GASTROESOPHAGEAL

REFLUX IN INFANT

INTRODUCTION:

MOST COMMON ESOPHAGEAL DISSORDER BY INCOMPETENT LES

FUNCTIONAL GER AS MINOR DEGREE REFLUX
GER : STOMACH CONTENTS BACK UP TO ESOPHAGUS, DURING OR AFTER
MEAL , WHEN THE L.E.S. OPENS
REFLUX : * IS PAINFULL CRYING CONSTANLY, REFUSE TO EAT AND
POORLY SLEEPING
* FEEDING DISORDERS, INADEQUATE WEIGHT GAIN, STRICTURE
ESOPHAGUS
* PREMATURE MORE HIGHER RISK, ASPIRATION FOLLOW BY
INFECTION AND WHEEZING

ACHALASIA : REFLUX A CROSS A DILATED

ESOPHAGUS

EPIDEMIOLOGY :
* APPROXIMATELLY OF INFANTS
VOMIT :
85 % VOMIT DURING FIRST WEEK
10 % NEXT 6 WEEKS ,
* MOSTLY WITHOUT TREATMENT JUST
BY UPRIGHT POSITION AND EAT
THICK FOOD ONLY

Pathogenesis of
Gastro-esophageal
Reflux
Mucosal Defence

Lower esophageal
sphincter

Acid clearance
- peristalsis
- salivary bicarbonat
Crural diaphragm

Acid
pepsin
Bile
trypsin
Gastric
emptying

PATHOGENESIS :

LOWER ESOPHAGUS HYPOTONIA

WAS POSTULATED TO BE
RESPONSIBLE
IN PREMATURE LOWER ESOPHAGUS
TONE IS RATHER UNDEVELOPED
LES. RELAXATION CONDITION WAS
SLUMPED BY : SUPINE POSITION

Pathogenic Factors
in GER Mechanisms of GER

pharynx & esophagus

3 (reflux clearance)

lower esophageal
2
sphincter
(anti reflux barrier)

stomach
(gastric emptying)

Transient LES relaxation

Intra-abdominal pressure
Reduced esophageal
capacitance
Gastric compliance
Delayed gastric emptying
Mechanisms of Esophageal
Complications
Impaired esophageal clearance
Defective tissue resistance
Noxious composition of
refluxate
Mechanisms of Airway
Complications
Vagal reflexes
Impaired airway protection

SIGNS AND SYMPTOMS

SPITTING AND VOMITING

CRYING AND /OR IRRITABLE
POOR APPETITE
SORE THROAT
CHRONIC COUCH
STRIDOR
FAILURE TO THRIVE
RECURRENT PNEUMONIA
APNEA AND/OR BRADYCARDIA
ABDOMINAL AND/OR CHEST PAIN
SANDIFER SYNDROME ( posturing with opistho tonus
or torticollis )

PREDISPOSING FACTORS
1. Anatomic predisposing factors

THE ANGLE OF HIS (ESOPHAGUS AND

STOMACH AXIS)
HIATAL HERNIA DISPLACE THE LES.
INTRAGASTRIC RESSISTENCE
INCREASE INTRAGASTRIC PREASSURE
AND TENSSION OF LES. LEAD TO
REFLUX AND VOMITING.

2. Physiologic predisposing factors

INCREASE OF INTRAABDOMINAL PRESSURE

CHRONIC RELAXATION OF SPHINCTER
SMALL RESERVOIR CAPACITY OF
ESOPHAGUS
DECREASED GASTRIC EMPTYING
REDUCE ESOPHAGUS ACID CLEARENCE
SUPINE POSITION

3. Others predisposing factor

MEDICATION (valium, theophylline)

FOOD ALLERGY
POOR DIETERY HABITS
MOTHERS FACTORS :

* alcoholism
* smoking

WORKUP IN DIGNOSING

HISTORY :
* parents condition
* mothers habits
* proces of vomiting * complication
IMAGING STUDIES ON UPER GI-tract
* studies on anatomy and motility
* gastric scintiscan
pH EXAMINATION : continuous esoph.pH
MANOMETRY : useful for infants GER
ESOPHAGOGASTRODUODENOSCOPY :

1. History :
a. Parent condition :
- mothers feeling and warrying on
spit up & crying
- vomiting
- refuse for drinking
- BWG & cough
- method and profile of infant feeding
b. Proces of vomiting :
frequent spitup follwed by crying and vomiting
c. Complication :
eating disorders, growth faltering, wheezing,
cough, recurrent pneumonia

2. Imaging studies:

Upper GI.imaging studies :

** only for evaluating the anatomy, but not
sensitive for GER

Gastric scintiscan
** to asses the gastric emptying, observe
reflux and evaluate the aspiration
** disadvantages : need immobilization and
cannot detect late postprandial reflux

3. Esophagography

Barium esophagography by fluorocospy

* GER is episodic, reflux my not
demonstrated

* strictura esophagy can be demonstrated

4. Ph. probe

Continuous esophageal pH probe in distal

esophagus
Evaluate the acid reflux
Formerly as criterian standard overused
Evaluate the quantification of reflux and
the ability to esthablish a relationship with
atypical symptoms
Evaluate the grade of esophagitis

Position of the pH electrode during

24 hours pH monitoring

Datalogger
pH electrode
5 cm

Lower esophageal
sphincter

pH metry

technical principle

gastric pH < 4
esophageal pH 5 - 6.8
pH registration (0.25 Hz) and analysis
episodes of pH < 4 or > 7.5 in the esophagus
that fulfill the criteria of the standard algorithm
are considered GER

J Pediatr Gastroenterol Nutr 1992;14:467-71

5. Manometry
More accessible tool for infants and
children
To assess esophageal motility and
LES function

6. esophagusgastroduodenoscopy
Useful in unresponsible medical
treatment patients
To assess anatomy of GI-tract
Visualization of mucusa

MANAGEMENT

MEDICAL CARE :
* POSITION ON FEEDING
* FOOD QUALITY thicked food
small portie
MEDICATION : * gastric peristaltic
* antacids
SURGICAL CARE : inhance LES

MEDICAL CARE

MOST CASES ARE FUNCTIONAL GER.

CONSERVATIVE METHOD BY:
* upright posistion after feeding
* elevating the head of the bed
* prone position and seated posture
FEEDING :
* thickened feeds with cereal
* small , frequent diet and lower cal.expenditure

MEDICATION

PROKINETIC AGENTS :
to augment cholinergic activity, stimulate
muscular activity decreased in reflux
ANTACIDS :
usually used as diagnostic tool in providing
symptomatic relief in infants
H2 RECEPTOR ANTAGONIST :
like antacids but not reduce the acids production
PROTON PUMP INHIBITOR :
indicated in patients needing complete acid
suppression

COMPLICATIONS

FEEDING IMPACTS :
deplecid in food intake
REGURGATION IMPACTS :
vomiting, aspiration, bronchopneumonia
CHEMICAL TRAUMATIC :
irritation by gastric acids on esophagus
* irritable crying and vomiting
* esophagitis
* stricture of distal esophagus

PROGNOSIS :
1. MOST CASES 80% RESOLVE BY 18
MONTHS
2. SURGICAL TREATMENT IS EXCELLENT
COMPLEX MEDICAL PROBLEM IS POOR
3. LIFESTYLE MODIFICATION :
* continuing medication on respiratory complic.
* posture in feeding and in beding

PARENTS EDUCATION

INFANT PERIODE STILL DEPENDED

ON MOTHER OR CARE GIVER
INFORMATION SHOULD BE GIVEN IN
SIMPLE AND CLEARLY
MAKE THE PARENT CONCERNED TO
THE BABYS CONDITION
STEP OF THE COMPLICATION AS THE
BASE OF THE MANAGEMENT

SUMMARY :
* CONCERNING WITH THE COMPLICATION
DEFINITION, CLASSIFICATION, PATHOMECHANISM ARE IMPORTANT ON OF
GER.
* MANAGEMENT :
primair : thckening food & upright position
secundar : plus medicamentous
tertiar : surgical

thank
you
Thank you