GERD IN CHILDREN
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Transcript of GERD IN CHILDREN
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