Peptic ulcer disease in the pediatric population is relatively uncommon with an annual incidence of approximately 5.4 per 100.00 [5]. Peptic ulcer disease can be divided as primary or secondary. Helicobacter pylori is one of the most common causes for primary PUD. Secondary ulcers are precipitated by physiological stress, severe burns (Curling’s ulcer), raised intracranial pressure (Cushing’s ulcer), drugs (steroids, nonsteroidal anti-inflammatory drugs), and other severe illnesses (gastroenteritis, shock, malaria, sepsis, or cancer) [1,2].
Complications such as perforations and hemorrhage, like the one seen in patients with severe malaria are more common in patients with secondary PUD and should be treated as emergencies. However, these are often missed or not considered in the differential diagnoses of acute abdomen. Either because the condition itself and the complications are very rare or because gastrointestinal symptoms like dyspepsia, vomiting, diarrhea, hepatitis, gastrointestinal bleed, abdominal pain, subacute intestinal obstruction like symptoms or acute abdomen are already common presentations in patients with acute malaria [1-3,7,8].
A retrospective study with a sample of 52 patients done by Hau et al. found that duodenal peptic ulcers (79%) are more common than gastric ulcers 21%. Duodenal perforations in children associated with malaria have been described by. Goldman, Bhandari and Dewanda. We found No cases of gastric perforation associated with malaria in Portuguese and English literature [2,6-8]. The exact mechanism for bowel perforation in patients with malaria is not well known and the cause maybe multifactorial. Some risk factors have been associated with duodenal perforation. Physiological stress caused by inflammatory substances, severe dehydration, microvasculature changes are thought to be involved in the pathophysiologic mechanism of bowel perforation associated with malaria [3,8]. Some of those factors may also be implicated in the mechanism for gastric perforation associated with malaria.
One of the proposed mechanisms that may be involved in bowel perforation in patients with malaria is ischemia that can be caused by: sequestration of RBCs in the microvasculature leading to microvascular changes or a severe dehydration and shock associated with acute diarrhea. Severe acute bowel ischemia will then lead to bowel perforation [2,8]. Inflammatory mediators like tumor necrosis factor, and free oxygen radicals, which have been implicated as causative factors in diarrhea and intestinal bleeding seen in malaria may also have a role in the etiology of PDU [3].The other causative factors working alone or in combination may be stress of acute severe illness, severe anemia and oral NSAIDs intake for pain or fever control in patient with acute malaria [3].
