Issues in diagnosis management of

GERD in children

PRESENTED BY:Virendra Gupta

GUIDED BY: Dr. B. S. Sharma Sir

DefinitionsGER

Passage of gastric contents into the esophagus with or without regurgitation or vomiting.

NASPGHAN GUIDELINES 2009;49:498-547.

Retrograde movement of gastric contents across the lower esophageal sphincter (LES) into the esophagus.

Nelson textbook of pediatric_19th e-

Regurgitation (spitting-up) -Effortless movement of stomach contents into the esophagus and mouth.

Nelson textbook of pediatric_19th e-

DefinitionsGERD Presence of troublesome symptoms and/or complications of persistent GER.

NASPGHAN GUIDELINES 2009;49:498-547

orGER becomes pathological when it causes troublesome symptoms and physical complications, hence the term gastro esophageal reflux disease (GERD).

Nelson textbook of pediatric_19th e-

GERD-EPIDEMIOLOGY

• GERD – One of the commonest gastrointestinal diagnoses in pediatric practice in the West

• Prevalence of an abnormal quantity of GER in infants- 8%

Vandenplas et al ,Pediatrics 1991;88:834-840

GERD-EPIDEMIOLOGY

• 10 % of babies from a well baby clinic(62 / 602 babies) had symptoms of GER

De S et al Trop Gastroenterol. 2001 ; 22(2):99-102

• GER - 35% of cases with respiratory symptoms (recurrent bronchopneumonia, reactive airway disease and chronic cough)

Jain A et al, J Trop Ped.2002;48:39-42

Prevalence of GERD in Asthmatic Children

• A significant no. of childhood asthmatic patients experience GERD

• 25-75% have abnormal intra esophageal pH

• Only 50% have esophageal symptoms of GERD

Pediatr Drugs.2005;7:177-186

J Pediatr Gastroenterol Nutr 2001; 32: S1

CONDITIONS WITH HIGHER PREVALENCE

• Cerebral palsy

• Mentally challenged

• TEF

• Obesity

GER- NATURAL COURSE

Infant reflux• 1st few months of life - Becomes evident• 4 month of life - Peaks • 12 month of life - Resolves in up to 88% • 24 month of life - Resolves nearly all older children• Tend to be chronic, waxing and waning• 50% completely resolves• 50% resembles adult patterns of GER

PREVALENCE OF GER IN INFANCY

0

10

20

30

40

50

60

70

% o

f in

fan

ts

0-3 months 4-6 months 7-9 months 10-12 months

Age (months)

> 1 time a day

Arch Pediatr Adolescent Med 1997:151-159

GER is common in infants and most of them outgrow it by 1 year of age

AETIOLOGY OF GERD• Genetic predisposition• Environmental factors

– Food habit – Eating fast– Obesity – Stress – Exposure to tobacco smoke

• Nerologically impaired children

ESOPHAGUS

• Exposed to a variety of potentially noxious substances.

• Major challenge to the integrity of esophageal function is GER

ESOPHAGEAL DEFENSES: THREE TIERS

• Anti reflux barrier - Lower esophageal sphincter, The diaphragmatic pinchcock and Angle of His

• Esophageal clearance - Limit the duration of contact between luminal contents and esophageal epithelium

• Esophageal mucosal resistance - Comes into play when reflux contact time is prolonged

LES• High pressure zone-Length

3-6 cm & Pressure of about 20 mmHg

• Pressure < than 6 mmHg favors GER

• 20% of all reflux episodes occur in relation to a decreased basal low resting LES pressure

(Cadiot et al Gut 1997)

INTRA-ABDOMINAL ESOPHAGUS

• Rt & Lt crus of diaphragm produces a pinch cock action to constrict esophagus at the hiatus

• Length of the intra abdominal esophagus->2cm

ANGLE OF HIS

•An acute angle between the greater curvature of the stomach and the esophagus •If the angle is obtuse as in hiatal hernia this favors GER episodes.

PATHOPHYSIOLOGY OF GERD

• Transient LES relaxation• Reduced esophageal body

peristalsis

Gastricdistension

Vagally mediated abnormal

neural control of LES

Increase in GER

Haital herniaobtuse angle of His

Low basal LES toneDefective LES motilityIncreased TLESRs

Overfeeding overweight

increased abdominal pressure

Impaired pH neutralizationDelayed acid clearance Poor mucosal resistanceGERD

symptoms

Neonates/Infants

Regurgitation-especially postprandially

Signs Of Esophagitis- (irritability, arching, choking, gagging, feeding aversion)

failure to thrivePoor weight gain

Older Children/Adolescents

Early morning nauseaAbdominal discomfortBurps that burnSub sternal painHeartburn Recurrent vomiting •Sandifer syndrome-

neck contortions (arching, turning of

head)

Non GI Manifestations of GERDExtra-esophageal symptoms

Otorhinolaryngeal

• Chronic otitis media

• Hoarseness

• Globus sensation

• Persistent cough

• Sore throat

Pulmonary

• Asthma

• Recurrent pneumonias

• Chronic Cough

• Apnoea

Non GI Manifestations of GERD

Extra-esophageal symptoms

•Excessive coughing,

•Irritability

•Sleep disturbances

•Poor appetite

• Acute life threatening events (ALTE)

• Bradycardia

• Abnormal posturing / arching (Sandifer’s syndorme)

• Dental erosions / waterbrash

COMPLICATIONS

• Erosive esophagitis• Stricture• Barrett esophagus• Adenocarcinoma• Weight loss• Failure to thrive • Progressive pulmonary

fibrosis• Adenoidal enlargement• Otitis media

Asthma & GERD

Coexistence seems to be more frequent than would be expected for a chance occurrence.

Asthma GERD

Asthma + GERD

Does GERD cause Asthma ? Does asthma cause GERD?

Does Asthma Trigger GERD? Proposed Mechanisms

Coughing

Increase Intraabdominal

Pressure

Increasing Pressure Gradient

Across The LES

Asthma Medications

Lower LESPressureGERD

Does GERD Trigger Asthma?

Am J Med 2001; 111: 37S

Reflux TheoryDirect contact between

gastric refluxate and lung tissues

Inflammation of the airway

Bronchial smooth muscle

reactivity

Does GERD Trigger Asthma?

Moser et al, Gastroenterology 1991; 101: 1512Tuchman et al, Gastroenterology 1984; 87: 872

Reflex TheoryEsophagus and bronchial tree have identical embryological derivation

Share common innervation (via vagus nerve) and common reflexes

Stimulation of receptors in distal esophagus by refluxate

Leads to vagal reflux

Producing bronchial constriction and/or cough

GER& ASTHMA

• Medical therapy does not consistently improve pulmonary function, asthma symptoms or need of asthma medication

• Approach to GER related asthma should be individualized

• Selected subgroup of asthmatics benefit from anti reflux therapy

Cochrane Systematic Review

Naspghan’s Recommendations

Asthma exacerbations despite compliance with asthma therapy

Frequent episodes of nocturnal asthma or nocturnal cough

Two or more courses of systemic corticosteroids per year despite maintenance asthma medication use.

Work up and /or initiation of empiric therapy for GERD in the child with asthma should be considered in the following situations:-

All patients with severe refractory asthma should undergo

oesophgeal pH monitoring to evaluate the presence of GERD.

Severe refractory asthma

When to suspect GERD associated Asthma?

• Associated typical symptoms of GERD

• Nocturnal cough

• Difficult to control asthma

GER & Chronic cough

• GERD is currently considered the third leading cause of chronic cough affecting an estimated 20 % of patients

• Most patients do not have heartburn or regurgitation

• Anti reflux therapy combined with lifestyle changes have reported cough resolution in 70-100% of patients

DIAGNOSIS

• GERD is diagnosed on basis of history & clinical features

• An empiric trial of PPI therapy is a widely used diagnostic test

GERD symptoms questionnaire

• Developed for infants and young children

• Individual symptom score calculated as the product of symptom frequency and severity score

• Useful in distinguishing symptomatic GERD from healthy children

Deal L et al JPGN 2005

INVESTIGATIONS FOR GERD

Goal Investigation

1-Documenting reflux

2-Documenting tissue

damage

3-Establishing GER as

etiology of episodic symptoms

4-Documenting Anatomical deficiency

1-24 hr pH monitoring

-Scintiscan

2-Endoscopy, Occult blood

in stool

3-pH monitoring

4-Barium study

DIFFERENTIALS

Esophageal motility disorders

Eosinophilic esophagitis

Crohn's disease

•Most quantitative and sensitive method•Cumbersome & not easily available•Used to correlate symptoms with reflux episode•Probe inserted acc to length calculated by strobel’s formula {5+ 0.252x length in cm}•All medications discontinued 72hrs before test•Reflux episode: ph <4•Reflux index : % of time when esophageal ph is <4•Mild- 5- 10%•Moderate -10-20%•Severe >20%•Now wireless capsules are available

24 HOUR ESOPHAGEAL PH MONITORING

INDICATIONS FOR ESOPHAGEAL PH MONITORING

1. For assessing efficacy of acid suppression during treatment

2. Evaluating apneic episodes in conjunction with a pneumogram and perhaps impedance

3. Evaluating atypical GERD presentations such as chronic cough, stridor, and asthma

Performed in children withvomiting and dysphagiaEvaluate for-AchalasiaEsophageal Strictures StenosisHiatal HerniaGastric OutletIntestinal Obstruction It has poor sensitivity and specificity in the diagnosis of GERD

CONTRAST RADIOGRAPHIC STUDY (USUALLY BARIUM)

•In most of patients normal so not useful for GERD

•To identify complications like ulcers, strictures, barrett’s esophagus

•Biopsies can be obtained for early diagnosis of barrett’s & cancers

•Biopsies can differentiate other causes of esophagitis like eosinophilic esophagitis

ENDOSCOPY

• Both for diagnosing GERD and for understanding esophageal function

• Cumbersome test

• Multiple sensors and a distal ph sensor

• Document acidic reflux, weakly acidic reflux, and weakly alkaline reflux

• An important tool in respiratory symptoms

• Determination of nonacid reflux

MULTICHANNEL INTRALUMINAL IMPEDANCE (MII)

Evaluates for-• Visible airway signs a/w extra esophageal

GERDPosterior laryngeal inflammationVocal cord nodules

• Diagnosis of silent aspiration

• Evaluation for dysmotility

LARYNGOTRACHEOBRONCHOSCOPY

•Using of high-dose proton pump inhibitor (PPI)

•useful in adolescent and adults

•Diagnosis most of time clinical

•Response to treatment is considered as confirmed diagnosis

Pitfalls•Does not include diagnostic tests

•Gastritis & peptic ulcers presents & responds similarly

•20% may have placebo effects

EMPIRICAL ANTIREFLUX THERAPY (THERAPEUTIC TRIAL)

•Helpful in diagnosing delayed gastric emptying

•Low radiation hazard

•Useful when fundoplication is considered

NUCLEAR SCINITISCAN

ESOPHAGEAL MOTILITY TESTING

• RESEARCH TOOL

• USEFUL TO EVALUATE NON RESPONDERS

ESOPHAGEAL IMPEDENCE

USEFUL FOR NON ACID REFLUX AS DETECT LIQUID IN ESOPHAGEAL LUMEN

GERD Investigations

• To establish a cause and effect relationship between reflux and symptoms such as irritability, heart burn , coughing, choking etc.

• To exclude exacerbating causes such as gastric emptying delay, anatomical abnormalities

• To document damage due to reflux and to exclude associated conditions-esophageal strictures, Barret,s esophagus etc.

Management of GERD

Treatment Goals of GERD

TREATMENT

• POSITIONING

• DIETARY MEASURES

• PHARMACOTHERAPY

• SURGERY

POSITIONING

• Head end elevation about 30 degree

• Left lateral positioning• Prone positioning• <1yr not recommended, can

be done in awake state as during sleep risk of SIDS outweigh the benefits

• Don’t use soft bed during prone positioning

DIETARY MODIFICATIONS

• Small feed with increase in frequency• Increase proportion of solids or semisolids • Avoid spicy foods, tea, coffee, cola & late evening

meals alcohol & tobacco• Avoid acid containing foods like citrus juices,

carbonated beverages, and tomato juices• Chewing gum is useful as it increases production of

bicarbonate containing saliva & increases rate of swallowing and promote acid clearance

PHARMACOTHERAPY

ACID REDUCING AGENTS• H2 receptor antagonists• Proton pump inhibitors• Antacids

PROKINETICS• Metaclopromide • Bethanechol• Erythromycin• Baclofen• Cisapride

Proton pumpHistamineH+

K+

H+

K+,Cl- K+,Cl-HCl

K+

H2 receptors antagonists

Proton pump inhibitors

Antacids

Mode of Action

Thus PPIs block the final step in gastric acid secretion.

ANTACIDS

• Good for symptomatic relief as are short acting

• Best to take app. 1 hr after meal or before symptoms of reflux

• Calcium containing antacids should be avoided as promote gastrin secretion

• Use antacids containing both aluminum & magnesium

HISTAMINE ANTAGONISTS

• Selective inhibition of histamine receptors on gastric parietal cells• Best taken 30 minutes before meals as blood levels peaks when

stomach is producing acid actively• Effects last for 6 hrs• Used for uncomplicated GERD• Tachyphylaxis or diminution of response after long term used

• CIMETIDINE 40mg/kg /day TID • RANITIDINE 1-2 mg/kg /day BD• FAMOTIDINE1 mg/kg day BID• NIZATIDINE 10 mg/kg /day BID

PROTON PUMP INHIBITOR

• Shuts off acid production more completely and for longer period of time

• Especially useful for complications or inadequate response by histamine receptor antagonists

• Available as capsules containing enteric coated granules that can be emptied in soft foods or liquids

• Should be taken30 minutes before meals for maximal effect

• No PPI is approved for use in infants

• OMEPRAZOLE 0.3-3.5mg/kg /day BD• LANSOPRAZOLE<10KG 7.5 MG OD, 10-30 KG 15 MGOD >30KG 30MG

OD[0.73-1.66mg/kg/day]• PANTOPRAZOLE[0.5 -1 mg /kg/day]• ESOMEPRAZOLE 1.0 mg/kg QD

PRO MOTILITY DRUGS

• Increase pressure in LES & strengthen peristalsis of esophagus , speeds up gastric emptying

• None affects the frequency of TLESRs

• Most effective when 30 min before meals

• Reserved for non responders or to enhance other treatments of GERD

• METOCLOPROMIDE 0.4-0.8 mg/kg / day QID[5,10 MG,5MG/5ML] (dopamine-2 and 5-HT3 antagonist)

• BETHANECHOL (cholinergic agonist)• ERYTHROMYCIN (motilin receptor agonist)• BACLOFEN (centrally acting γ-aminobutyric acid (GABA) agonist )• CISAPRIDE 0.8 mg/ kg/day QID[1MG/ML,10 MG, 20MG](serotonergic agent)• MOSAPRIDE 0.5-0.8 mg/kg/day QID

FOAM BARRIERS

• Composed of an antacid and a foaming agent

• Forms physical barrier to reflux

• Best taken after meals

• Available as magaldrate with alginate

SURGERY

• FUNDOPLICATION IS DONE

• USUALLY WHEN MEDICAL THERAPY FAILS

• DONE BY LAPAROSCOPY OR LAPAROTOMY

• COMPLICATION IS STICKING OF FOOD

ENDOSCOPIC TREATMENT

• SUTURING OF LES

• APPLICATION OF RADIOFREQUENCY WAVES

• INJECTION OF MATERIAL INTO WALLS

REASONABLE APPROACHES

Take Home Message

• A common childhood problem

• More common in select pediatric populations

• Diagnosis is essentially clinical , based on high index of suspicion

• Trial of therapy is justified in patient with high degree of suspicion

• Investigations required in individualized cases