Reflujo Gastroesofgico en Pediatra .

Dra. Marina Orsi. Orsi.

DEFINICIN
 Reflujo

GE : movimiento retrgrado de

contenido gstrico en el esfago.

 Enfermedad

por RGE: sntomas o RGE:

complicaciones vinculables al RGE y / o dao tisular causado por RGE

FISIOPATOLOGA


Las relajaciones transitorias del EEI son la causa ms frecuente del RGE en nios y en adultos. Una RT se define como una disminucin abrupta de la presin del EEI , no relacionada a la deglucin o la peritalsis. Las RT tambin ocurren en sujetos sanos, pero en el RGE patolgico la frecuencia y su duracin es o.

Relajaciones transitorias del EEI

Las RT del EEI son la causa + frecuente de RGE en nios y adultos.
UES

Pharynx

Esophagus

RT se define como disminucin abrupta de la P del EEI, no relacionada a deglucin o perstasis.

Angle of His

Crural diaphragm Pylorus

LES

RT ocurren en individuos sanos, pero en el RGE patolgico su frecuencia y duracin es mayor.

Stomach

Tracings reprinted from Kawahara et al, Gastroenterology 1997;113:399

Capacidad Gstrica
La distensin gstrica sera un potente estmulo para la RT. Vaciamiento gstrico.

Menor longitud Menor capacidad Gravedad

Iactante

La extensin proximal se relaciona con la intensidad de los sntomas y con el movimiento

Adulto Adult

Emerenzian y col. AJGAJG-2005

RGE: RGE:
movimiento retrgrado del contenido gstrico hacia el esfago.

Fisiolgico y normal Asintomtico o regurgitacin Se resuelve espontneamente Postprandial Durante primeros 2 aos de vida

Regurgitador o Vomitador Feliz :

Es el lactante que regurgita y / o vomita con variable intensidad , sin otro sntoma acompaante. Crece bien y est sonriente. Tiene Reflujo Gastroesofgico Fisiolgico.

Enfermedad por Reflujo Gastroesofgico.

Es el lactante o nio con sntomas digestivos y / o extradigestivos que se vinculan al dao tisular producido por la intensidad o a la frecuencia e intensidad de los episodios de reflujo. Se denomina : Reflujo Gastroesofgico Patolgico.

RGE = ERGE
Capacidad defensiva superada produce inflamacin cido Pepsina Contendido biliar

Vmitos - regurgitaciones Prdida peso - pobre Nauseas - Irritabilidad Ardor - dolor epigstrico Disfagia - Anemia Tos nocturna - cronica Asma Neumonias recurrentes Apnea / ALTE Trastorno alimentacin Esofagitis Estenosis esofgica

Sntomas Complicaciones
Dao tisular

Hematemesis / Anemia Hiperextensin cuello Barrett Adenocarcinoma

SNTOMAS


Vmitos. Regurgitaciones. Naseas. Arcadas. Arcadas.

Epigastralgia . Pirosis. Hematemesis. Melena.

SNTOMAS .
    

Anemia. Irritabilidad. Retardo ponderal. B.O.R. - Asma Neumonas reiteradas.

    

Tos Recurrente. EstridorEstridor-Laringitis Dolor torcico. E .A .A .V. Sme de Sandifer.

Diagnstico Diferencial .
  

Trastornos metablicos. Sndrome Pilrico. Alergia a la protena de la leche de vaca. Infecciones (gastroenteritis(gastroenteritisinf.urinaria )

Hipertensin endocraneana. Trastornos hidroelectrolticos. Gastritis -Duodenitis. Enf.lceropptica.

 

DIAGNSTICO
HISTORIA CLNICA
y Edad

al comienzo del cuadro clnico. y Sntomas al inicio y en el tiempo. tiempo. y Evolucin segn tipo de alimentacin. y Curva de crecimiento ( Peso Talla ) y Asociacin con sntomas ORL o con y Sntomas respiratorios o con y Sntomas neurolgicos

DIAGNSTICO
 Seriada

Gastroduodenal bajo radioscopa. radioscopa.  Video-Deglucin con S.G.D. Video Endoscopa alta con biopsias.  pHmetra de 24 horas.  Manometra Esofgica.  Gamma - cmara.  Impedanciometra Intraluminal MulticanalMulticanalpHmetra / manometra de 24 hs.

Hernia Hiatal con RGE

Aspiracin

Gamma-Cmara

Correlacin sintomtica apnea - rge

pnea

pHmetra en un paciente con EAAV

A

1 pH

IR:28,2%

2 pH

IR:6,9%

3 pH

IR:1.8%

Rol de la endoscopa en el RGE patolgico

      

Para evaluar la presencia o no del dao mucoso y la severidad del mismo. Cuando los sntomas son importantes y la pHmetra es normal. Cuando la clnica parece sugerir otros diagnsticos ej : esofagitis eosinofilica ; gastritis por Helicobacter Pylori . Cuando los sntomas no ceden con el tratamiento. En el seguimiento del RGE patolgico persistente. Previo a la ciruga del RGE. Cuando se decide dar de alta al paciente.

Esfago Normal

Esofagitis

Esofagitis Eosinoflica

Historia.


En la Edad Media , Maimonides describi que el asma ocurra con mayor frecuencia despus de las festividades. A fines del siglo XIX ,Sir William Osler not la relacin entre cenas abundantes y la presencia de episodios asmticos nocturnos. nocturnos. l lo describi : los ataques pueden deberse por de irritacin directa de la mucosa bronquial o por va refleja por el estomago. estomago.

HISTORIA.
 En

1937, Bray propuso que cenas copiosas podan causar distensin gstrica que generara por va refleja broncoconstriccin a traves del nervio vago.

En 1976 , Mays sugera que el 50% de los asmticos podan tener RGE patolgico y deban ser evaluados en ste sentido.

OBSTRUCCIN de la VIA AEREA

Posibles mecanismos

LUZ (material aspirado, moco secretado) LAMINA PROPIA (edema) MSCULO (bronco-espasmo, laringo - espasmo ) BRONQUIO: Tres lugares potenciales de obstruccin de la va area. La luz bronquial puede encontrarse disminuda por material de origen extra o intra-pulmonar. Por otro lado la lmina propia puede estar engrosada por edema y por ltimo la contraccin muscular puede estrechar la luz

Esfago

Posibles mecanismos involucrados en la enfermedad respiratoria relacionada al Obstruccin Luminal RGE

Arbol Traqueobronquial Aspiracin
QUIMICA
Liberacin de mediadores inflamatorios

Reflujo

Material aspirado

Moco Edema Contraccin Msculo liso Bronquial

NEURAL Aferentes v. area

Aferentes Esofgicos

Eferentes de la v. area

Que es la IMPEDANCIOMETRIA ( Z ) ?
RESISTENCIA AL FLUJO CORRIENTE Medicin inversa de la conductividad elctrica de la pared de un rgano o su contenido

POR QUE CAMBIA LA IMPEDANCIOMETRA? No hay bolo = pocos iones = alta impedancio

Bolo est presente = muchos iones = impedancia baja

Fundamentos de la impedancia
Bolus Presente
Impedancia

Entrada del Bolus

Salida del Bolus

Tiempo

Impedance Ring Set

Escala de Impedancia
Conductividad Baja = Impedancia Alta

I m p e d a n c i a

Aire Recubrimiento esofgico Saliva Comida Reflujo

Impedanciometra Intraluminal Multicanal. Multicanal.

      

Detecta RGE cido y no cido . Puede establecer diagnstico en pacientes con sntomas refractarios durante el tratamiento mdico. Permite evaluarlos con o sin medicacin. Correlaciona sntomas con episodios cidos o no cidos. Cuantifica el patrn de reflujo y la correlacin sintomtica tambien en el perodo post-prandial. post-prandial. Es capaz de diagnosticarel reflujo supra-esofgico. supraPuede monitorear a los lactantes pequeos con alimentacin muy frecuente.

Fundamentos de la impedancia
MII Detecta el movimiento del bolus
Tragar
Movimiento del bolus Bolus Entry Bolus Entry

Reflujo

Bolus Entry

Bolus Entry

Bolus Entry

Bolus Entry

Bolus Entry

Bolus Entry

Bolus Entry

Bolus Entry

Bolus Entry

Bolus Entry Movimiento del bolus

Utilidad de la monitorizacin de Impedancia-pH Impedancia

Cuantificacin de tiempo de exposicin cida (tiempo de exposicin qumica) qumica) Correlacin de reflujo cido con sntomas Correlacin de reflujo no cido con sntomas Cuantificacin de la capacidad de aclaramiento del bolus (aclaramiento fsico) Tiempo de exposicin al bolus y fsico) altura de la migracin Determinacin precisa de la frecuencia de los fallos en la barrera antirreflujo
  

  

Pacientes GERD en terapia de supresin cida Reflujo postprandial ReRe-reflujo cido

Monitorizacin de IIM-pH detecta todo tipo de reflujo IIM

Clasificacin de episodios segn su pH



cido

Movimiento retrgrado del bolus + una cada del pH por debajo de 4 o que ocurre cuando el pH ya est por debajo de 4

Dbilmente cido (Minor Acid) No cido

Movimiento retrgrado del bolus en el que el pH no cae por debajo de 4.0 pero desciende ms de una unidad

Movimiento retrgrado del bolus en el que el pH no cae por debajo de 4.0 y no desciende ms de una unidad.

Impedance pH Catheter

Pediatric Model

13 cm 11 cm 9 cm 7 cm 5 cm 3 cm

6 impedance channels 1 pH channel

pH 3 cm

Deglucin.

Reflujo

Reflujo No Acido

Reflujo Acido

Acid ReReflux
Acid GER # 1 Acid GER # 2

pH Remains Below 4.0

45

Historia
Publicaciones

desde 1996 en JPGN hasta la actualidad

Trabajos

en Pediatrics , Journal of Pediatrics , Archives Disease of Childhood , Gut , American Journal of Gastroenterology 192 trabajos con 32 review adultos y nios.

Bsquedas

Impedanciometra Intraluminal Multicanal

pH catteres IIM

Combined MultiChannel Intraluminal Impedance and pH Esophageal Testing Compared to pH Alone for Diagnosing Both Acid and Weakly Acidic Gastroesophageal Reflux Hila A, Agrawal A, Castell DO Clinical Gastroenterology and Hepatology, 2007; 5 172-77 A, A, 172  

60 consecutive patients were studied with MII-pH studies off acid suppression therapy MIIAll studies initially were read by exclusively analyzing the pH tracing for acid reflux episodes Subsequently, all studies were blindly read again analyzing MII-pH detected acid reflux MIIepisodes (pH decrease to below 4.0 plus MII-detected retrograde bolus movement) MIIOnly 49 % of acid reflux episodes detected by single channel pH monitoring were associated with retrograde bolus movement as detected by MII. MII. pH alone overstated the percent time below 4.0 by approximately 2 fold over MII-pH (pH MIIonly percent acid exposure time was a mean of 5.8 % versus MII-pH of 2.7 %) MIIThe most common reason pH only overstated acid reflux was pH drops associated with swallows. (81% of patients had acid swallows despite being instructed to not ingest acidic beverages outside of meal periods) Acid pH monitoring specificity for acid symptom index calculation was 67% as compared to MII-pH. This is to state a significant trait for acid pH monitoring to overstate acid MIIreflux, resulting in overstating the temporal association of acid reflux to symptoms. This is critical in that Symptom Index (SI) is frequently the primary basis of study interpretation.

 

The study concludes The use of pH alone for the detection of acid reflux is The very sensitive but lacks specificity compared with MII-pH. pH alone may overMIIoverdiagnose abnormal acid reflux in up to 22% of tested patients. Also, the use of patients. pH for the detection of weakly acid reflux has poor sensitivity.

American Journal of Gastroenterology ISSN 0002-9270 2007 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2006.00936.x Published by Blackwell Publishing PRACTICE GUIDELINES

ACG Practice Guidelines: Esophageal Reflux Testing

Ikuo Hirano, M.D.,1 Joel E. Richter, M.D.,2 and the Practice Parameters Committee of the American College of Gastroenterology* Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; and 2Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania Investigations and technical advances have enhanced our understanding and management of gastroesophageal reflux disease. The recognition of the prevalence and importance of patients with endoscopy-negative reflux disease as well as those refractory to proton pump inhibitor therapy have led to an increasing need for objective tests of esophageal reflux. Guidelines for esophageal reflux testing are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the Board of Trustees. Issues regarding the utilization of conventional, catheter-based pH monitoring are discussed. Improvements in the interpretation of esophageal pH recordings through the use of symptom-reflux association analyses as well as limitations gleaned from recent studies are reviewed. The clinical utility of pH recordings in the proximal esophagus and stomach is examined.

Newly introduced techniques of duodeno-gastroesophageal reflux, wireless pH capsule monitoring and esophageal impedance testing are assessed and put into the context of traditional methodology. Finally , recommendations on the clinical applications of esophageal reflux testing are presented.
(Am J Gastroenterol 2007;102:668685)

Evaluation of Gastroesophageal Reflux with the Multichannel Intraluminal Impedance-ph probe in Patients with Respiratory or Digestive Presentation.
Orsi,M.; Cohen Sabban,J.;Donato Bertoldi,G; DAgostino,D. Pediatric Gastroenterology & Hepatology Division.Hospital Italiano de Buenos Aires Argentina.

Gastroesophageal Reflux (GER) in respiratory patients may have no digestive symptoms and this is known as silent or occult reflux. The 24 hr Multichannel Intraluminal Impedance (IMM)-ph monitoring is a new procedure which enables the study of the quality (acid / non acid) of the refluxate. It is a matter of debate if there is a different acid / non acid pattern between children with an exclusive respiratory presentation and those with typical digestive symptoms. Aim: To evaluate with the Multichannel Intraluminal Impedance ph probe the presence of acid or non acid episodes in children with respiratory or digestive clinical presentation at different age.

Methods: Since January 2005 to April 2006, a prospective study was conducted at the Hospital Italiano in Buenos Aires in 140 children ( 59 girls, 81 boys ) Children were referred to the Gastroenterology Unit by the neumonologists or the pediatricians to be evaluated for GER. Patients were divided according to symptoms in: Respiratory (recurrent : cough , neumonia, broncoespasm , laryngitis, asthma ) or Digestive ( regurgitation, vomiting , epigastric pain , pirosis ) Considering the age into Group I : <2 years ( x::7 months r: 3 to 23m ) 64 infants ; Group II : > 2 years ( x : 6.9 years r: 2-16y ) 76 children.
Exclusion criteria were: cardiac disease, congenital anomalies, mental retardation, cerebral palsy or on digestive medications. The evaluation was performed during one day with a Sleuth Monitoring Recorder using catheters (ZPN S61CO1E) with 7 impedance sensors and one pH probe at the distal end

Results: Children with Digestive symptoms n: 57 presented 3026 reflux episodes; acid: 1697, non-acid:1329; the Respiratory presentation n : 83 had 3396 total reflux events, acid :2068 , non acid 1328. In the following table the results divided in GI and GII according age and clinical presentation .
Group I N Total Acid Non Acid Digestive 37 2094 1051 1043 Respiratory 27 1324 755 569 Group II N Total Acid NoAc Digestive 20 960 646 314 Respiratory 56 2072 1313 759

The statistical analysis with the paired t Test showed a significant difference in: GII D vs R p < 0.00478 with number of total reflux episodes
Digestive Respiratory GII vs GI p<0.0093 GI vs GII p<0.0013 have > number of acid episodes have > number of nonacid episodes

Conclusions: The respiratory patients, particularly infants, because of increased non acid episodes should be studied with the 24-hour Multichannel Intraluminal Impedance to avoid misdiagnosis. Instead, elder children with typical digestive symptoms can be properly evaluated with conventional phmetry because of a more acid pattern. Other studies are necessary to help us understand the real advantage with this new technology .

Evaluation of gastroesphageal reflux with the Multichannel Intraluminal Impedance- pH Impedanceprobe in children with respiratory symptoms.
Orsi,M.; Cohen Sabban,J.;Donato Bertoldi,G.; DAgostino,D. Pediatric Gastroenterology & Hepatology Division. Hospital Italiano de Buenos Aires Argentina.

Aim: To evaluate the proportion of acid or non acid episodes of gastroesophageal reflux in children with respiratory symptoms. To determine the symptom correlation and the height of the episodes.

Methods.
Since January to December 2005, a prospective study was conducted 45 children (28 boys,17 girls) with a median age of 6.1 years (r: 216 years). Children were referred by the pulmonologists to the Pediatric Gastroenterology Division of the Hospital Italiano in Buenos Aires. Patients with cardiac disease, congenital anomalies, mental retardation, cerebral palsy or on digestive medications were excluded. The evaluation was performed during one day with a Sleuth Monitoring Recorder using catheters (ZPN S61CO1E) with 6 impedance sensors and one pH probe at the distal end.

Results
In the 45 children studied: 1850 reflux episodes were observed, 1179 (63.7%) were acid and non acid : 671(36.2%). The pH probe detected 984 acid events. The proximal channel was reached in 1152(62.2%) episodes; 65% acid and 35% non acid of them. Symptomatic correlation with cough: Total : 420, Acid 211(50.3%9) and Non acid 209(49.7%).

Summary
The Multichannel Impedance and the pH probe demonstrated similar results to evaluate acid reflux. However, 36.2% of non acid episodes were only detected by impedance. The most frequent symptom observed was cough with a symptom correlation of 49.7% with non acid reflux. The proximal channel was reached in 62.2% of all of them .

Conclusions
In respiratory patients, the 24-hour Multichannel Intraluminal Impedance-pH monitoring resulted a good method to study gastroesophageal reflux because is capable of providing a more dynamic and complete information of the different types of reflux events. Other studies are necessary to help us understand the benefits and / or limits of this new technology.

Ventajas
  

y Desventajas Actuales


Es ambulatorio. No requiere de alta complejidad Pueden evaluarse los nios bajo tratamiento con IBP No anestesia Es bien tolerado Mnimamente invasivo  El consenso de ESPGHANESPGHANNASPGHAN publicado en oct 2009 lo incuye dentro de las pruebas Dx. 

No hay valores de normalidad en Pediatria

   

Lleva tiempo el anlisis de los datos

Las sondas son costosas

Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Hepatology, ( NASPGHAN ) and the European Society for Pediatric Gastroenterology, Hepatology, and Hepatology, Nutrition (ESPGHAN)
CoCo-Chairs: Yvan Vandenplas and yColin D. Rudolph Committee Members: zCarlo Di Lorenzo, Eric Hassall, jjGregory Liptak,Lynnette Mazur, #Judith Sondheimer, Annamaria Staiano, yyMichael Thomson,zzGigi Veereman-Wauters, and Tobias G. Wenzl VeeremanTobias
UZ Brussel Kinderen, Brussels, Belgium, {Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Childrens Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA, {Division of Pediatric Gastroenterology, Nationwide Childrens Hospital, The Ohio State University, Columbus, OH, USA, Division of Gastroenterology, Department of Pediatrics, British Columbia Childrens Hospital/University of British Columbia, Vancouver, BC, Canada, jj Department of Pediatrics, Upstate Medical University, Syracuse, NY, USA, Department of Pediatrics, University of Texas Health Health Sciences Center Houston and Shriners Hospital for Children, Houston, TX, USA, #Department of Pediatrics, University of Colorado Colorado Health Sciences Center, Denver, CO, USA, Department of Pediatrics, University of Naples Federico II, Naples, Italy, {{Centre for Paediatric Gastroenterology, Sheffield Childrens Hospital, Western Bank, Sheffield, UK, {{Pediatric Gastroenterology & Nutrition, Queen Paola Childrens Hospital-ZNA, Antwerp, Belgium, andKlinik fur Kinder- und HospitalandKlinik fu KinderJugendmedizin, Universitatsklinikum der RWTH Aachen, Aachen, Germany Universita

Journal of Pediatric Gastroenterology and Nutrition49:498547 Nutrition49:498 # 2009

pHmetra de 24 horas ( Guidelines 2009 )

This test is a valid quantitative measure of esophageal acid exposure with established normal ranges. In pH studies performed with antimony electrodes, an RI > 7% is considered abnormal, an RI < 3% is considered normal , and an RI between 3% and 7% is indeterminate. However, the severity of pathologic acid reflux does not correlate consistently with symptom severity or demonstrable complications. In children with documented esophagitis, normal esophageal pH monitoring

suggests a diagnosis other than GERD.

Esophageal pH monitoring is useful for evaluating the efficacy of antisecretory therapy. It may be useful to correlate symptoms (eg, cough, chest pain) with acid reflux episodes and to select those infants and children with wheezing or respiratory symptoms in whom GER is an aggravating factor.

The sensitivity, specificity, and clinical utility of pH monitoring for diagnosis and management of possible extraesophageal complications of GER are not well established

Impedanciometra Intraluminal Multicanal pHmetra de 24 hs

This test detects acid, weakly acid , and nonacid reflux episodes. It is superior to pH monitoring alone for evaluation of the temporal relation between symptoms and GER. The technology is especially useful in the postprandial period or at other times when gastric contents are nonacidic. The relation between weakly acid reflux and symptoms of GERD requires clarification. Measurement of other parameters such as SI or SAP may be of additional value to prove symptom association with reflux, especially when combined with MII . Whether combined esophageal pH and impedance monitoring will provide useful measurements that vary directly with disease severity, prognosis, and response to therapy in pediatric patients has yet to be determined.

Tratamiento de Prueba con IBP

An uncontrolled trial of esomeprazole therapy in adolescents with heartburn ,epigastric pain, and acid regurgitation showed complete resolution of symptoms in 30% to 43% by 1 week, but the responders increased to 65% following 8 weeks of treatment . Another uncontrolled treatment trial of pantoprazole in children ages 5 to 11 years reported greater symptom improvement at 1 week with one 40-mg dose compared with one 10-mg or 20-mg dose (64). After 8 weeks all of the treatment groups improved. Similar improvement in symptoms over time has been observed in adults with erosive esophagitis (198,199). One study of infants with symptoms suggestive of GERD who were treated empirically with a PPI showed no efficacy over placebo

The 2-week PPI test lacks adequate specificity and sensitivity for use in clinical practice. In an older child or adolescent with symptoms suggesting GERD, an empiric PPI trial is justified for up to 4 weeks.
Improvement following treatment does not confirm a diagnosis of GERD because symptoms may improve spontaneously or respond by a placebo effect.

There is no evidence to support an empiric trial of pharmacologic treatment in infants and young children as a diagnostic test of GERD.

El iceberg del RGE Alternativas Teraputicas

Tratamiento quirrgico

Tratamiento farmacolgico

Cambio de hbitos La mayora de los lactantes y nios mejoran con cambio de hbitos y dieta. Los ms afectados requieren medicacin y algunos pocos deberan ser intervenidos quirrgicamente

TRATAMIENTO
Lactante Vomitador. Vomitador.
 Espesamiento

de la alimentacin: casera o en base a frmulas AR.  Cuidar el volumen en cada toma.  Posicin prona postprandial a 30.

Si no responde a stos cambios ( 2 a 3 semanas ) es posible intentar una serie de tratamiento y valorar la respuesta al mismo.

Tratamiento Mdico. Mdico.

 Proquinticos :


Metoclopramida:pasa la barrera hematoenceflica,

la dosis terapetica y la dosis txica son muy cercanas ,lo que facilita las intoxicaciones.

Cisapride : 0.1mg-0.2mg / kg /dosis cada 6 hs. a 8 0.1mghs , con una dosis mxima de 0.8mg/ kg / da. Por el riesgo de prolongacin del QT- QTc se recomienda QTrealizar ECG previo y suspenderlo ante asociaciones medicamentosas o metablicas de riesgo.

Domperidona :0,3 mg / kg / da en 3 dosis diarias

Tratamiento Mdico.
ANTICIDOS: El objetivo es disminuir el pH gstrico y as cambiar la calidad del material refludo , mejorar el clearance y favorecer el aumento de la Presin del EEI .
   

Ranitidina: Ranitidina: Omeprazol: Omeprazol:

5 - 10 mg / kg / da oral cada 12 hs. 0,7 - 2,4 mg / kg /da cada 12 hs.

Lanzoprazol : 0,5 1 mg / kg / da en 1 dosis diaria Esomeprazol : 0,6mg - 1,5 mg / kg / dia 1dosis /d?

Uso de Inhibidores de Bomba de protones en nios

Journal of Pediatric Gastroenterology and Nutrition 49:498 49:498547 # 2009 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and Hepatology, North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Hepatology,

PPIs currently approved for use in children in NorthAmerica NorthAmerica are omeprazole, omeprazole, lansoprazole, lansoprazole, and esomeprazole. esomeprazole. omeprazole and esomeprazole are approved. No PPI has been approved for use in infants younger than 1 year of age.
Most studies of PPIs in children are openopen-label and uncontrolled. In children, as in adults, PPIs are highly efficacious for the treatment of symptoms due to GERD and the healing of erosive disease. PPIs have greater efficacy than H2RAs. At this moment, in Europe, only Europe,

Children 1 to 10 years of age appear to require a higher dose per kilogram for some PPIs than adolescents and adults. Young children require higher per kilogram doses to attain the same acid blocking effect or area under the curve (304 (304306). This may not apply to all of the PPIs(307). There are few pharmacokinetic data for PPIs in infants, but studies indicate that infants younger than 6 months may have a lower per-kilogram dose perrequirement than older children and adolescents (308,309).

Uso de Inhibidores de Bomba de protones en nios

Journal of Pediatric Gastroenterology and Nutrition 49:498 49:498547 # 2009 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition
y

PPIs inhibit acid secretion by blocking Na Na KK- ATPase, the final common pathway of parietal cell acid secretion, often called the proton pump. Studies in adults have shown that PPIs produce higher and faster healing rates for erosive esophagitis than H2RAs, which in turn are better than placebo (122).

Despite their efficacy in the management of acid related disorders, PPIs have limitations as a consequence of their pharmacologic characteristics. They must be taken once per day before breakfast and must be protected from gastric acid by enteric coatings. Bioavailability of PPIs is decreased if they are not taken before meals. meals. However, taking the medications before meals effectively delays absorption and onset of their antisecretory effect. Most available PPIs are therefore regarded as delayed release preparations.

The superior efficacy of PPIs is largely because of their ability to maintain intragastric y pH at or above 4 for longer periods and toinhibit meal-induced acid secretion, a mealcharacteristic notshared by H2RAs. In contrast with H2RAs, the effect ofPPIs does not H2RAs, diminish with chronic use. The potent suppression of acid secretion by PPIs also results in decrease of 24-hour 24intragastric volumes, thereby facilitating gastric emptying and decreasing volume reflux.
y

Achievement of maximal acid suppressant effect can take up to

4 days.

Tratamiento Quirrgico
RGE que no responde a tratamiento mdico . Riesgo de complicaciones severas ej : Estenosis pptica Esfago de Barrett. Episodios con riesgo de vida para el paciente. Persistencia de esofagitis severa a pesar del tratamiento mdico. En nios con dao neurolgico al que se le realice una gastrostoma y presente RGE persistente.

Ciruga Antireflujo.
  

Operacin de Nissen. Operacin de Thal. Operacin de Boix Ochoa.

Hoy en da se puede realizar en forma convencional o por va laparoscpica inclusive ya existe una serie peditrica publicada con tcnica endoscpica. Para establecer cual es el abordaje mas conveniente en cada caso, todava falta tiempo , que permita comparar las diferentes series. Las ventajas de cada tcnica depende entre otras cosas del entrenamiento del equipo quirrgico

Gracias por su atencin !!

Caminante, no hay camino, se hace camino al andar A.Machado.