GASTRO-ESOPHAGEAL-REFLUX

Definition
• GER: the involuntary passage of gastric contents
into the esophagus
• Regurgitation: reflux dribbled effortlessly into or
out of the mouth
• Vomiting: forceful expulsion of gastrointestinal
contents into the esophagus
VOMITING VARIATION
• Common symptom occur in infants and
children
• Mild illness or fatal disease
• Physiologic gastroesophageal reflux
• Overfeeding
• Excessive crying
Clinical gastrointestinal symptoms in the first 4
months of life
• Infantile colic
• GER
• Transient lactose intolerance
• Constipation
• Cows milk allergy
Regurgitation: is it a problem ?
162 infants aged 1-12 months
Visit to the hospital for immunization (RSCM)
• Frequency of regurgitation
• Perception of parents ?
Results  table
Epidemiology (1)
• GER is a physiologic phenomena
• postprandial
• Regurgitation occur everyday in 70'% infants
aged 4 months and 25% of parents considered
as a problem
• Most of physiologic GER resolve
spontaneously by the age of 6-9 months
Epidemiology (2)
• GER resolve spontaneously in 55% infants at
10 months of age and 81% by the age of 18
months
• The peak onset of GER is at 1 -4 months of age
• 10% of GER in infants have complications
• Incidence of GER in premature babies is higher
• 81% of premature infants with GER
experiencing episodic apnea
Etiology-pathogenesis of GER
• Incompetence of LES
• Delayed gastric emptying
• Anatomic position of LES above the diaphragm
in infancy
Natural history GER
Akibat ketidakseimbangan faktor pencegah dan
penyebab → GER

Gangguan pengosongan Bayi Gangguan Kontraksi ↑Gastrin

Lambung esofagitis sudut esof-sfinkter diafragma serum

TLSER ↑ Peristaltik mudah refluks Tekanan SEB ↑

esofagus↓

GER
CMA and GER (lacono et al 1996)
• 204 infants with GER diagnosed with 24 hours pH
monitoring 8 esophageal histopathology
• 41 % of the 204 infants with GER were diagnose
with CMA
• Children with symptoms of colitis, atopic
dermatitis, rhinorhea, allergies or family history of
allergies should warrant greater suspicion of CMA
 Classification of GER

Functional or physiologic GER

Pathologic GER
Secondary GER

GER and GERD

 Complication of GER

Due to regurgitation : Failure to thrive

Due to esophagitis : Irritability, Anorexia,
Hematemesis, Melena
Respiratory symptom : Recurrent cough, wheezing,
sinusitis, apnea, cyanotic spells, Stridor, hoarness
Neurobehavioural symptom: Abnormal posture
and movement, Sandifer syndrome
Clinical Features Differentiating GER and GERD
in Infants
GER
Regurgitation with normal weight gain
No signs or symptoms of esophagitis
No significant respiratory symptom
No neurobehavioral symptoms
GERD
Regurgitation with weight loss or inadequate weight gain
Persistent irritability, pain in infants, dysphagia, food refusal,
hematemesis, melena, iron deficiency anemia
Apnea and cyanosis, sleep disturbance, wheezing or stridor,
aspiration or recurrent pnemonia, chronic cough, hoarseness
Abnormal posturing.
Clinical Features GER
Clinical Features GER
usual unsual congenital & CNS disorder

Specific complication

- Regugirtation - Disphagia - Cronical TR - Intracranial tumor

- Nausea - Hematemesis disease - CP
-Vomiting - Melena - Epigastric pain - Physicomotor
- Apnea, SIDS Retardation
- BW ↓, falure to thrive
- Iritable ( baby )
- refuse drink/eat
• Carre J ? vomit ( 80%) ? Vomit when baby lie
down after given the food. gastric content pH
< 4  esophagitis  stricture  disphagi or
oesophageal bleeding  a tough propotion
Criterion relation between GERD and
pulmonary disease in child
1. Existence of asthma attack
2. Recuring pneumonia
3. Chronical paroxymal cough
4. Recuring Wheezing
5. Paroxymal vomit attack
Endoscopic/histologic Esophagitis in Selected Medical
Conditions

Conditions N Positive esophagitis

Asthma 28 75 (%)
Recurrent croup 16 75
Chronic cough 37 31
apnaa 44 75
Sinusitis 10 100
Stridor 67 6?
Laryngomalacia 28 75
Subglotic stcnosis 34 68

Yellon & Goldeberg, 2001

Presenting symptoms at admission in children with
GER Ashom et al, 2002
76 children (2-17 years) diagnosed with GER Ashom et al, 2002

Abdominal pain 48(63%)

Heartburn 26(34%)
Respiratory 22(29%)
Regurgitation
symptoms 17(22%)
Retrosternal pain 14(18%)
Vomiting 12(16%)
Indication for evaluation
Diagnosis is uncertain
Failure of conservative treatment
Suspect of complications
~ Failure to thrive
~ Esophagitis
~ Respiratory complication
~ Neurobehavioral symptom
Parental anxiety
Diagnostic evaluation
• Barium meal
• Flouroscopy with contrast barium
• Peripheral blood and ferritin
• Esophageal pH monitoring = pH metri
• Scintigraphy
• Endoscopy and biopsy
• Manometry
• Bioelectric impedance monitoring
Barium meal
• Sometime can not detect GER since reflux is
an episodic event
• Rough quantification of reflux
• Presence of esophagitis and dismotily
• Exclude anatomic defect such as antral web,
• stenosis and malrotation
Flouroscopy with contrast barium
to evaluate esophageal condition.
Especially peristaltic and regurgitation
when the baby swallow
Peripheral blood and ferritin
• Iron deficiency anemia indicate the presence
of esophagitis in infants with persistent
vomiting and irritable with or without
hematemesis
• Considered the possibility of other cause of
iron deficiency anemia
Esophageal pH monitoring
• Gold standard
• Frequency and duration of reflux episode can
be measured
• Correlation between reflux event and episodic
apnea
• Chronic respiratory symptom in infants can be
cause by reflux, even without vomiting (silent
GER)
Scintigraphy
• Milk labeled with technetium99m
• Can not detect anatomic defect
• Possibility to detect reflux is higher than
barium meal
Endoscopy and biopsy
• To detect esophagitis
• GER with atypical manifestation such as
neurobehavioral symptom
Management of GER (1)

Conservative treatment
• Adequate burp
• Small frequent feeding
• Thickening of formula
• Positioning
Thickening of formula
• Decrease frequency and volume of vomiting and
infant crying
• Increase caloric density, benefit for infants who arc
failure to thrive
• Special formula
• 1 teaspoon of rice flour or maize for 100 ml of water:
boiled and suspension used for diluting formula
• Hole has to be wide enough to allow easy drip
Management of GER (2)

• Pharmacologic treatment
• Prokinetic: cisapride (0.2 mg/'kg dose 3-4 doses)
• Acid suppressor
• Cimetidinc (20-40 mg/kg/day 3-4 doses)
• Ranitidinc (4-8 mg/kg/day 2-3 doses)
• Omeprazole (1-3 mg/kg day 1-2 doses)
• Surgical intervention: Fundoplication
 Skema pendekatan terapi pada GER

Phase 1A nasehat ke orang tua

Phase 1B AR formula
Phase 2 prokinetic
Phase 3 postion, head
Adjuvant terapi elevated 300
Phase 4 H2 bloker
Esofagitis proton-pomp inhibitor
Phase 5 surgery (fundoplasty)