006 Jul-Aug;29(4):401–5. PMID: 17051838.

2. Otjen JP, Iyer RS, Phillips GS, Parisi MT. Usual and unusual causes of pediatric gastric outlet obstruction. Pediatr Radiol 2012 Jun;42(6):728–37. PMID: 22457062.