A Case of Small Bowel Ulcer Associated with Helicobacter pylori
11-year-old girl\nEpigastric pain and nonbilous vomiting\nAn 11-year-old girl presented with a history of stabbing epigastric pain every 10 minutes and nonbilous vomiting more than 10 times a day. She did not have fever or diarrhea.\nShe had undergone a gastrotomy and removal of an 8 cm trichobezoar 6 years previously. She ate hair on the floor at that time habitually. She had not been administered medication during the past 3 months.\nShe was 140 cm (25-50th percentile) in height and 34 kg (25-50th percentile) in weight, and her vital signs were: blood pressure, 100/60 mmHg; pulse, 88 beats per minute; respiratory rate, 20 breaths per minute; and temperature, 36.2℃. On admission, she had a clear mental status but seemed acutely ill. Neither conjunctiva were pale, and both sclera were icteric. Respiratory and heart sounds were normal. Abdominal distention was not observed, but bowel sounds were mildly activated. She complained of severe tenderness in the epigastric area with no rebound tenderness. No hepatosplenomegaly or other abdominal mass was detected on abdominal palpation. There was no patchy baldness or abnormalities of the skin or mucosa.\nOn admission, initial laboratory tests showed hemoglobin, 13.2 g/dL; hematocrit, 38.3%; white blood cell count, 13,260/mm3 (neutrophils 88.5%); platelet count, 272,000/mm3; erythrocyte sedimentation rate, 9 mm/hr; and C-reactive protein, 1.6 mg/L. The biochemical profile consisted of serum protein, 6.7 g/dL; albumin, 4.7 g/dL; total bilirubin, 0.5 mg/dL; direct bilirubin, 0.2 mg/dL; aspartate aminotransferase, 17 IU/L; alanine aminotransferase, 11 IU/L; blood urea nitrogen, 6.8 mg/dL; creatinine, 0.5 mg/dL; and amylase, 55 U/mL. A blood coagulation test showed a prothrombin time-internationalized normal ratio, 1.17; and activated partial thromboplastin time, 27.0 sec. Urine analysis showed specific gravity, 1.025; pH, 6.0; negative for protein, glucose, blood, urobilinogen, bilirubin, and nitrite, but positive for ketone bodies. No white blood cells or red blood cells were observed in the urine.\nA simple abdominal X-ray was unremarkable at admission. Abdominal computed tomography (CT) revealed a 4 cm sized low attenuating mass-like lesion in the stomach (). We performed esophagogastroduodenoscopy (EGD) for identifying a recurrence of trichobezoar (). Mucosal erythema was observed in the gastric antrum, but no ulcerative lesions were found in the stomach. A scar, which was considered a gastrotomy suture line, and a duodenal bulb with structural deformity were noted. We suspected transition of the mass below the stomach, so we inserted a longer endoscopic fiber using a CF-Q260AL (Olympus, Tokyo, Japan). We inserted the fiber 60 cm from the incisor without kinking and approached the proximal jejunum. We found multiple longitudinal ulcerative lesions from the duodenal bulb to the proximal jejunum, although there was no trichobezoar or mass causing a mechanical bowel obstruction. We performed a small bowel series after marking the endoscopic approach level using clips () and found normal contrast transition without obstruction or abnormal findings near the mass. Partial hypertrophy of the bowel mucosal fold was noted, but no abnormality was found in the ileocecal portion. The rapid urease test in the duodenal bulb was negative.\nChronic inflammation with lymphoid follicles was noted on pathological examination of the ulcerative lesion ().\nSerum gastrin level and the autoimmune antibody test were performed to determine the cause for the small bowel ulcer. The laboratory findings showed serum gastrin, 57.0 pg/mL; negative anti-neutrophil cytoplasm antibodies and anti-Saccaromyces cerevisiae antibodies; and negative Tb-polymerase chain reaction of the bowel mucosa tissue. The patient received lansoprazole (15 mg/dose, twice a day). On the day of discharge, 4 days after admission, the epigastric pain improved, and she returned to a normal diet. After discharge, she received H. pylori eradication therapy, including lansoprazole (15 mg/dose, twice per day), amoxicillin (50 mg/kg/day in two divided doses), and clarithromycin (30 mg/kg/day in two divided doses) for 2 weeks. She took additional lansoprazole (15 mg/dose, once per day) for 4 weeks, subsequently. Eight weeks after stopping the medication, the urea breath test was negative. The patient has not had any specific symptoms for 18 months.