Gastroesophageal Reflux Smt VI 2011

7/29/2019 Gastroesophageal Reflux Smt VI 2011

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Difinition : Gastro Esophageal Reflux

(GER) vs Gastro Esophageal Reflux

Disease (GERD)

Clinical manifestations

Diagnostic approach

Treatment (conservative,pharmacological)


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Regurgitation : involuntary or passive,

effortless reflux through mouth e.g GER

Vomiting : forceful retrograde expulsion of

gastric contents e.g. pylorus stenosis Rumination : voluntary through mouth with

rechewing or reswallowing

Nausea : sick feeling (subjective) before

vomiting with autonomic symptoms e.g.chemotherapy


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Reflux of gastric contents into esophagus

Normal physiologic process

50% of infants 0-3 months of age



20% of pH probe reflux episodes are visible

reflux

Result of Transient LES relaxations


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Gastroesophageal reflux (GER):

Physiologic passage/passive reflux of

gastric content into the esophagus due

to incompetent lower esophageal

sphincter (LES)

Gastroesophageal reflux disease

(GERD): GER that causes symptoms or

complications that effect quality of life

Nonerosive reflux disease (NERD) :

GERD without erosive esophagitis


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Excessive spitting up in the first week of lif (in 85-90%)

Symptomatic by 6 weeks (10%)

Symptoms resolve without treatment by age 2 (60%)

Forceful vomiting (occasional)

Aspiration pneumonia (30%)

Chronic cough, wheezing, and recurrent

pneumonia (later childhood)

Rarely may cause laryngospasm, apnea, and

bradycardia


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GERD # VomitingNot all vomiting are GERD

Many GERD children do not vomit


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GERD

Erosive esophagitisExtraesophagealreflux disease


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Transient LES relaxation(TLESR)

Immature LES

Shorten intra-abdominalLES

Low esophageal volume

Impaired esophagealclearance

Delayed gastric emptyingtime

Incresed intra-abdominalpressure

Shortoropharynx

Smallstomach size

Immature LES

Age : 1 Month


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Normal Gastroesophageal Anatomy - GER


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GI Motility online(May 2006) | doi:10.1038/gimo21

Incompetent antireflux mechanism

Gastric content into esophagus and beyond

Mucosal damage Symptomsand / or


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GI Motility online(May 2006) | doi:10.1038/gimo21

IncompetentLES

Reflux

Decreased LESpressure

Decreasedperistalsis

Esophagitis

Prolonged esophagealmucosal acid contact


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Regurgitation Vomiting

Heartburn

Persistent irritability

Food refusal

Hematemesis, anemia

Odynophagia,

dysphagia

Failure to thrive, poor

weight gain

... . . . .

.


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Respiratory : asthma, hyperactive airway

disease, recurrent pneumonia/bronchitis,

apnea or ALTE (apparent life-threatening

event), upper airway diseases (laryngitis,

laryngomalacia)

Others : Sandifers syndrome (Reflux,

back arching, stiffness and torticollis)


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Dysphagia

Feeding refusal Abdominal Pain

Heartburn

Poor weight gainIrritability

Recurrent regurgitation/vomiting


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64

34

29

2218

16

0

10

20

30

40

50

60

70

Symptoms

Recurrent AbdominalPain

Heartburn orepigastric pain

Respiratory symptoms

Regurgitation

Retrosternal pain

Vomiting

N=76

Patients(%)

Frequency of PresentingSymptoms in Children With GERD

Ashorn et al, Scand J Gastroenterol 2002;37:638


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Symptoms Weight loss or poor weight

gain (dysphagia, feeding

refusal)

Irritability Frequent regurgitation

Heartburn or chest pain

Hoarseness

Cough

Apnea

Wheezing or stridor

Hematemesis


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Findings

Esophagitis

Esophageal stricture Barretts esophagus

Laryngitis

Hypoproteinemia Anemia


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Associations

Reactive airway disease

Recurrent stridor Chronic cough

Recurrent pneumonia

ALTE (Apparent life-threatening event) SIDS ( sudden infant death syndrome)


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PE : BW 5900 g, length 63 cm

GA : Active, mild pallor, no jaundice

HEENT : HC 43 cm, anterior fontanelle 2x2

cm, no bulging, normal eye movementHeart : WNL

Lung : WNL

Abdomen : Soft, no mass, no distension, notenderness, no hepatosplenomegaly


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GER/GERD

Gut obstruction GI inflammation:

Cows milk proteinallergy, eosinophilicesophagitis

Other motilitydisorders :gastroparesis

Infection Increased intracranial

pressure

Metabolic & endocrinedisorders

Extra GI CausesGI Causes


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Bilious vomiting

Projectile vomiting

Onset after 6 months of life

Failure to thrive GI bleeding

Fever

Abdominal distension, tenderness

Lethargy, seizure

Bulging fontanelle, macro/microcephalus


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What is the proper management?

A. A. 24-h ph monitoring

B. B. Barium contrast study

C. C. UGI endoscopy

D. D. Start prokinetics

E. E. Start proton pump inhibitor


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Exclude malignancies

Dilated esophagus,residual material.

Inflammation andulceration

Stasis - candidainfection.

The LES does not open

spontaneously,traversed easily withgentle pressure


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Upper GI study and UpperEndoscopy


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PH meter


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Elevated resting LES

pressure

Incomplete LES

relaxation

Peristalsis orsimultaneouscontractions


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CBC : Hct 30%

Upper GI series :

normal Blood sugar,

electrolyte, amonia :normal

Upper endoscopy

Dx :GERD with esophagitis

Treatment : lasoprazole 7.5 mg OD


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Life-style modification(LSM)

Pharmacological treatment :

Prokinentics ; Acidsuppression : Antacids,PPIs, H2RA

Surgery (Nissenfundoplication , Stretta

procedures)


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Positioning following feeds, keep infant

upright up to an hour after feeds

In older children, mealtime more than 2

hours before sleep and sleeping with headelevated

Thickening formula with cereal

Medication Surgical


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More frequent and small volume

feeding

Proper feeding technique

Milk thickening agents/thickened

formulas

Position therapy ??


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Prone position : proneposition significantly

increase the risk for SIDS.

Not generally

recommended for GERtherapy (NASPGHAN,JPGN

2001)

Left lateral decubitus :

improve reflux index ininfants (Tobin,JM,et al

,Arch Dis Child,1997)


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Cisapride

Metoclopramide

Domperidone

Erythromycine

5-HT4 receptoragonist

Dopamin

antagonist Peripheral

dopamin

antagonist

Motillin receptor

QT prolong

Extra-pyramidal

signs Minimal

Abnormal LFT

Drug Mechanism Side effects


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Metoclopramide reduces daily symptoms,

compared to placebo and reduce reflux index

Metoclopramide may have some benefit in

comparison to placebo but must be weighedagainst possible side effects

From limited evidences available (4RCTs), there is

no clear evidence of efficacy of domperidone for

GERD treatment in young children

Cochrane Database Sys Rev 2004

Pritchard,et al. Br J Clin Pharmacol 2005;59:725-9


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There are no ideal prokinetic drugs fortreatment of pediatric GERD

Available prokinetics in Indonesia :- Cisapride : side effects

- Metoclopramide : side effects

- Domperidone : efficacy ?

- Erythromycin : for gastroparesis


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Histamine 2 receptor antagonists Ranitidine 5-10 mg/kg/day, bid-tid

Famotidine 1mg/kg/day, OD or bid

Proton pump inhibitors Omeprazole 1-2mg/kg/day, OD

Lanzoprazole child >1y, 15mg(BW30kg) OD

Pantoprazole 20-40 mg OD (children >5y) OD


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Improve GERD symptoms both in erosive and

non-erosive esophagitis

Erosive esophagitis heals after PPI treatment for

8-12 weeks

More effective than H2RA in acid suppression

FDA approve omeprazole and lansoprazole for

treatment of GERD in children > 1 year


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Approach to Infants withregurgitation and Vomiting


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Infants with regurgitation and vomiting

Complications of GER

Alarm symptoms Investigate for other diagnosis

GER GERD

Reassure LSM

Resolve by 18 Mo of age

No

YesPhysiologic

GER

Consider UGI studyAcid suppression Rx

Modified from Thai Ped GERD Guideline 2004


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Infants with regurgitation/vomitingsuspected GERD

SuspectedCMPA

Poor weight gain despite of properfeeding

Suspectedesophagitis

GI contrast studyscrening lab

LSM prokinetic and/oracid suppression 2-4 wks

LSM acid suppression (+prokinetic 2-4 wks

No ResponseResponse

Continue Rx 8-12 wksor until resolve

Consult Ped GI

Upper endoscopy


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Infants with GERD (n=20) have morefeeding problems, compare with normal

infants (n=20) More food refusal

Lack of development of age appropriatedfeeding skills

Mathisen et al, J Pediatr Child Health 1999;35: 163-9


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A 8-year-old boy presents with recurrentregurgitation, occasional vomiting and heartburn for3 months

Treatment with domperidone but no response

PH : Infant regurgitation, resolved at 12 months ofage

PE: Weight at 90th percentile and otherwise normal


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A. A. 24-h pH monitoring

B. B. Barium contrast studyC. C. Upper Endoscopy

D. D. Start other prokinetics



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A. A. 24-h pH monitoring

B. B. Barium contrast studyC. C. Upper Endoscopy

D. D. Start other prokinetics



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Barium Contrast Study :

Exclude GI Obstruction

Upper Endoscopy :Erosive esophagitis

Exclude other causes


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Approach to typical GERDin Children


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Children with symptom Suggestive with GERD

No Alarm Yes

AtypicalTypical

LSMPPi 4 wks

No response

ResponseFrequentrelapse

Endoscopyother Dx

F/U


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Frequent / severevomiting

Weight loss

Dysphagia,odinophagia

GI bleed, anemia


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Avoid large meal Avoid chocolate, spicy food, peppermint and

orange juice Do not lie down immediately after eating Lose weight, if obesity Position : left lateral +/- elevation the head

of the bed


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Gastroesophageal Reflux Smt VI 2011

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