GASTROESOPHAGEAL REFLUX

GER --- GERD

 GASTROESOPHAGEAL REFLUX

DEFINITION:

• PATHOPHYSIOLOGY
• EPIDEMIOLOGY
• CLINICAL SYMPTOMS
• DIAGNOSIS
• THERAPY
• FOLLOW UP

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• DEFINITION GER:

• INVOLUNTARY REFLUX OF GASTRIC CONTENTS

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DEFINITION GERD:

• INVOLUNTARY REFLUX OF GASTRIC

• CONTENTS WITH SYMPTOMS OR
• COMPLICATIONS

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FINDINGS:

• ESOPHAGITIS

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FINDINGS:

• ESOPHAGITIS
• STRICTURES

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FINDINGS:

• ESOPHAGITIS
• STRICTURES
• LARYNGITIS

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FINDINGS:

• ESOPHAGITIS
• STRICTURES
• LARYNGITIS
• ANEMIA

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FINDINGS:

• ESOPHAGITIS
• STRICTURES
• LARYNGITIS
• ANEMIA
• PNEUMONIA

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PATHOPHYSILOGY:

• RELAXATION OF LES
• DIAPHRAGM
• INCISURA CARDIALIS
• MOTILITY OF ESOPHAGUS

• NEUROGENIC

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NO TREATMENT:

• EROSION & ULCERATION OF MUCUS MEMBRANE

• STENOSIS
• MALIGNANCY

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EPIDEMIOLOGY:

• 66% OF ALL INFANTS TILL 4 MONTHS

• 5% WITH 12 MONTHS

• 2 – 10 % TODDLERS &
SCHOOLCHILDREN

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SYMPTOMS:

• INFANTS vs. TODDLERS

• PHYSIOLOGIC GER vs.

• PATHOLOGIC GERD

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INFANT:

• VOLUME OF ESOPHAGUS

• PHYSIOLGICAL REGURGITAION

• NORMAL FEEDING

• NORMAL WEIGHT GAIN

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SYMPTOMS I:

• VOMITING
• FAILURE TO THRIVE
• IRRITABILITY
• HEART BURN
• HEMATEMESIS
• DYSPAHGIA

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SYMPTOMS II:

• APNEAS/ALTE
• WHEEZING
• HOARSNESS
• COUGH
• POSTURE

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ESOPHAGITIS:

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ESOPHAGITIS:

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HIATAL HERNIA:

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DIAGNOSTIC PROCEDURES:

• HISTORY
• ULTRASOUND
• GASTRIC ENEMA
• SCINTIGRAM
• pH-MONITORING
• ENDOSCOPY

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HISTORY:

• VERY IMPORTANT
• EXACT AND THOROUGH
• EXAMINATION

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ULTRASOUND:

• ROUTINE IN PEDIATRIC PATIENTS

• THICKNESS OF MUCOUS MEMBRANE
• CARDIAC REGION
• EMPTYING OF STOMACH

• NOT DEFINITELY RELIABLE

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GASTRIC ENEMA:

• ANATOMY OF UIT
• SWALLOWING
• FILLING OF STOMACH
• EMPTYING OF STOMACH
• PROVOCATION OF GER EPISODES
• EXCLUSION OF HIATAL HERNIA

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SCINTIGRAM:

• TECHNETIUM SOLUTION
• RADIOACTIVE CAMERA
• NOT STANDARDIZED
• TIME CONSUMING & EXPENSIVE
• EXPOSURE TO RADIOACTIVITY

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pH-MONITORING I:

• 24 HOURS MONITORING
• GOLD STANDARD
• DIFFERENCE pH ESOPHAGUS vs.
• STOMACH

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pH-MONITORING II:

• 16 – 24 HRS. MEASUREMENT
• PROCOTCOL (ACTIVITIY, FEEDING,
• SLEEPING, SIGNS OF REFLUX,
• BREATHING PATTERN)

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pH-MONITORING III:

• INDEX OF REFLUX

• COURSE OF TOTAL pH
• COURSE OF pH < 4
• PERCENT PART OF TOTAL TIME

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ENDOSCOPY:

• GENERAL ANESTHESIA
• ONLY WHEN GERD IS SUSPECTED
• VISUALIZATION OF ESOPHAGUS
• STOMACH, DUODENUM
• HISTOLOGY

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THERAPY:
• DIET
• POSTURE
• MEDICATION
– ANTACIDA
– PROKINETICS
– H2 RECEPTOR ANTAGONISTS
– PROTON PUMP INHIBITOR

SURGERY
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DIET:

• CHANGE IF COW‘S MILK ALLERGY

• ANTIREFLUX FORMULAS
• REPEATED SMALL FEEDINGS
• NO CHANGE IN BREAST FEEDING

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POSTURE:

• PRONE vs. SUPINE

• PRONE: SID RISK
• DISCUSSION OF SITTING POSITION

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MEDICATION I:

• DEPENDENT ON SYMPTOMS, AGE,

• PROGNOSIS

• SOCIETIES OF GASTROENTEROLOGY
• RECOMMEND STEPWISE PROCEDURE

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MEDICATION II:

• PROKINETICS: NOT AVAILABLE

• ANTACIDS: NOT IN CHILDREN
• ALGINATES: NOT IN CHILDREN
• METOCLOPRAMID: NO EFFECT IN CHILDREN
• ERYTHROMYCIN: NOT RECOMMENDED
• GAB-RECEPTOR-ANTAGONIST: MIGHT BE HELPFUL IN
TETRASPASTIC CHILDREN
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MEDICATION III:

• H2-RECEPTOR-ANTAGONISTS
• NOT ENOUGH STUDIES IN CHILDREN
• PPI (OMEPRAZOL, PANTOPRAZOL)
• NOT ENOUGH EXPERIENCE IN CHILDREN

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SURGERY:

• 85 – 90 % SUCCESS
• CAREFUL INDICATION

• PROBLEMS: GASBLOAT, DUMPING SYNDROME,

IMPOSSIBILITY TO VOMIT

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 FLOW SHEET GERD

REPEATED FEEDINGS
CLINICAL COURSE POSTURE
REDUCTION OF AMOUNT
MEASUREMENTS COW‘S MILK FREE

NO IMPROVEMENT PPI or H 2 BLOCKERS

ENEMA pH
ENDOSCOPY PPI

NO IMPROVEMENT

MEDICATION
SURGERY ?

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FOLLOW UP:

• MEDICAL TREATMENT 10 WEEKS

• ESOPHAGITIS: CONTROL ENDOSCOPY

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SUMMARY:

• OFTEN IN INFANTS, BENIGN COURSE

• DIAGNOSIS BY HISTORY
• COMPLICATIONS NEED FURTHER PROCEDURES
• DIFFERENT TREATMENTS: FEEDING, POSTURE,
MEDICATION, SURGERY

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