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Gastroesophageal Reflux (GER)

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Elaine Porter, MD Pediatric Resident, PGY-2 Children s Hospital of the King s Daughters Esophagitis Barrett's esophagus (Extremely rare in pediatrics – PowerPoint PPT presentation

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Title: Gastroesophageal Reflux (GER)


1
Gastroesophageal Reflux (GER)
  • Elaine Porter, MD
  • Pediatric Resident, PGY-2
  • Childrens Hospital of the Kings Daughters

2
Definitions
  • GER Passage of gastric contents into the
    esophagus, a normal physiologic process in
    healthy infants, children, and adults but may
    cause distress for caregivers or patients.
  • Gastroesophageal reflux disease (GERD) Passage
    of gastric contents into the esophagus that
    results in troublesome symptoms or complications
    for the infant, child, or adolescent, and not for
    the caregiver alone.
  • (PIR 201233243)

3
Definitions
  • Regurgitation Commonly referred to as spitting
    up, is the effortless passage of gastric
    contents into the pharynx or mouth.
  • Vomiting The forceful expulsion of the gastric
    contents while rumination is voluntary,
    habitual, and effortless regurgitation of
    recently ingested food.
  • (PIR 201233243)

4
Objectives
  • Understand other diseases and conditions that may
    mimic GERD.
  • Understand methods of diagnosing GERD.
  • Describe therapeutic options for the treatment of
    GERD (including lifestyle modifications, medical
    therapies, and surgical therapies).

5
Case 1
  • M.G. - 6 week old female infant, ex 34 week
    premie presents in clinic for f/u of spitting up
    with every feed.
  • Frequent burps and upright position after feeds.
  • Exclusively BF until a day ago, started Neosure
    22 - decrease milk supply.
  • No BM x 2 days, slightly distended abdomen.
  • Growth parameters within normal limits. Mom wants
    to know if she should switch formula and if her
    baby will get better.
  • Without further history at this point what
    information would you convey to mom?

6
Case 1
  • BHx - maternal preeclampsia, HELLP, prior HSV
    lesions, GBS , adequately treated. Stable on
    discharge after a relatively benign course in
    Level 2 nursery.
  • Diagnosed with NEC after presenting to clinic
    with bloody stools at 2 weeks of life admitted,
    NPO status, triple antibiotic.
  • D/c in stable condition with f/u in clinic. First
    f/u a week ago infant with adequate weight gain
    despite spitting up with feeds.
  • Given further history would you recommend any
    further testing for infant?

7
Epidemiology
  • 50 of infants lt 3 months of age and 67 of
    infants at 4 months of age will have at least one
    episode of regurgitation daily.
  • By 12 months of age, however, only 5 experience
    episodes of regurgitation.
  • Uncomplicated reflux reassurance by PCP
  • Referral to a pediatric GI is recommended if
    symptoms gt 12 to 18 months of age

8
Etiology
  • Transient relaxation of the lower esophageal
    sphincter (LES).
  • Gastric distention associated with large volume
    feeds (100150 mL/kg per day) causes more
    frequent transient LES relaxation.
  • Delayed Gastric emptying.
  • In neurologically impaired children, decreased
    basal LES tone.

9
(No Transcript)
10
Signs and Symptoms - GI
  • Infants
  • Regurgitation or spitting up
  • Happy spitters benign physiologic GER
  • Hematemesis
  • Feeding difficulties
  • Arching of the back/irritability
  • Children
  • Heartburn
  • Dysphagia
  • Chest pain
  • Hematemesis
  • Feeding difficulties
  • Regurgitation
  • Vomiting

11
Signs and Symptoms - Extraintestinal
  • Infants
  • Failure to thrive
  • Wheezing
  • Stridor
  • Persistent cough
  • Apnea/ALTE
  • Irritability
  • Sandifer syndrome
  • Children
  • Persistent cough
  • Wheezing
  • Laryngitis
  • Stridor
  • Chronic asthma
  • Recurrent pneumonia
  • Dental erosions
  • Anemia

12
Supraesophageal manifestations of GER
http//www.gastroscan.ru
13
Categorization of symptoms
14
Worrisome signs and symptoms
  • Bilious emesis
  • GI bleeding
  • FTT
  • Forceful or projectile vomiting
  • Emesis beginning after 6 months of age
  • Difficulty swallowing
  • h/o food allergies
  • Fever
  • Diarrhea/constipation
  • Abdominal pain
  • Hepatosplenomegaly
  • Lethargy
  • Bulging fontanelle
  • Anxiety or disordered eating
  • Suspicion of genetic or metabolic disease

15
Non reflux causes of vomiting
  • Infections sepsis, meningitis, UTI
  • Anatomic obstruction - FB, pyloric stenosis,
    malrotation, intussusception
  • GI esophagitis, achalasia, gastroparesis, IBD
  • Neurologic ICP, migraine
  • Respiratory pneumonia
  • Renal obstructive uropathy, renal insufficiency
  • Cardiac CHF
  • Oncology lymphoma, other solid tumors
  • Psychologic/Behavioral overfeeding, rumination

16
Differential Diagnosis
17
Differential Diagnosis
18
A. Normal Esophagus
B. Severe Peptic esophagitis
19
A. Erosive esophagitis severe erythema and
edema with linear ulcerations, associated with
chronic GERD. B. Eosinophilic esophagitis
white plaques, linear ridging, and
trachealization of the esophagus consistent with
eosinophilic esophagitis.
20
Infectious esophagitis C. (Candida) white
plaques consistent with candidal esophagitis in a
patient with Crohn disease. D. (Herpes simplex
Virus) severe ulcerations consistent with herpes
simplex virus infection.
21
Barretts esophagus
22
Histological progression of untreated reflux
Barretts epithelium
Esophagitis
Normal epithelium
23
Diagnostic Studies
  • Empiric trial of acid suppression
  • PPI - 4 week trial suggested, 2 weeks
    insufficient
  • Barium contrast radiography
  • Anatomic abnormalities
  • Mimickers Webs, strictures, achalasia, hiatal
    hernia, gastric outlet obstruction (Antral web,
    pyloric stenosis)

24
  • Esophageal stricture. Upper GI series
    demonstrating a tapered circumferential mid and
    lower esophageal stricture.

25
  • Achalasia. Proximal esophageal dilation and
    birds
  • beak appearance suggestive of achalasia.

26
Radiograph of a Sliding hiatal hernia. The
lower esophageal sphincter (arrow) and a pouch of
stomach have herniated through the diaphragmatic
hiatus (arrowhead)
27
Diagnostic Studies
  • Esophageal pH monitoring
  • Trans - nasal catheter with one or more probes
  • Monitors frequency and duration of acidic
    esophageal reflux episodes
  • Associated with pH lt 4.0
  • Measures total episodes and number of episodes
    lasting gt 5 minutes, duration of longest episodes
  • Monitors efficacy of acid suppression
  • Limitations
  • Infants who feed q2-4 hours, feedings may buffer
    gastric acidity

28
Diagnostic Studies
  • Combined multiple intraluminal impedance and pH
    monitoring (MII)
  • Measures air, fluids, and solids in esophagus
  • Detects acid and non-acid reflux
  • Distinguishes between antegrade (swallowed) and
    retrograde (regurgitated) boluses
  • Benefits Can be used while patient on acid
    suppression

29
Diagnostic Studies
  • Esophageal manometry
  • Assesses peristalsis and U/LE sphincters
  • Motility disorders
  • Limitations Does not detect reflux (acid or
    non-acid)
  • Scintigraphy (GES)
  • Labels food with 99-technitium
  • May identify reflux and aspiration (Sensitivity
    15 59) (Specificity 83 - 100)
  • Not recommended to diagnose or manage reflux in
    infants and children

30
Diagnostic Studies
31
Reflux patterns by pH probe
32
Reflux patterns by pH probe
33
Prognosis of GER
  • Most uncomplicated GER will be out - growned by
    7 12 months of age
  • Children with neurological impairment, obesity,
    interstitial lung disease, anatomic GI
    abnormalities, malrotation, hiatal hernia,
    prematurity higher risk of GERD and its
    complications

34
Complications of GER
  • Esophagitis
  • Barrett's esophagus (Extremely rare in pediatrics
    lt 0.25)
  • Esophageal Strictures (rare 5)
  • Adenocarcinoma
  • Associated frequently with asthma in pediatric
    population
  • Aspiration of gastric contents leads to
    hyper-responsiveness and inflammation
  • Decreased LES tone from increased intra-thoracic
    pressure
  • Hoarseness and chronic cough
  • Dental caries
  • ALTEs

35
Treatment of GER
  • Thicken formula (1 tbsp per 2 oz)
  • Antiregurgitant formulas have not been proven to
    decrease regurgitation compared with thickened
    feeds
  • Changing the type of formula does not positively
    affect GER symptoms
  • Prone positioning decreases the number of
    regurgitation events, however supine to sleep
  • Lifestyle changes in children and adolescents
  • Transpyloric feeding

36
Pharmacological Treatment
  • Antacids - act within minutes to buffer acids
  • Administer caution with aluminum containing
    products (osteopenia, rickets, microcytic anemia,
    neurotoxicity)
  • Histamine 2 receptor antagonist (H2RAs)
  • Decrease acid production by biding to H2 receptor
    on parietal cells
  • Used to heal esophagitis and reduce symptoms of
    GERD
  • Proton pump inhibtors
  • Suppress gastric acid irreversibly by blocking
    H/K ATPase
  • Not approved for children lt 12 months
  • Generally safe, 12 - 14 have idiosyncratic
    reactions headache, diarrhea, constipation,
    nausea
  • Drug induced hypergastremia may occur
  • Abnormal intestinal bacterial overgrowth (Candida
    in neonates, higher incidence of NEC)

37
Pharmacological Treatment
  • Pro-kinetic agents
  • Bethanechol, baclofen, domperidone (potential
    adverse effects)
  • Metoclopramide
  • Reactions dystonic reactions, gynecomastia,
    permanent tardive dyskinesia
  • Erythromicin
  • Prolonged QT interval
  • Pyloric stenosis
  • Surface agents
  • Sucralfate (Sucrose, sulfate, aluminum)

38
Surgical Treatment
  • Nissen Fundoplication
  • Increases LES and increases intra-abdominal
    length of the esophagus
  • Up to 10 of children will have complications
  • Up to 10 will require surgical revision

39
Potential causes of treatment failure
40
medscape
41
Review of Case 1
  • M.G. - 6 week old female infant, ex 34 week
    spitting up with every feed.
  • Exclusively BF until a day ago, started Neosure
    22 - decrease milk supply.
  • H/o NEC, no BM x 2 days, slightly distended
    abdomen.
  • Growth parameters within normal limits. Mom wants
    to know if she should switch formula and if her
    baby will get better.

42
References
  • Gastroesophageal Reflux
  • Gastroesophageal Reflux, Pediatrics in Review
    201233243, Jillian S. Sullivan and Shikha S.
    Sundaram
  • Gastroesophageal Reflux, Pediatrics in Review
    199213174, Susan R. Orenstein
  • Gastroesophageal Reflux, Pediatrics in Review
    March 2007 28101-110 doi10.1542/pir.28-3-101,
    Sonia Michail
  • Focus on Diagnosis New Technologies for the
    Diagnosis of Gastroesophageal Reflux Disease,
    Pediatrics in Review 200829317, Jason E.
    Dranove,
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