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Definitions
Definitions
GER Passage of gastric contents into esophagus Regurgitation Passage of refluxed gastric / Spitting-up content into oral Pharynx & mouth Drooling Vomiting Expulsion of refluxed gastric contents from mouth GERD Gastric contents reflux into the Esophagus/oropharynx & produce symptoms/complications Voluntary, habitual regurgitation of recently ingested Rumination food that is subsequently spitted up or re-swallowed
Definitions
Prevalence
GER is a physiological phenomenon, occurring in every
individual. Most episodes of reflux are limited to the distal esophagus, and are brief and asymptomatic. asymptomatic.
Prevalence
It may also result from mechanical factors at play in
chronic lung disease or upper airway obstruction, as in chronic tonsillitis. Other causes include systemic or local infections (urinary tract infection, gastroenteritis), food allergy, metabolic disorders, intracranial hypertension and medications such as chemotherapy. In some cases, secondary reflux results from stimulation of the vomiting center by afferent impulses from circulating bacterial toxins, or stimulation from sites such as the eye, olfactory epithelium, labyrinths, pharynx, gastrointestinal and urinary tracts, and testes. These stimuli usually cause vomiting.
Textbook of Pediatric Gastroenterology and Nutrition, Stefano Guandalini, 1st Ed, 2004
Prevalence
A small degree of reflux is common in all infants, infants, and it is only infants who have moderate to severe chronic reflux that tend to come to the pediatrician's attention One of the most common causes of GER is overfeeding, so a careful history is important A history of coughing, gagging, and arching of the back with extensor posturing during feeding may result from direct aspiration, whereas the aspiration, presence of these symptoms soon after feeding may suggest GER In severe reflux, the infant may have poor weight gain
Definitions
Recurrent vomiting occurs in 50% of infants in the first three months of life, in 67% of four month old infants, & in 5% of 10 to 12 month old infants. Vomiting resolves spontaneously in nearly all by 24 months!
Etiology
Genetic predisposition Environmental factors Food habit Eating fast Obesity Stress Exposure to tobacco smoke Neurologically impaired children, Repaired esophageal atresia, BPD, cystic fibrosis, ?H. pylori
Etiology
Spectrum of Manifestations
pain
Manifestations
Manifestations
Complications
Esophagitis Peptic stricture Barretts esophagus Failure to thrive Pulmonary / ENT disease Sandifers syndrome / torticollis
GERD
Asthma
5050-60% of childhood asthmatic patients experience GERD
Pedatr Drugs.2005;7:177-186 Drugs.2005;7:177-
Diagnosis
GERD is diagnosed on basis of history & clinical features
No fool proof test for diagnosis An empiric trial of PPI therapy is a widely used
diagnostic test for GERD in adults and this approach is expanding to pediatric practice now1
Differential Dx of GER
Emesis shortly after feeds GER If the emesis is projectile & the child is 1 to 3 months old pyloric stenosis Poor weight gain & emesis pyloric stenosis or metabolic disorder Drug Tx: Macrolide antibiotics emesis and diarrhea, chemotherapeutic agents & toxic ingestions emesis Child with VP shunt, vomiting shunt obstruction & o icp Emesis with seizure or headache or both intracranial process Diarrhea, emesis, & fever gastroenteritis. Fever, abdominal pain, & emesis appendicitis Bilious emesis & abdominal pain I.O.
Differential Dx of GER
Most cases of emesis are caused by GER, acute gastroenteritis, or systemic disorders such as tonsillitis, otitis media, or urinary tract infection The differential diagnosis for GER in the adolescent may include pneumonia, costochondritis, pericarditis, pulmonary embolism, arrhythmias, ischemia due to an anomalous coronary artery, pancreatitis, cholecystitis, peptic ulcer disease, and anxiety In the older child, GER is often manifested as epigastric abdominal or chest pain. Define the pain's location and severity and whether it radiates and is constant or intermittent. Burning epigastric or chest pain is probably reflux in the adolescent, especially if it occurs after meals when the patient lies down.
GERD vs Dyspepsia
Distinguish from Dyspepsia
o Ulcer-like symptoms-burning, epigastric Ulcersymptomspain o Dysmotility like symptoms-nausea, symptomsbloating, early satiety, anorexia
Very often physiological, esp < 6 mo 90% resolve <12-18mo <12Carre Nelson
> 2yr age adulthood Vomiting > 2 yr age never physiological GERD usually a chronic, relapsing disease with waxing & waning Completely resolving in no more than half
Irritability with feeds Recurrent pneumonias / chronic cough Generally unhappy baby Failing to thrive Torticollis [?Sandifers syndrome] Persistent vomiting at 18-24mo 18-
Investigations
CBC: Normal Electrolytes: hypochloremic, hypokalemic
metabolic alkalosis with severe reflux CXR: for aspiration pneumonia & changes due to recurrent aspiration UPPER GI CONTRAST STUDY - not a test for reflux - stricture / achalasia / mass - road map UPPER GI ENDOSCOPY, BIOPSIES 24HR INTRAESOPHAGEAL pH GASTRIC EMPTYING STUDY
pH Monitoring
The 24-hour pH probe monitor is the gold standard for Dx 24A catheter at the LES measures episodes of reflux over a 2424-hour period: requires hospitalization An esophageal intraluminal pH < 4.0 for at least 15 seconds defines an episode of reflux Recorded values include total time with pH below 4.0, upright time with pH less than 4.0, supine time with pH less minutes, than 4.0, number of reflux episodes longer than 5 minutes, and duration of the longest reflux episode. Disadvantages: inability to diagnose nonacid reflux and to Disadvantages: distinguish primary and secondary (allergy to milk protein or other food) causes of reflux, the inability to determine the presence or severity of esophagitis, and poor tolerance of the probe in some children
Impedance Monitoring
Esophageal impedance/pH monitoring is a novel technique that can be used to detect both acid and nonacid reflux. reflux. This test uses a probe similar to that used in standard pH monitoring to measure the change in electrical resistance that occurs across its sensors with the passage of intraluminal material Advantages of this test include the ability to identify the content, direction, and localization of any reflux. This test reflux. may yield better diagnostic sensitivity than pH probe in patients treated with antacids Disadvantages include a lack of standardized pediatric normal ranges and increased cost relative to standard pH probe Investigational tool
Endoscopy
Endoscopy is used to visualize and obtain a biopsy sample from the esophageal mucosa and to diagnose esophagitis, stricture, & Barrett esophagus. esophagus. Although there is no validated grading system for children, erosion or ulceration is indicative of esophagitis Biopsy should be performed in most cases, even if the mucosa appears relatively normal, because there is a normal, significant tendency for histologic grade to exceed visual endoscopic findings Endoscopic ultrasonography has been described as an adjunct to endoscopy to evaluate the integrity of Nissen fundoplication in children and adults
Goals
Eliminate symptoms
Prevent relapse
Pediatric GERD
Adult GERD
Management
Explanation, reassurance Diet, lifestyle Position Antacids Anticholinergics [e.g., XbethanecolX] bethanecolX Prokinetics [XmetoclopramideX, XcisaprideX] [XmetoclopramideX cisaprideX H2H2-Receptor Antagonists PPI AntirefluxAntireflux-Surgery
Avoid overfeeding Holding upright and burping: prone head-up headposition for at least 20 minutes after a feeding
Avoid tight clothing and passive smoking A short trial of a hypoallergenic diet can be
used to exclude milk or soy protein allergy before pharmacotherapy
Post-feed Positioning
No food or drink for 2 hours before bed-time bedElevate head of bed (6) if nocturnal symptoms Avoid foods (caffeine, chocolates, spicy or fatty
foods, citrus foods, tomato, carbonated beverages)
Weight loss if overweight Avoidance of smoking and alcohol The efficacy of positioning for older children is
unclear, but some evidence suggests a benefit to left side position & head elevation during sleep
GER Bed
Elevation
Prokinetics
e.g. metoclopramide (dopamine-2 and 5HT-3 (dopamine5HTantagonist), bethanechol (cholinergic agonist), and erythromycin (motilin receptor agonist) & cisapride Act on through their effects on LES pressure, esophageal peristalsis or clearance and/or gastric emptying, No effect on TLESR No clear scientific evidence on efficacy Not US FDA approved for GERD in children Cisapride-cardiac side effect: Banned CisaprideMetaclopramide- extra pyramidal side effects Metaclopramide(>20%)
Antacids (Alginate-) (AlginateRapid but transient relief of symptoms by acid neutralization No role on source of acid secretion Needs to be given more than 6 doses per day Can not be used for a prolonged period because of side effects of diarrhea (magnesium) and constipation (aluminum) and rare reports of more serious side effects of chronic use Aluminium containing antacids may cause aluminium toxicity Occasional formation of large bezoar-like bezoarmasses of agglutinated intragastric material
H2RAs
Acid-suppressant therapy is recommended in Acidsevere esophagitis, but this does not rectify primary disordered motility, a major pathophysiological mechanism Definite benefit in treatment of mild-to-moderate mild-toreflux esophagitis. H2RAs have been esophagitis. recommended as first-line therapy because of firsttheir excellent overall safety profile, but they are being superseded by PPI in this role, as increased experience with pediatric use and safety Less potent compared to PPI Associated with tachyphylaxis
Drugs: cimetidine, famotidine, nizatidine, & ranitidine
PPI
Provide the most potent antireflux effect by blocking the H+,K+-ATPase (proton pump) H+,K+channels of the final common pathway in gastric acid secretion In typical doses, diminish the daily production of acid (basal and stimulated) by 8095% 80 PPIs are superior to H2RAs in the treatment of severe and erosive esophagitis All proton pump inhibitors have equivalent efficacy at comparable doses An acidic pH is required for drug activation, & since food stimulates acid production, these drugs ideally should be given about 30 minutes before meals
PPI
Younger patients generally have increased metabolic capacity, resulting in the need for higher dosages of PPI per Kg in children compared to adults Generally cause remarkably few adverse effects. effects. The most common are nausea, abdominal pain, constipation, flatulence, & diarrhea. Subacute myopathy, arthralgias, headaches, and rashes also have been reported
Can interact with warfarin (esomeprazole, lansoprazole, omeprazole, & rabeprazole), diazepam (esomeprazole & omeprazole), & cyclosporine (omeprazole and rabeprazole). Omeprazole inhibits CYP2C19 (thereby decreasing the clearance of disulfiram, phenytoin, and other drugs) and induces the expression of CYP1A2 (thereby increasing the clearance of imipramine, several antipsychotic drugs, tacrine, and theophylline)
PPI
Prolonged use of PPIs can result in vitamin B12 deficiency as a consequence of impaired release of vitamin B12 from food in a non-acid nonenvironment Potential consequences of prolonged acid suppression, include the risk of proliferation of gastric flora and the risk of developing enterochromaffinenterochromaffin-like cell hyperplasia, hypergastrinemia) (hypergastrinemia) gastric malignancy
PPI Trial
Expect response in 2-4 weeks (whether using H2RA or PPI) If no response Change from H2RA to PPI If no response Maximize dose of PPI Therapy indicated for a minimum of 8-12 weeks If PPI response inadequate despite maximal dosage, confirm diagnosis : EGD, 24 hour pH monitor Failure to control symptoms with high-dose PPI highnon-acidtreatment raises the likelihood of non-acidrelated causes for the symptoms
PPI Doses
Medication
H2RAs
Famotidine Ranitidine 1 mg/kg/day 5-10 mg/kg/day Twice daily Twice daily or thrice daily
Dose
Frequency
PPIs
Lansoprazole 0.4-2.8 mg/kg/day 0.4e30 Kg: 15 mg/d > 30 Kg: 30 mg/d 0.2-3.5 mg/kg/day 0.2< 10 Kg: 10 mg/d u 10 Kg: 20 mg/d 2020-40 mg/day, 0.5 -1 mg/kg/d < 20 kg: 10 mg 20 kg: 20 mg Once daily > 1 yr
Omeprazole
Once daily
> 2 yr
Pantoprazole Esomeprazole
> 5 yr > 1 yr
J Pediatr Gastroenterol Nutr 2002; 35: 308-317,J Pediatr Gastroenterol Nutr 2005; 40: 319 - 327
Even those patients who do not fully respond to medical management should be treated for 8 weeks before surgical therapy is considered, unless the patient is experiencing life-threatening symptoms! life-
PPI: Lansoprazole
Key Points
GER can be physiological or
pathological (GERD)