Gastroesophageal Reflux Disease
Transcript of Gastroesophageal Reflux Disease
Seoul National University Children’s Hospital Pediatric Gastroenterology, Hepatology and
NutritionFellow. Sang Hee, Cho
Gastroesophageal Reflux Disease
Gastroesophageal reflux (GER) : passage of gastric contents into the esophagusGER disease (GERD) : symptoms or complications of GER
Infancy GER- 50% of infants in the first three months of life- 67% of four month old infants- 5% of 10~12 month old infants : resolves spontaneously in nearly all of these infants: small minority of infants develop GERD with symptoms - anorexia, irritability, hematemesis,- dysphagia (difficulty swallowing), - odynophagia (painful swallowing), - arching of the back during feedings, - anemia, failure to thrive
Colin D. Rudolph et al. Pediatric GE Reflux Clinical Practice Guidelines. JPGN, 2001;32:S1-S31
History and Physical Examination
Barium Contrast Radiography
Esophageal pH Monitoring
Multichannel Intraluminal Impedance
Endoscopy and Biopsy
Scintigraphy
Empiric Therapy
Diagnostic Approaches
History and Physical Examination
Barium Contrast RadiographyUpper gastrointestinal series : useful to detect anatomic abnormalities : pyloric stenosis, malrotation, hiatal hernia,
esophageal stricture : sensitivity (31-86%), specificity (21-83%), positive predictive value (80-82%) : brief duration of the upper GI series false negative results
: frequent occurrence of non-pathhological reflux false positive results
Diagnostic Approaches
Reflux index : percentage of the total time - esophageal pH is <4- the most valid measure of reflux - reflects the cumulative exposure of the esophagus to
acidSensitivity : 87-93.3%, Specificity : 92.9-97%Mean upper limit of normal of the reflux index
: 11.7% in infants 0 to 11 months: 5.4% in children 0 to 9 years old: approximately 6% in 432 normal adults
upper limit of normal of the reflux index : up to 12% in the first year of life and up to 6% there-
after
Esophageal pH Monitoring
Esophageal pH Monitoring
Multichannel Intraluminal Im-pedance
Michiel P. et al. Role of the MCII Technique in Infants and Children. JPGN, 2009;48(1):2-12
New diagnostic tool for GERD Combination with manometry : determination of the relation
between esophageal pressures and esophageal bolus flow Symptom Index (SI) = No. of reflux-related symptom/total No. of symptom (positive when above 50%)Symptom Sensitivity Index (SSI) = No. of reflux-related symptom/total No. of reflux (abnormal when higher than 10%)Symptom association probability score (SAP) : statistical means of calculating the probability that the
symptoms and GER episodes found are unrelated : calculated as (1.0-P) * 100%
Multichannel Intraluminal Im-pedance
Michiel P. et al. Role of the MCII Technique in Infants and Children. JPGN, 2009;48(1):2-12
Impedance(electrical resis-tance)
: resistance to electrical current flow between two electrodes
: impedance being inversely proportional to ionic concen-trations of luminal contents
: bolus with relatively low ionic contents (eg, air) : higher im-pedance measurements com-pared with a bolus with rela-tively high ionic contents (eg, saline, refluxate)
Multichannel Intraluminal Im-pedance
Multichannel Intraluminal Im-pedance
Michiel P. et al. Role of the MCII Technique in Infants and Children. JPGN, 2009;48(1):2-12
Multichannel Intraluminal Im-pedance
Limitation : Poor reproducibility, no normal range, costly and time-consuming technique
Multichannel Intraluminal Im-pedance
Endoscopy and Biopsypresence and severity of esophagitis, stric-
tures and Barrett's esophagus,exclude other disorders, such as Crohn's
disease, webs and eosinophilic or infectious esophagitis
Diagnostic Approaches
Lundell. et al. Endoscopic assessment of oesophagitis. Gut. 1998;45;172
Lifestyle Changes-Feeding Changes in Infants-Positioning Therapy for Infants
Pharmacological TherapiesAcid Suppressants
-Histamine-2 receptor antagonists (H2RAs) -Proton Pump Inhibitors-Antacids
Prokinetic TherapySurface Agents
Surgical Treatment
Treatment Options
Pharmacological Thera-pies
Rome III crite-ria
Paul E. et al. Childhood Functional Gastrointestinal Disorders. Gastroenterol-ogy. 2006;130:1519-26
Must include all of the following in otherwiseHealthy infants 3 weeks to 12 months of age:1. Regurgitation 2 or more times
per day for 3 or more weeks2. No retching, hematemesis,
aspiratioin, apnea, failure to thrive, feeding or swallowing difficulties, or abnormal pos-turing
Bilious vomitingGI bleeding : he-
matemesis, hema-tochezia
Forceful vomitingOnset of vomiting after
6 months of lifeFailure to thriveDiarrheaConstipationFeverLethargy
Hep-atosplenomegaly
Bulging fontanelleMacro/microcephalySeizuresAbdominal tender-
ness, distentionGenetic disorder
(eg:Trisomy21)Other chronic disor-
ders(eg:HIV)
Warning Signals in the vomiting infant
Colin D. Rudolph et al. Pediatric GE Reflux Clinical Practice Guidelines. JPGN, 2001;32:S1-S31
Management of an infant with uncomplicated GER(the “happy spit-ter”)
Algorithm
Colin D. Rudolph et al. Pediatric GE Reflux Clinical Practice Guidelines. JPGN, 2001;32:S1-S31
Algorithm
Management of an infant with vomiting and poor weight gain
THANK YOU!!!
Consisted of 14 items – maximum possible score of 31Characteristics of regurgitation : frequency, volumeFeeding refusalWeight gainIrritabilityCrying : daily frequency and correlation with mealHiccupsArching backRespiratory symptomsPosture
Score 7 : value usually indicated as the threshold limit over which the presence of GERD is a possible risk
Infant Gastroesophageal Reflux Question-naire