Refractory eosinophilic duodenal bulb ulcer associated with Helicobacter pylori eradication in children: a multicenter study

Abstract Refractory eosinophilic duodenal bulb ulcers (REDU) following Helicobacter pylori (HP) eradication are rarely reported. This study aimed to investigate REDU in pediatric populations post-HP eradication. This multicenter retrospective analysis included children admitted to the Gastroenterology Departments of three children’s hospitals between January 1, 2016, and August 31, 2025. Eligible cases were pediatric patients diagnosed with REDU across the three centers. For the REDU group, clinical characteristics, laboratory tests, endoscopic findings, HP treatment strategies, and follow-up data were analyzed. Thirty patients (mean age 10.0 ± 3.4 years) were diagnosed with REDU, including 19 with HP eradication-related REDU and 11 with idiopathic REDU. Compared with HP-associated duodenal bulb ulcer (DBU) control group, the HP eradication-related REDU group had higher rates of anemia, elevated peripheral blood eosinophils (EOS) count, endoscopic giant DBU, bulbar stenosis, repeated endoscopies, and HP eradication therapies (all P < 0.01). REDU patients presented with punched-out DBU featuring a clean, thin white base; 76.7% (23/30) of REDU patients had giant DBU. Before treatment, among the entire REDU cohort, EOS counts 100 cells/HPF were noted in 17 cases (56.7%), while counts ≥ 50 cells/HPF were observed in 13 cases (43.3%). Serum cytokine assay showed that IL-8 was significantly elevated. All patients were treated with dietary avoidance and proton pump inhibitor (PPI) therapy. Recurrence was common, occurring in 9 of 16 patients (56.2%) following PPI dose reduction or discontinuation, with a median interval of 50.0 [35.0, 120.0] days. HP eradication may be associated with REDU in children via eosinophilic infiltration, emphasizing the need for systematic monitoring of immune-related complications post-eradication.