gastroesophageal reflux (ing)

8/10/2019 Gastroesophageal Reflux (Ing)

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GER : the involuntary passage of gastriccontents into the eshopaghus

Regurgitation : reflux dribbled efffortlesslyinto or out of the mouthVomiting : forceful expulsion of

gastrointestinal contents into theesophagus


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3 months old infant with regurgitation 4-6times a day

Sometimes through out from the noseWeight gain is OK (normal growth)Parenteral concern

Gastro Esophageal Reflux (GER)


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9 months old infant with regurgitation 4-6times a day since 3 months old

Refuse to feedSometimes with hematemesisFailure to thrive

Gastro Esophageal Relux Disease (GERD)


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6 years old child with sinusistisNot response to standard treatment

Referring for esophageal PH monitoringRelated to gastroesopageal refluxGood response to prokinetic drug

Spectrum of GERD


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GER and GERDInfant - Older Children - Adult


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FrequencyOf

Regurgitation

Age0-3 mo

Age4-6 mo

Age&-3 mo

Age10-12

mo

1-4

x/day

74% 65% 30% 4%

>4x/day 21% 10% 5% 0%Problem

?

24% 18% 16% 4%


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GER is a physiologic phenomenaPostprandial

Regurgitation occur everyday in 70%infants aged 4 months and 25% ofparents considered as a problem

GER resolve spontaneously in 55% infantsat 10 months of age and 81% by the ageof 18 months


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Infants Older child /adolescent

- Feeding refusal- Recurrent vomiting- Poor weight gain- Iritability Colic- Apnea or apparent lifethreatening event(ALTE)- Arching or head-tilting(pseudo torticollis)

- Recurrent vomiting- Heartburn- Esophagitis- Dysphagia- Asthma- Reccurent pneumonia- Upper airway symptoms(e.g : chronic cough,hoarse voice)


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Incompetense LES (lower esophagealsphincter)

Delayed gastric emptyingAnatomic position of LES above thediaphragma in infancy


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Due to regurgitation respiratory symptomFailure to thrive - recurrent cough, wheezing,sinusitis - apnea, cyanotic spells

-stridor, hoarnessDue to esophagitis

Irritability Neurobehavioral symptom

Anorexia - abnormal posture andmovemenHematemesis - sandifer syndromemelena


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GER GERD Regurgitation with normalweight gain

No signs or symptoms ofesophagitis

No significant respiratorysymptom

No neurobehavioral

symptomps

Regurgitation with weight lossor inadequate weight gain

persistent irritability, pain ininfants, dysphagia, food refusal,hematemesis, melena, iron,deficiency anemia apnea and cyanosis, sleepdisturbance, wheezing orstridor, aspiation or reccurentpnemonia, chronic cough,hoarseness abnormal posturing, sandiferssyndrome


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GER

OdynophagiaHeartburn

Esophagitis

Fundoplication

Diagnosticprocedure

VisceralHyperalgesia

Refuse to eatAnorexiaEarly satiety


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Diagnosis is uncertainFailure of conservative treatment

Suspect of complications- failure to thrive- esophagitis

- respiratory complication- neurobehavioral symptomParenteral anxiety


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Barium mealEsophageal PH monitoring

ScintigraphyEndoscopy and biopsyManometry

Bioelectric impedance monitoring


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Gold standardFrequency and duration of reflux

episode can be mesuredCorrelation between reflux event andepisodic apnea

Chronic respiratory symptom infants canbe cause by freflux, even withoutvomiting (silent gastroesophageal reflux)


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To detect esophagitisGER with atypical manifestation sucj as

neurobbehavioral symptom


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Conservative treatmentAdequate burp

Thickening of formulaHypoallergenic formulapositioning


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Pharmacologic treatmentProkinetic : cisapride (0.2 mg/kg/dose 3-

4 doses)Acid supressor- cimetidine (20-40 mg/kg/day 3-4 doses)- ranitidine (4-8 mg/kg/day 2-3 doses)- omeprazole (1-3 mg/kg/day 1-2 doses)

surgical interventionfundoplication


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Infection Intestinal obstruction- otitis media - pyloric stenosis- gastroenteritis - malrotation- urinary tract infection - intussuception- meningitis

non obstructive GIdisease

Drug and toxic - gastroesophageal refluxMetabolic diseases - appendicitis

- gastritis


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Hypertrophic pyloric stenosis- same onset at 4 weeks old- expulsive vomiting- peristaltic wave- abdonimal mass- abdominal ultrasonographyIntestinal obstruction (anatomic defect)- antral web, stenosis and malrotation- barium meal


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GER is a common symptom occur ininfants and usually resolve spontaneously

with ageDiagnostic evaluation has to be done inpathologic GER to confirm the diagnosisand complications, including bariummeal, esophageal PH monitoring andendoscopy


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Treatment follow stepwise approach,starting fro conservative advice to

medical treatmentSurgical intervention (fundoplication)reserve only for for cases failed tooptimal medical treatment

gastroesophageal reflux (ing)

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