GER GERD€¦ · GERD -pathophysiology •transient lower oesophageal sphincter (LES) relaxation...
Transcript of GER GERD€¦ · GERD -pathophysiology •transient lower oesophageal sphincter (LES) relaxation...
GER GERD
GER – GASTROESOPHAGEAL REFLUX passive return of gastric contents retrograde into the oesophagus
GERD – GASTROESOPHAGEAL REFLUX DISEASE –
GERD definition: Gastroesophageal reflux disease which causes adverse signs and symptoms
GERD
Gastroesophageal reflux disease which causes adverse signs and symptoms
GERD - pathophysiology
• transient lower oesophageal sphincter (LES) relaxation unassociated with swallowing
• delayed gastric emptying
• increased acid secretion
• hiatal hernia
DISEASES ASSOCIATED WITH INCREASED RISK OF GERD IN CHILDREN
• cerebral palsy• Down syndrome• oesophageal atresia with repair• hiatal hernia• asthma• bronchopulmonary dysplasia• cystic fibrosis• obesity
GERD in children
GERD in full-term infants
GERD in children olderthan 1 year
FACTORS PREDISPOSING TO FUNCTIONAL GER IN INFANTS
• short oesophagus• low pressure of LES• supine position • small gastric volume and compliance• fluid diet • high volume of meals
(150 ml per kg per 24h)
GER IN INFANTS
• Functional GER (physiological uncomplicated reflux) 30% of infantsReffers to healthy infants „happy spitters” with regurgitation
• Pathogenic GER (GERD) 1:300Infants with complications: symptoms of esophagitis, respiratory or neurobehavioral problems
GERD-SYMPTOMS IN INFANCY
SIGNS OF OESOPHAGITIS• loss of apetite• poor weight gain• iron deficiency anemia• hematemesis
CHANGES IN BEHAVIOUR• irritability• sleeping problems• Sandifer’s syndrome
RESPIRATORY SYMPTOMS• chronic cough (often
nocturnal)• recurrent infection
of lower and upper respiratory tract
• wheezing• apnea
SANDIFER’S SYNDROME
Arching or twisting of the neck or back in infants and small children with severe acid GERD (1%)
The head positioning is the mecha nism to protect the airways and reduce discomfort associated with acid reflux
SANDIFER’S SYNDROME
GERD - SYMPTOMS IN ELDER CHILDREN
• vomiting• chestpain• epigastric pain • waterbrush• dysphagia• odynophagia• loss of apetite
• chronic cough• hoarseness and/or laryngitis• sore throat• dental erosions• halitosis
GERD - DIAGNOSTIC EVALUATION
• trial of acid–supressing drugs (PPI 2-4 weeks)
• oesophageal 24h pH probe monitoring /multichannelintraluminal impedance monitoring
• gastroscopy with esophageal biopsy
• barium radiography
ESOPHAGEAL pH-PROBE MONITORING
• pH probe placed in distal oesophagus measures the severity and frequency of acid reflux (numer and duration of reflux episodes with esophageal pH<4)
• Usefull in demostrating an association between acid reflux and atypical symptoms (cought, apnea, stridor)
MULTICHANNEL INTRALUMINAL IMPEDANCE MONITORING
detects movements of both acidic and nonacidic fluids, solids and air in the oesophagus
Combined pH/MII monitoring is a test of choice to diagnose non specific symptoms
GASTROSCOPY WITH ESOPHAGEAL BIOPSY
reflux esophagitismucosal damage (erosions, ulcer) at the lower part
of the oesophagus
BARIUM RADIOGRAPHY(UPPER GI TRACT SERIES)
• usefull for evaluating anatomic abnormalities of g.i. tract:hiatal herniaesophageal/duodenal stricture malrotation
• not usefull for evaluating GERD
BARIUM RADIOGRAPHY
MANAGEMENT OF GER IN INFANTS „Happy spitters”
• reduce the feeding volume /increase the frequency of feedings
• thickened feedings with cereals• upright position after feeding• parenteral reassurance on therapeutic course
In most cases of GER no diagnostic study is requiredReflux resolves spontaneusly in 85% infants
by 12 month of age
THICKENING FEEDINGS
• potato starch• rice• carob (sain’t John’s bread)
Formulas for infants with GER
AR – Anti Regurgitationem
CAROB TREE AND FRUITS
REFLUX BOARD
REFLUX BOARD
MANAGEMENT OF GERD IN INFANTS
• lifestyle modifications
• exclusion of cows-milk allergy
• farmacological treatment
• surgery (?)
2 weeks milk-free diet with extensively hydrolised milk formulaand milk challenge
GERD IN INFANTS DIFFERENCIAL DIAGNOSIS
• food allergy (cow’s milk allergy)• congenital anomalies of gastrointestinal tract • urinary tract infections• hydrocephalus, increased intracranial pressure• metabolic disorders
MANAGEMENT OF GERD IN ELDER CHILDREN
• lifestyle modificationsavoidance carbonated drinks, chocolate, caffeine, foodcontaining high amount of fat, spices and acid (citrus juices)
• pharmacological treatmentacid suppresants (PPIs, H2RAs)antiacidsprokinetic agents
• surgery (?)
GERD PHARMACOLOGICAL TREATMENT
• antiacids
• proton pomp inhibitors
• H2- blockers
• prokinetics
ANTIACIDS
- directly buffer acid in oesophagus and stomach- heal mucosal inflammation- less effective than PPIs- adverse effects: aluminium toxicity- on demand
• alginates• sucralfat• aluminium and magnesium salts• hyaluronic acid• sodium bicarbonate
PROTON PUMP INHIBITORS
• omeprazole 1 mg/per kg/day for 6 weeks -3 months• lansoprazole• esomeprazole• dexlansoprasole
administration: 30 minutes before meals (1-2 dose/day)safe, fewer side effectsdexlansoprasole – may be given after meals
H2-BLOCKERS
- decrease the secretion of acid by inhibiting histamine-2 receptor - less effective than PPIs- effect of tachyphylaxis
• ranitidine (5-10 mg/kg/d divided in 2-3 doses)
PROKINETICS
- increase lower esophageal sphincter pressure- improve gastric emptying- administration 3-4 times/day before meals- adverse effects: cisapride-cardiac arrhytmia, diarrhoea
• cisapride (serotonin receptor agonist)• domperidone (metoclopramide derivate)• itopride >16y (dopamine receptor antagonist)
PRECAUTIONS IN THE USE OF CISAPRIDE
• Total dose should not exceed 0.8 mg/kg per/day Avoid concomitant use of macrolides, such as erythromycin, azithromycin and clarithromycin and azole antifungals such as ketoconazole
• Do not use in patients with a previous history of dysrhythmias or electrolyte disturbances.
• Use with caution in premature infants with immature cytochrome P450 3A4 activity
• ECG monitoring during treatment is required Parental education about proper dosing and drug interactions
NISSEN FUNDOPLICATION
Stomach (gastric fundus) is wrapped around the lower part of the esophagus restoring the function of LES
ANTIREFLUX SURGERY
Severe symptoms unresposive to medications• Persistent vomiting with failure to thrive• severe oesophagitis or oesophageal stricture• life threatening apneis spells• large hiatal hernia• neurological handicap• chronic pulmonary dis. unresponsive to treatment
ULCER DISEASE
• Ulcer – disruption in the mucosal layer of the stomach or duodenum
• Erosion – superficial ulcer (disruption of the epithelium)
• Gastritis –inflammation of the gastric mucosa without disruption of the mucosa (may be confirmed only by histologic examinatiotion)
ULCER DISEASE
DEFENSIVE FACTORS
• mucous gel layer• local production
of bicarbonate• regulation of gastric acid
secretion• adequate mucosal blood flow
OFFENSIVE FACTORS
• Helicobacter pylori infection • acid-pepsin environment• mucosal ischemia• Bile• NSAID
Helicobacter pylori
• spiral gram negative bacteria
• colonizes mucus adhering gastric mucosa
• produces urease, catalase, cytotoxins, lipopolysaccharase
• urease converts urea to ammonium and bicarbonate
Helicobacter pylori-prevalence
• Prevalence in Poland: 30% children 84% adults
• 80-90% patients H. pylori positive is asymptomatic• 10-15% develop ulcer disease/antral gastritis• 0,1% - risk of neoplasm in future (gastric lymphoma and
adenocarcinama)
ULCER DISEASE - SYMPTOMS
• abdominal pain - epigastric area or righ upper quadrant, worsened at night and after the meals
• vomiting, nausea• loss of apetite • poor growth• iron deficiency anaemia• upper GI bleeding
ULCER DISEASE - COMPLICATIONS
• acute bleeding (neonates)• iron deficiency anaemia (chronic bleeding)
• perforation
• gastric outlet obstruction (duodenal and pyloric channel ulcers)
ULCER DISEASE - DIAGNOSIS
• Gastroduodenoscopy- diagnostic aim- therapeutic aim for acute bleeding-urease test- biopsy with hematoxylin and eosin staining
• 13C-urea breath test
• H. pylori antigen in stool (cheap, sensitive, noninvasive)
• serum antibodies against H. pylori (not reliable, usefull for epidemiological reserch)
H. pylori infection in childrenantral nodular gastritis (nodular gastropathy)
Helicobacter pylori–associated peptic ulcer in the duodenal bulb
ULCER DISEASE -TREATMENT
PROTON PUMP INHIBITORS (6-8 weeks)1 mg/per kg/day (0,5-3,3)
• omeprazole • lansoprazole• pantoprazole • esomeprasole• dexlansoprasole
Recommended options for first-line therapy for H pylori infection
H pylori antimicrobial susceptibility
Known• Susceptible to CLA and to MET PPI-AMO-CLA 14d with
standard dose• Resistant to CLA, susceptible to MET PPI-AMO-MET 14d or
bismuth-based• Resistant to MET, susceptible to CLA PPI-AMO-CLA 14d or
bismuth-based• Resistant to CLA and to MET PPI-AMO-MET 14d with high
dose for amoxicillin or bismuth-based
Unknown• High-dose PPI-AMO-MET 14d or bismuth-based
Helicobacter pylori eradicationsecond-line treatment
quadriple therapy
I Amoxicillin + Metronidazole + bismuth salts +PPI or
II Amoxicillin + Metronidazole + Tetracyclin +PPI (children > 11y)
biopsy with culture and susceptibility testing
H. pylori treatment (drugs and doses)
• PPI: 1-2 mg/kg/d (high dose 2-2,5 mg/kg/d)• Amoxicillin: 50mg/kg/d (high dose 60-100mg/kg/d)• Claritromycine : 20 mg/kg/d• Metronidazole: 20 mg/kg/d• Bismuth salts: 8 mg/kg/d
Indications for the treatment of Helicobacter pylori infection in children
• active or previous gastric and duodenal ulcer• chronic gastritis • long term NSAID’s treatment or immunosupressive
treatment
• iron deficiency anaemia resistant to treatment• idiopathic thrombocytopenia