GGASTROASTRO EESOPHAGEAL SOPHAGEAL RREFLUXEFLUX ( ( G E R G E R ))

( ( RREFLUKS EFLUKS GGASTRO ASTRO EESOFAGIAL / SOFAGIAL / R G E R G E ))

Bambang MulyawanBambang Mulyawan

FK-UMMFK-UMM

Pendahuluan / Definisi

• RGE : disfungsi sfingter esofagus bawah RGE : disfungsi sfingter esofagus bawah (SEB) (SEB) regurgitasi isi lambung ke regurgitasi isi lambung ke esofagusesofagus

• Makanan / minuman yg kembali dari Makanan / minuman yg kembali dari lambung ke esofagus : lambung ke esofagus : 11. masuk kembali ke . masuk kembali ke lambung lambung 22. dikeluarkan. dikeluarkan mulut/”muntah” mulut/”muntah”

Pendahuluan ..... (lanjutan)

• Regurgitasi : kembalinya Regurgitasi : kembalinya tanpa upaya tanpa upaya makanan yg sudah ditelan ke dalam mulutmakanan yg sudah ditelan ke dalam mulut

• Fisiologik: GER Fisiologik: GER REGURGITASI PD REGURGITASI PD BAYI NORMALBAYI NORMAL

• Patologik : Patologik : GERD , episode sering / GERD , episode sering / persisten persisten eosofagits, gejalan akibat eosofagits, gejalan akibat espiratoriespiratori

Definition

• Passive transfer of Passive transfer of gastric contents into gastric contents into the esophagus due the esophagus due

to transient or to transient or chronic relaxation chronic relaxation

of the lower of the lower esophageal esophageal sphinctersphincter

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Definisi

• GER : mengalirnya secara involunter isi GER : mengalirnya secara involunter isi lambug ke dalam eosofaguslambug ke dalam eosofagus

• Regurgitasi : gejala paling umum dari GER Regurgitasi : gejala paling umum dari GER infantilinfantil

• ““gumoh “ spitting upgumoh “ spitting up

Definitions

• Gastroesophageal RefluxGastroesophageal Reflux – Involuntary return of gastric Involuntary return of gastric

contents into the esophagus as a contents into the esophagus as a result of a dysfunctional lower result of a dysfunctional lower esophageal sphincteresophageal sphincter

• Physiologic vs Pathologic Physiologic vs Pathologic

• Extraesophageal RefluxExtraesophageal Reflux

Epidemiologi

• Insidens RGE di Indonesia : ?Insidens RGE di Indonesia : ?

• 50% pada Bayi Baru Lahir : “normal”50% pada Bayi Baru Lahir : “normal”

• Klinis : refluks / muntah ? Klinis : refluks / muntah ?

• Refluks : pasif karena katup esofagus – Refluks : pasif karena katup esofagus – lambung belum berfungsi baik. lambung belum berfungsi baik. Muntah:pengeluaran isi lambung Muntah:pengeluaran isi lambung mulut mulut dengan paksadengan paksa

Epidemiology• First described as a clinical entity in pediatrics in the 1950’sFirst described as a clinical entity in pediatrics in the 1950’s

– incidence 1/4000 live birthsincidence 1/4000 live births

• Cherry and Margulies (1968) - Cherry and Margulies (1968) - contact ulcers of the larynxcontact ulcers of the larynx

• Three-fold predominance in boys over girlsThree-fold predominance in boys over girls

• Increased incidence in certain clinical conditionsIncreased incidence in certain clinical conditions– neurologic impairment neurologic impairment

– prematurity (70% preemies <1700 grams) prematurity (70% preemies <1700 grams)

– diaphragmatic herniadiaphragmatic hernia

– esophageal atresia esophageal atresia

– feeding tubesfeeding tubes

– gastric/intestinal mobility disorders gastric/intestinal mobility disorders

– various syndromesvarious syndromes

Epidemiologi

• Birth to 2 yearsBirth to 2 years– Physiologic, especially < 6 monthsPhysiologic, especially < 6 months– 90% resolve by 12-18 months90% resolve by 12-18 months

• 2 years to adulthood2 years to adulthood– Vomiting is never physiologicVomiting is never physiologic– GERD is chronic relapsing diseaseGERD is chronic relapsing disease

Epidemiologi

• Gastroesophageal Reflux (GER)Gastroesophageal Reflux (GER)– Reflux of gastric contents into esophagusReflux of gastric contents into esophagus– Normal physiologic processNormal physiologic process– 50% of infants 0-3 months of age50% of infants 0-3 months of age– 25% of infants 3-6 months of age25% of infants 3-6 months of age– 5% of infants 10-12 months of age5% of infants 10-12 months of age– 20% of pH probe reflux episodes are visible 20% of pH probe reflux episodes are visible

refluxreflux– Result of Transient LES relaxationsResult of Transient LES relaxations

Pengertian / istilah

• “ “ Possetting” : pengeluaran isi lambung Possetting” : pengeluaran isi lambung sehabis makan, meleleh keluar dari mulut, sehabis makan, meleleh keluar dari mulut, didahului sendawa/ “glegeken”didahului sendawa/ “glegeken”

• ““Rumination” : keluarnya isi lambung ke Rumination” : keluarnya isi lambung ke dalam mulut, mengunyah dan telan kembalidalam mulut, mengunyah dan telan kembali

• Istilah masyarakat : ‘olab’ (Sunda), Istilah masyarakat : ‘olab’ (Sunda), ‘gumoh’ (Jawa), ‘menduga’ ‘gumoh’ (Jawa), ‘menduga’ (Minang),‘meluah’(Bali)(Minang),‘meluah’(Bali)

Pengertian / istilah . . .

• Gastroesophageal reflux (GER) = Gastroesophageal reflux (GER) = physiologic refluxphysiologic reflux

• GERD = gastroesophageal reflux disease = GERD = gastroesophageal reflux disease = reflux with complicationsreflux with complications

• Dysphagia = difficulty or problems with Dysphagia = difficulty or problems with swallowingswallowing

G E R X G E R D

• Gastroesophageal reflux (Gastroesophageal reflux (GERGER), passage of ), passage of gastric materials into the esophagus, is a gastric materials into the esophagus, is a normalnormal physiologic process that canphysiologic process that can progress progress to to gastroesophageal reflux disease (gastroesophageal reflux disease (GERDGERD) when ) when the expelled gastric materials produce the expelled gastric materials produce undesirable symptoms and complicationsundesirable symptoms and complications

• It is therefore appropriate to think of GER as a It is therefore appropriate to think of GER as a normal, benign physiologic process that normal, benign physiologic process that precedes GERD, a pathologic processprecedes GERD, a pathologic process

Anatomy and Physiology

• Esophageal phaseEsophageal phase– Peristalsis moves food to stomachPeristalsis moves food to stomach– Lower esophageal sphincter relaxesLower esophageal sphincter relaxes– Upper esophageal sphincter, Lower esophageal Upper esophageal sphincter, Lower esophageal

sphincter constrict preventing refluxsphincter constrict preventing reflux

Oesophagus: Conduit between mouth and stomach

Stomach: Digestion of proteins; foodstuffs reduced to liquid form; storage; sterilisation

Pancreas: Digestive enzymes for digestion of fats, carbohydrates and proteins

Liver: Bile salts for digestion/absorption of fats in small intestine

Gallbladder: Stores and concentrates bileSmall intestine: Final stages of chemical digestion and nutrient absorption

Large intestine: Water absorption, bacterial fermentation and formation of faeces

Mouth: Foodstuffs broken down by chewing; saliva added as lubricant

Pathophysiology

• The primary barrier against GE The primary barrier against GE reflux is the lower esophageal reflux is the lower esophageal sphinctersphincter– sphincter lacks appropriate sphincter lacks appropriate

tone or other incompetencytone or other incompetency

– gastric volume or pressuregastric volume or pressure

– poor gastric emptyingpoor gastric emptying

– altered neuromuscular altered neuromuscular developmentdevelopment

– abnormal esophageal motilityabnormal esophageal motility

– acuity of the angle of Hisacuity of the angle of His

– other anatomic defectsother anatomic defects

Pathophysiology

1.1. A decrease in lower esophageal sphincter (LES) A decrease in lower esophageal sphincter (LES) tone –-- the most important factors tone –-- the most important factors

2.2. Changes in the pressure gradients between the Changes in the pressure gradients between the esophagus and stomachesophagus and stomach

3.3. Stress maneuvers include straining, crying, Stress maneuvers include straining, crying, coughing, eating, or the valsalva maneuver coughing, eating, or the valsalva maneuver

4.4. Other factors include gastric distention, Other factors include gastric distention, delayed esophageal clearance and gastric delayed esophageal clearance and gastric emptying, neurologic disease, and hiatal herniaemptying, neurologic disease, and hiatal hernia

Patogenesis

• Neonatus : tonus otot SEB belum sempurna, Neonatus : tonus otot SEB belum sempurna, panjang belum maksimalpanjang belum maksimal

• Para ahli : penyebab RGEPara ahli : penyebab RGEketidak ketidak mampuan SEB menahan kembalinya isi mampuan SEB menahan kembalinya isi lambung karena tekanan SEB yg rendah/ lambung karena tekanan SEB yg rendah/ cenderung pada periode relaksasi otot SEBcenderung pada periode relaksasi otot SEB

• Dapat terjadi pd > tekanan intra abdominal, Dapat terjadi pd > tekanan intra abdominal, meteorismus, sepsis, tumormeteorismus, sepsis, tumor

Patogenesis • Jarang terjadi pd waktu tidur : pengosongan Jarang terjadi pd waktu tidur : pengosongan

lambung dan aktifitas menelan lebih lambatlambung dan aktifitas menelan lebih lambat• Posisi tengkurap dg kepala lebih tinggi Posisi tengkurap dg kepala lebih tinggi

menurunkan frekuensi RGEmenurunkan frekuensi RGE• Pengaruh pH esofagus : < 4 merangsang Pengaruh pH esofagus : < 4 merangsang

peningkatan peristaltiknya > insidens RGEpeningkatan peristaltiknya > insidens RGE• RGE: menimbulkan ggn pertumbuhan, striktura, RGE: menimbulkan ggn pertumbuhan, striktura,

esofagitis, hematemesis,infeksi sal nafas berulang, esofagitis, hematemesis,infeksi sal nafas berulang, kadang menimbulkan kematian mendadak kadang menimbulkan kematian mendadak (( Sudden Infant Death Syndrome ) Sudden Infant Death Syndrome )

Faktor Resiko

• Genetic - autosomal dominantGenetic - autosomal dominant• Immaturity of the LESImmaturity of the LES• Increased abdominal pressureIncreased abdominal pressure• Gastric distentionGastric distention• Esophagus dysmotilityEsophagus dysmotility• PrematurityPrematurity• Neurologic problemsNeurologic problems• Chronic lung disorderChronic lung disorder• H.Pylori infectionH.Pylori infection• Cow’s milk allergyCow’s milk allergy

Gejala klinis

• ““Muntah” tidak proyektil/ ortu menganggap Muntah” tidak proyektil/ ortu menganggap normal, kecuali terus menerusnormal, kecuali terus menerus

• Infeksi paru berulangInfeksi paru berulang

• Muntah saat bayi ditidurkan setelah makanMuntah saat bayi ditidurkan setelah makan

• Bila pH isi lambung < 4 : esofagitis, Bila pH isi lambung < 4 : esofagitis, striktura, disfagia, perdarahanstriktura, disfagia, perdarahan

• Gagal tumbuh kembang (Gagal tumbuh kembang (Failure to thrive)Failure to thrive)

GER Symptoms

• Vomiting (72%)Vomiting (72%)

• Abdominal pain (36%)Abdominal pain (36%)

• Feeding problems (29%)Feeding problems (29%)

• Failure to thrive (28%)Failure to thrive (28%)

• Irritability (19%)Irritability (19%)

• Heartburn (1%)Heartburn (1%)

Clinical Features

• RegurgitationRegurgitation—mild symptoms—no treatment—mild symptoms—no treatment• Recurrent vomiting occurs in 50%of infants in the first Recurrent vomiting occurs in 50%of infants in the first

three months of life, in 67% of four month old infants, three months of life, in 67% of four month old infants, and in 5% of 10 to 12 month old infantsand in 5% of 10 to 12 month old infants

• OesophagitisOesophagitis, failure to thrive or recurrent aspiration , failure to thrive or recurrent aspiration pneumonia—severe and complications—need to pneumonia—severe and complications—need to treattreat

• Risk of severe GERRisk of severe GER —premature infants,infants with —premature infants,infants with cerebral palsy,and infants with congenital cerebral palsy,and infants with congenital oesophageal anomaliesoesophageal anomalies

Clinical Presentation• Classic symptomsClassic symptoms

– vomiting, pain / irritability, failure to thrivevomiting, pain / irritability, failure to thrive• Hiccuping, yawning, and sneezingHiccuping, yawning, and sneezing

• Severe symptomsSevere symptoms– Pulmonary compromise Pulmonary compromise

• apnea, pneumonia, wheezing, asthma, stridorapnea, pneumonia, wheezing, asthma, stridor

– Epigastric bleeding, anemia, hematemesisEpigastric bleeding, anemia, hematemesis

– esophagitisesophagitis

– Sandifer syndromeSandifer syndrome

• ““Silent reflux”Silent reflux”

Gejala klinis

• Bila asam lambung ke faring : aspirasi pneumoni, obstruksi Bila asam lambung ke faring : aspirasi pneumoni, obstruksi dg gejala spt asmadg gejala spt asma

• Penyakit paru : serangan apnea, pneumoni berulang, batuk Penyakit paru : serangan apnea, pneumoni berulang, batuk malam hari /kronis, wheezing berulang, sering muntah malam hari /kronis, wheezing berulang, sering muntah malammalam

• Sudden Infant Death Syndrome (SIDS) : imaturitas sal nafas Sudden Infant Death Syndrome (SIDS) : imaturitas sal nafas

/ rentan infeksi, / rentan infeksi, Resapiratory Distress SyndromeResapiratory Distress Syndrome, , infeksi infeksi

paru berulangparu berulang, , spasme laringspasme laring

• Perdarahan mukosa esofagus distal karena erosi dan radang Perdarahan mukosa esofagus distal karena erosi dan radang kroniskronis

• Head cocking (Head cocking (gerakan seperti mengangguk), anemi besi gerakan seperti mengangguk), anemi besi ((Sindrom Sandifer )Sindrom Sandifer )

Complications of gastroesophageal reflux

• Recurrent vomitingRecurrent vomiting• Weight loss or poor weight gainWeight loss or poor weight gain• Irritability in infantsIrritability in infants• RegurgitationRegurgitation• Heartburn or chest painHeartburn or chest pain• HematemesisHematemesis• Dysphagia or feeding refusalDysphagia or feeding refusal• Apnea Apnea • Wheezing or stridorWheezing or stridor• HoarsenessHoarseness• CoughCough

Diagnosis

• Fluroskopi dg kontras BariumFluroskopi dg kontras Barium

• Memeriksa pH esofagusMemeriksa pH esofagus

• Radionuclide Gastro EsofagosgrafiRadionuclide Gastro Esofagosgrafi

• Biopsi esofagusBiopsi esofagus

• Keterlambatan waktu pengosongan Keterlambatan waktu pengosongan lambunglambung

Diagnosis Banding

• Hiatus herniaHiatus hernia

• AkhalasiaAkhalasia

• Stenosis pilorus hipertrofi kongenitalStenosis pilorus hipertrofi kongenital

• Obstruksi/ atresia duodenumObstruksi/ atresia duodenum

• Mekonium ileusMekonium ileus

Penatalaksanaan

• 80% kasus dapat teratasi dg intervensi minimal, sebelum 80% kasus dapat teratasi dg intervensi minimal, sebelum dipertimbangkan pembedahandipertimbangkan pembedahan

• Pemberian ASI/SF dan posisi bayi, formula hipoalergi, Pemberian ASI/SF dan posisi bayi, formula hipoalergi, anti regurgitasianti regurgitasi

• Penambahan serealPenambahan sereal

• Farmakoterapi : antasida dan pelindung mukosa Farmakoterapi : antasida dan pelindung mukosa ( sukralfat), prokinetik ( domperidone,metoclopramide), ( sukralfat), prokinetik ( domperidone,metoclopramide), antagonis reseptor histamin H2 ( cimetidine, ranitidin), antagonis reseptor histamin H2 ( cimetidine, ranitidin), inhibitor pompa proton ( omeprasol, lansopresol) inhibitor pompa proton ( omeprasol, lansopresol)

• Pembedahan anti refluks : pd RGE dg komplikasi beratPembedahan anti refluks : pd RGE dg komplikasi berat

Summary • Very common during 1Very common during 1stst year of life year of life• Reduced LES pressure or greater LES relaxationReduced LES pressure or greater LES relaxation• GERGERDD = Aspiration (chronic cough or wheeze), = Aspiration (chronic cough or wheeze),

Esophagitis, failure to thriveEsophagitis, failure to thrive• Dx: Clinical, Esophageal pH probe, Dx: Clinical, Esophageal pH probe, UGI series (anatomy)UGI series (anatomy)

• Medical tx: Thickened feeds, position, acid Medical tx: Thickened feeds, position, acid suppression, pro-kinetic agentsuppression, pro-kinetic agent

• Surgical tx: Nissen fundoplicationSurgical tx: Nissen fundoplication

Anatomy and Physiology

• Swallowing reflex begins at Swallowing reflex begins at 16 weeks gestation16 weeks gestation

• Can suckle by 2Can suckle by 2ndnd to 3 to 3rdrd trimestertrimester

• 34 weeks, infant can suckle 34 weeks, infant can suckle and feed normallyand feed normally

• Pharyngeal phase earlier Pharyngeal phase earlier developeddeveloped

• Oral preparatory phase Oral preparatory phase maldeveloped in premature maldeveloped in premature infantsinfants

Anatomy and Physiology

• Infant larynx at C2-C3Infant larynx at C2-C3

• Adult larynx at C5-C7Adult larynx at C5-C7

• At 4 months, enlargement of oropharynx, At 4 months, enlargement of oropharynx, descent of larynx causes dysphagiadescent of larynx causes dysphagia

• Chewing begins at 6 monthsChewing begins at 6 months

• 40% efficacy of chewing at 6 years40% efficacy of chewing at 6 years

Anatomy and Physiology

• Swallow divided into 4 phasesSwallow divided into 4 phases– Oral preparatory phaseOral preparatory phase– Oral transport phaseOral transport phase– Pharyngeal phasePharyngeal phase– Esophageal phaseEsophageal phase

Anatomy and Physiology

• Oral preparatory phaseOral preparatory phase– Suckle in infant, mastication in child and adultSuckle in infant, mastication in child and adult– Soft palate meets base of tongue and epiglottis Soft palate meets base of tongue and epiglottis

allowing breathing during suckleallowing breathing during suckle

• Oral transport phaseOral transport phase– Anterior tongue propels bolus back to Anterior tongue propels bolus back to

oropharynxoropharynx

Anatomy and Physiology

Pharyngeal phasePharyngeal phase– Vocal folds closeVocal folds close– Arytenoid cartilages tilt up and forwardArytenoid cartilages tilt up and forward– Base of tongue moves posteriorlyBase of tongue moves posteriorly– Epiglottis moves posteriorlyEpiglottis moves posteriorly– Soft palate closes off nasopharynxSoft palate closes off nasopharynx– Larynx elevates, cricopharyngeal muscle Larynx elevates, cricopharyngeal muscle

relaxesrelaxes

Anatomy and Physiology

• Cough reflexCough reflex– Present in 25% of children less than 5 days oldPresent in 25% of children less than 5 days old– Tactile receptors present at highest Tactile receptors present at highest

concentrations at larynx and bifurcations of concentrations at larynx and bifurcations of airwayairway

– C-fiber receptors respond to chemical stimuliC-fiber receptors respond to chemical stimuli– Stretch receptors present in bronchioles Stretch receptors present in bronchioles

Normal Daily GE Reflux

Hassall E 2005 Nelson SP 1998

20 GER episodes/24 hours are normal!!

Pathophysiology

The pathogenesis of GERD is involvingThe pathogenesis of GERD is involving• The frequency of reflux The frequency of reflux • Gastric acidity and gastric emptyingGastric acidity and gastric emptying• Esophageal clearing mechanismsEsophageal clearing mechanisms• The esophageal mucosal barrierThe esophageal mucosal barrier• Visceral hypersensitivityVisceral hypersensitivity• Airway responsivenessAirway responsiveness

1.1. PH (<4) in the refluxatePH (<4) in the refluxate

Diagnosis

• Upper GI SeriesUpper GI Series

The upper gastrointestinal (GI) series is neither The upper gastrointestinal (GI) series is neither sensitive nor specific for the diagnosis of GER, but is sensitive nor specific for the diagnosis of GER, but is useful for the evaluation of the presence of anatomic useful for the evaluation of the presence of anatomic abnormalities, such as pyloric stenosis, malrotation abnormalities, such as pyloric stenosis, malrotation and annular pancreas in the vomiting infant, as well and annular pancreas in the vomiting infant, as well as hiatal hernia and esophageal stricture in theolder as hiatal hernia and esophageal stricture in theolder child.child.

Diagnosis

• Esophageal pH MonitoringEsophageal pH Monitoring• Esophageal pH monitoring is a valid and Esophageal pH monitoring is a valid and

reliable measure of acid reflux. reliable measure of acid reflux. • Esophageal pH monitoring is useful to Esophageal pH monitoring is useful to

establish the presence of abnormal acid establish the presence of abnormal acid reflux, and to assess the adequacy of therapy reflux, and to assess the adequacy of therapy in patients. in patients.

• Esophageal pH monitoring may be normal in Esophageal pH monitoring may be normal in some patients with GERD, particularly those some patients with GERD, particularly those with respiratory complicationswith respiratory complications..

Diagnosis

• Endoscopy and BiopsyEndoscopy and Biopsy • Endoscopy with biopsy can assess the presence and Endoscopy with biopsy can assess the presence and

severity of esophagitis, strictures and Barrett’s severity of esophagitis, strictures and Barrett’s esophagus.esophagus.

• Exclude other disorders, such as Crohn’s disease Exclude other disorders, such as Crohn’s disease and eosinophilic or infectious esophagitis.and eosinophilic or infectious esophagitis.

• A normal appearance of the esophagus during A normal appearance of the esophagus during endoscopy does not exclude histopathological endoscopy does not exclude histopathological esophagitis; subtle mucosal changes such as esophagitis; subtle mucosal changes such as erythema.erythema.

Management

• Diet Changes in the InfantDiet Changes in the Infant• There is evidence to support a one to two-week trial There is evidence to support a one to two-week trial

of a hypoallergenic formula in formula fed infants with of a hypoallergenic formula in formula fed infants with vomiting.vomiting.

• Milk-thickening agents do not improve reflux index Milk-thickening agents do not improve reflux index scores but do decrease the number of episodes of scores but do decrease the number of episodes of vomiting.vomiting.

Management

• Positioning in the InfantPositioning in the Infant• Esophageal pH monitoring has demonstrated Esophageal pH monitoring has demonstrated

that infants have significantly less GER when that infants have significantly less GER when placed in the prone position than in the supine placed in the prone position than in the supine position. However, prone positioning is position. However, prone positioning is associated with a higher rate of the sudden associated with a higher rate of the sudden infant death syndrome (SIDS). In infants from infant death syndrome (SIDS). In infants from birth to 12 months of age with GERD, the risk birth to 12 months of age with GERD, the risk of SIDS generally outweighs the potential of SIDS generally outweighs the potential benefits of prone sleeping. Therefore, non-benefits of prone sleeping. Therefore, non-prone positioning during sleep is generally prone positioning during sleep is generally recommended.recommended.

Management

• Positioning in the InfantPositioning in the Infant• Supine positioning confers the lowest risk for SIDS Supine positioning confers the lowest risk for SIDS

and is preferred. and is preferred. • Prone positioning during sleep is only considered in Prone positioning during sleep is only considered in

unusual cases.unusual cases.• When prone positioning is necessary, it is particularly When prone positioning is necessary, it is particularly

important that parents be advised not to use soft important that parents be advised not to use soft bedding, which increases the risk of SIDS in infants bedding, which increases the risk of SIDS in infants placed prone.placed prone.

Management

• Positioning in the Child & AdolescentPositioning in the Child & Adolescent• In children older than one year it is likely that there is In children older than one year it is likely that there is

a benefit to left side positioning during sleep and a benefit to left side positioning during sleep and elevation of the head of the bed.elevation of the head of the bed.

• Lifestyle Changes in the Child & Lifestyle Changes in the Child & AdolescentAdolescent

• children and adolescents with GERD avoid caffeine,children and adolescents with GERD avoid caffeine,

chocolate and spicy foods that provoke symptomschocolate and spicy foods that provoke symptoms..

Management

• Acid-suppressant TherapyAcid-suppressant Therapy• Histamine-2 receptor antagonists (H2RAs) produce Histamine-2 receptor antagonists (H2RAs) produce

relief of symptoms and mucosal healing. relief of symptoms and mucosal healing. • Proton pump inhibitors (PPIs), the most effective Proton pump inhibitors (PPIs), the most effective

acid suppressant medications, are superior to H2RAs acid suppressant medications, are superior to H2RAs in relieving symptoms and healing esophagitis.in relieving symptoms and healing esophagitis.

• Chronic antacid therapy is generally not Chronic antacid therapy is generally not recommended since more convenient and safe recommended since more convenient and safe alternatives (H2RAs and PPIs) are available.alternatives (H2RAs and PPIs) are available.

Management

• Surgical TherapySurgical Therapy• Surgery is often considered for the child with GERDSurgery is often considered for the child with GERD

who has persistence of symptoms following who has persistence of symptoms following medicalmedical

management or who is unable to be weaned from management or who is unable to be weaned from medical therapy.medical therapy.

• The Nissen fundoplication is the most popular of The Nissen fundoplication is the most popular of the many surgical procedures that have been used.the many surgical procedures that have been used.

• Recently experience with laparoscopic procedures Recently experience with laparoscopic procedures has been reported. Results and complication rates has been reported. Results and complication rates do not appear to vary by procedure.do not appear to vary by procedure.

Management

• Prokinetic TherapyProkinetic Therapy• Cisapride reduces the frequency of symptoms, Cisapride reduces the frequency of symptoms,

including regurgitation and vomiting. including regurgitation and vomiting. • The potential for serious cardiac arrhythmias in The potential for serious cardiac arrhythmias in

patients receiving cisapride, appropriate patient patients receiving cisapride, appropriate patient selection and monitoring as well as proper use, selection and monitoring as well as proper use, including correct dosage (0.2mg/kg/dose QID) and including correct dosage (0.2mg/kg/dose QID) and avoidance of co-administration of contraindicated avoidance of co-administration of contraindicated medications, are important. medications, are important.

• Other prokinetic agents have not been shown to be Other prokinetic agents have not been shown to be effective in the treatment of GERD in child.effective in the treatment of GERD in child.

Gastro-Esophageal Reflux

Aim and Claim

1.1. Familiar with the Familiar with the normal features and normal features and assessment of assessment of digestive system.digestive system.

2.2. Get hold of theGet hold of the examination of examination of digestive system. digestive system.

Key points

◎◎ The common symptoms of gastrointestinal The common symptoms of gastrointestinal disease in childhood, its pathogenesis and disease in childhood, its pathogenesis and managementmanagement

◎◎ The presentation of common infections of The presentation of common infections of the gastrointestinal tractthe gastrointestinal tract

◎◎ Assessment for dehydration in a child with Assessment for dehydration in a child with diarrhoea and how to carry out rehydrationdiarrhoea and how to carry out rehydration

◎◎ Chronic gastrointestinal disorders that can Chronic gastrointestinal disorders that can lead to malabsorption and failure to thrive lead to malabsorption and failure to thrive

◎◎ Infections that can affect the liver Infections that can affect the liver

Normal Features and AssessmentNormal Features and Assessment

Oesophagus: Conduit between mouth and stomach

Stomach: Digestion of proteins; foodstuffs reduced to liquid form; storage; sterilisation

Pancreas: Digestive enzymes for digestion of fats, carbohydrates and proteins

Liver: Bile salts for digestion/absorption of fats in small intestine

Gallbladder: Stores and concentrates bileSmall intestine: Final stages of chemical digestion and nutrient absorption

Large intestine: Water absorption, bacterial fermentation and formation of faeces

Mouth: Foodstuffs broken down by chewing; saliva added as lubricant

Severe key points

1.1. Normal function of the gastrointestinal tract Normal function of the gastrointestinal tract

2.2. Oral feeding Oral feeding

3.3. Intestinal microfloraIntestinal microflora

4.4. Stool :meconium, green-brown transition stool, Stool :meconium, green-brown transition stool, gold-like stool, orange-like stool gold-like stool, orange-like stool

5.5. A palpable liver and a soft spleen tipA palpable liver and a soft spleen tip

6.6. A protuberant abdomen in infant and toddlers A protuberant abdomen in infant and toddlers

Examination Of The Gastrointestinal Tract

Examination of the gastrointestinal tract （ 1 ）

Systemic signs of dysfunction Systemic signs of dysfunction

◎ ◎AneamiaAneamia

◎◎JaundiceJaundice

◎◎ClubbingClubbing

◎◎OedemaOedema

◎ ◎Distended veinDistended vein

◎◎DehydrationDehydration

Examination of the gastrointestinal tract （ 2 ）

• Exposure pelvic regionExposure pelvic region ：： dondon‘‘t miss t miss torsion of the testis or incarcerated hernia torsion of the testis or incarcerated hernia

• Inspection of the abdomen Inspection of the abdomen

• Palpation of the abdomen Palpation of the abdomen

• Hernial orifices region Hernial orifices region

• Scrotum and anal regionsScrotum and anal regions

• Rectal examinationRectal examination

腹部检查 视诊视诊　　• 注意有无腹胀，肠型，肠蠕动波和腹式呼吸 注意有无腹胀，肠型，肠蠕动波和腹式呼吸 听诊听诊　　• 正常肠鸣音，每分钟正常肠鸣音，每分钟 11 ～～ 55 次。肠鸣音减少或消失，次。肠鸣音减少或消失，

可能为肠麻痹；肠鸣音不规则的亢进，提示有肠道感可能为肠麻痹；肠鸣音不规则的亢进，提示有肠道感染可能；肠鸣音高亢、气过水声、金属音则常表示肠染可能；肠鸣音高亢、气过水声、金属音则常表示肠梗阻的存在 梗阻的存在

叩诊叩诊　　• 腹胀明显者应检查肝浊音是否消失，有无移动性浊音，腹胀明显者应检查肝浊音是否消失，有无移动性浊音，

对腹腔脏器破裂、出血、穿孔的诊断甚为重要。鼓音对腹腔脏器破裂、出血、穿孔的诊断甚为重要。鼓音明显者提示肠腔充气，有梗阻可能。肝浊音区消失是明显者提示肠腔充气，有梗阻可能。肝浊音区消失是穿孔的表现 穿孔的表现

腹部检查 触诊触诊　　• 腹部触诊是关系到能否正确诊断的重要环节腹部触诊是关系到能否正确诊断的重要环节• 检查应由非疼痛部位开始，逐渐移向疼痛部检查应由非疼痛部位开始，逐渐移向疼痛部

位，要反复对比各部位的反应，找出压痛及紧位，要反复对比各部位的反应，找出压痛及紧张部位、范围和程度，可疑时应反复检查，最张部位、范围和程度，可疑时应反复检查，最好能争取在小儿安静时或入睡后再次检查好能争取在小儿安静时或入睡后再次检查

• 应强调三层（轻、中、重）检查法，在施行检应强调三层（轻、中、重）检查法，在施行检查中要观察各种手法时，患儿面部表情、局部查中要观察各种手法时，患儿面部表情、局部拒按、哭叫程度是否严重。若全腹柔软，疼痛拒按、哭叫程度是否严重。若全腹柔软，疼痛部位不固定，基本可排除外科急腹症 部位不固定，基本可排除外科急腹症

其他检查 • 注意皮肤出血点，瘀斑，黄疸有助于流行性脑注意皮肤出血点，瘀斑，黄疸有助于流行性脑

脊髓膜炎、败血症、紫癜及肝胆疾病引起腹痛脊髓膜炎、败血症、紫癜及肝胆疾病引起腹痛的诊断的诊断

• 心肺检查可协助诊断大叶性肺炎、胸膜炎，心心肺检查可协助诊断大叶性肺炎、胸膜炎，心脏疾患所致腹痛的诊断脏疾患所致腹痛的诊断

• 检查腹股沟，以免漏诊嵌顿性疝检查腹股沟，以免漏诊嵌顿性疝• 疑有急腹症时应作肛指检查，注意穹窿处有无疑有急腹症时应作肛指检查，注意穹窿处有无

触痛（腹膜炎）、肿块（卵巢囊肿扭转）及血触痛（腹膜炎）、肿块（卵巢囊肿扭转）及血便（肠套叠） 便（肠套叠）

Abdominal Pain

Aim and Claim

• Familiar withFamiliar with the causes acute abdominal the causes acute abdominal painpain

• Get hold of the causes of recurrent Get hold of the causes of recurrent abdominal pain abdominal pain

Acute Abdominal Pain• TraumaTrauma

• InflammationInflammation– Acute gastroenteritisAcute gastroenteritis

– AppendicitisAppendicitis

– PancreatitisPancreatitis

– Henoch-Schonlein PurpuraHenoch-Schonlein Purpura

• AnatomicAnatomic– Bowel obstructionBowel obstruction

– IntussusceptionIntussusception

– VolvulusVolvulus

– Incarcerated herniaIncarcerated hernia

– Gallbladder diseaseGallbladder disease

• Extra-abdominalExtra-abdominal– Lower lobe pneumoniaLower lobe pneumonia

– Strep pharyngitisStrep pharyngitis– DKA DKA (diabetic ketoacidosis) (diabetic ketoacidosis)

– UTI/pyelonephritisUTI/pyelonephritis

– Renal stonesRenal stones

• GynecologicGynecologic– PID PID (pelvic inflammatory disease) (pelvic inflammatory disease)

– Mittelschmerz Mittelschmerz （经间痛）（经间痛）– Dysmenorrhea Dysmenorrhea （痛经）（痛经）– Ovarian cystOvarian cyst

– Ectopic pregnancyEctopic pregnancy

Acute Abdominal Pain Evaluation

• Careful historyCareful history

- Quality/location/timingQuality/location/timing

- Relieving/aggravatingRelieving/aggravating

- Associated symptoms- Associated symptoms

• PhysicalPhysical

– Abdominal exams Abdominal exams –– serialserial

• Distention/BSDistention/BS

• Rebound/rigidity/Rebound/rigidity/guardingguarding

• TendernessTenderness

– Rectal examRectal exam

– Pelvic examPelvic exam

• Abdominal X-rayAbdominal X-ray

– FlatFlat

– UprightUpright

• Specific imagingSpecific imaging

– CT scanCT scan

– UltrasoundUltrasound

• Lab testsLab tests

– CBC/diff, ESR, CRPCBC/diff, ESR, CRP

– UrinalysisUrinalysis

– Serum amylase/lipaseSerum amylase/lipase

Flat: obstructionUpright: perforation

Recurrent Abdominal Pain

• InflammatoryInflammatory– CrohnCrohn’’s Diseases Disease

– Ulcerative ColitisUlcerative Colitis

– Celiac diseaseCeliac disease

• Acid peptic diseaseAcid peptic disease– EsophagitisEsophagitis

– GastritisGastritis

– Gastric/duodenal ulcerGastric/duodenal ulcer

– GE RefluxGE Reflux

• AnatomicAnatomic– Intrabdominal tumor Intrabdominal tumor

(Wilms, neuroblastoma)(Wilms, neuroblastoma)– MeckelMeckel’’s diverticulums diverticulum– MalrotationMalrotation

• Bloating/gas/diarrheaBloating/gas/diarrhea– Lactose intoleranceLactose intolerance– GiardiasisGiardiasis

• Functional Functional （（ 90%90% ））– Irritable Bowel SyndromeIrritable Bowel Syndrome– FRAPFRAP

Vomiting

Aim and claimAim and claim

Understand the causes of vomiting Understand the causes of vomiting

Vomiting• AnatomicAnatomic

– Pyloric stenosisPyloric stenosis

– Bowel obstructionBowel obstruction

– MalrotationMalrotation

– IntussusceptionIntussusception

– UlcerUlcer

– GE RefluxGE Reflux

• InflammatoryInflammatory– GastroenteritisGastroenteritis

– Systemic infectionSystemic infection

– AppendicitisAppendicitis

– PancreatitisPancreatitis

– HepatitisHepatitis

– Milk protein allergyMilk protein allergy

• MetabolicMetabolic– Inborn errorsInborn errors

– DKADKA

• CNSCNS– Increased ICPIncreased ICP

– MigraineMigraine

• Post-tussivePost-tussive

• Toxic ingestionToxic ingestion

• ChemotherapyChemotherapy

• PregnancyPregnancy

• GastroparesisGastroparesis– Post-infectiousPost-infectious

– Neurologic impairmentNeurologic impairment

Aim and claim

• Familiar Familiar with the clinical features of with the clinical features of gastro-esophageal refluxgastro-esophageal reflux

• Get hold ofGet hold of the diagnosis of gastro- the diagnosis of gastro-esophageal refluxesophageal reflux

• UnderstandingUnderstanding management of gastro- management of gastro-esophageal reflux esophageal reflux

Vomiting Evaluation

• Bile-stained vomiting suggests obstruction distal Bile-stained vomiting suggests obstruction distal to ampulla of Vaterto ampulla of Vater

• Abdominal plain filmAbdominal plain film– Flat: look for dilated loops of bowelFlat: look for dilated loops of bowel– Upright: look for free air under diaphragmUpright: look for free air under diaphragm

• Contrast radiograph (UGI series, barium enema)Contrast radiograph (UGI series, barium enema)• Electrolyte panel Electrolyte panel –– look for acidosis, disturbance look for acidosis, disturbance• Other labs: UA, amylase/lipase, LFTOther labs: UA, amylase/lipase, LFT• Appendicitis: CBC/diff, CT w/contrastAppendicitis: CBC/diff, CT w/contrast