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GERD

GERD. Objectives. Discuss the prevalence and significance of GERD in the pediatric population Discuss the diagnostic evaluation of the child with suspected GERD Review the management of GERD. Infants Referral Visit MD within the year Regurgitate > 2 times per day. Adults Referral

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GERD

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  1. GERD

  2. Objectives • Discuss the prevalence and significance of GERD in the pediatric population • Discuss the diagnostic evaluation of the child with suspected GERD • Review the management of GERD

  3. Infants Referral Visit MD within the year Regurgitate > 2 times per day Adults Referral Visit MD within the year Heartburn > 1 times per month Epidemiology: GER Iceberg 2% 2% 10 % 10 % 50 % 50 %

  4. Prevalence of Regurgitation in Infancy % of infants

  5. The Antireflux Barrier Esophagus Angle of His LES Stomach Crural Diaphragm

  6. Esophageal Capacitance 30 cm; 2x3 cm diam - Shorter esophagus (11 cm; 5 mm diam) - Smaller capacity Adult Infant Gravity

  7. Factors Predisposing to GERD Decreased resistance: Inadequate LES tone Inappropriate LES relaxation Inadequate supporting structures Increased gastric volume: Large meals Delayed gastric emptying Duodenogastric reflux Increased pressure: - Tonic (e.g. obesity, slouched posture) - Phasic (e.g. cough, sneeze, strain)

  8. Recurrent vomiting in infant Recurrent vomiting and poor weight gain in infant Recurrent vomiting and irritability in infant Recurrent vomiting in older child Heartburn in child or adolescent Dysphagia or feeding refusal Apnea or ALTE Asthma Recurrent pneumonia Upper airway symptoms Chronic cough Presenting Symptoms

  9. Bilious or forceful vomiting Hematemesis or hematochezia Vomiting or diarrhea Abdominal tenderness or distention Onset of vomiting after 6 months of life Fever, lethargy, hepatosplenomegaly Macrocephaly, microcephaly, seizures Warning Signals Suggestive ofa Non-GER Diagnosis Recurrent vomiting History and PE Are there warning signs?

  10. Signs of Complicated GERD • Poor weight gain • Excessive crying or irritability • Feeding problems • Respiratory problems, including: • wheezing • stridor • recurrent pneumonia

  11. What approach do you take in suspected GERD? • History and physical examination • Upper GI series • Upper endoscopy and biopsy • Esophageal pH or impedance monitoring • Empirical medical therapy * Most common 1st steps listed by pediatricians

  12. ADVANTAGES Useful for detecting anatomic abnormalities LIMITATION Cannot discriminate between physiologic and nonphysiologic GER episodes Upper GI

  13. Radiographs of Diagnoses that can Mimic GERD Malrotation Pyloric stenosis

  14. ADVANTAGES Enables visualization and biopsy of esophageal epithelium Determines presence of esophagitis, other complications Discriminates between reflux and non-reflux esophagitis LIMITATIONS Need for sedation or anesthesia Generally not useful for extraesophageal GERD Upper Endoscopy with Biopsy

  15. Examples of Endoscopic Findings Eosinophilic Esophagitis Erosive Esophagitis

  16. ADVANTAGES Detects episodes of reflux Determines temporal association between acid GER and symptoms Determines effectiveness of esophageal clearance mechanisms Assesses adequacy of H2RA or PPI dosage in unresponsive patients LIMITATIONS Cannot detect nonacidic reflux Cannot detect GER complications associated with “normal” range of GER Not useful in detecting association between GER and apnea unless combined with other techniques Esophageal pH Monitoring

  17. To establish a relationship between occult GER and chronic symptoms: Upper respiratory sx Chest pain Recurrent pneumonia Apnea/Cyanosis Irritability Intractable asthma To monitor efficacy of medical or surgical therapy: Acid blockers Prokinetic agents Following fundoplication When would it be USEFUL toobtain esophageal pH monitoring?

  18. Treatment Options Surgical Tx Medication Lifestyle Changes

  19. INFANTS Normalize feeding volume and frequency Consider thickened formula Consider non-prone positioning during sleep Consider trial of hypoallergenic formula OLDER KIDS Avoid large meals Do not lie down immediately after eating Lose weight, if obese Avoid caffeine, chocolate, and spicy foods that provoke symptoms Eliminate exposure to tobacco smoke Conservative Therapy

  20. Unthickened ready-to use infant formula = 20 cal/oz Thickened formula 1 tablespoon rice cereal per ounce = ~34 cal/oz Thickened Formula

  21. Comparison of Drug Therapies For Healing Erosive Esophagitis in Adults % of Patients

  22. PPIs in Infants andChildren With GERD • Pharmacologic studies with omeprazole and lansoprazole showing benefit • No randomized placebo-controlled trials • Multiple case series of children refractory to H2RA showing benefit

  23. Recommended Oral H2RA Dosages

  24. Oral PPI Dosages for GERD

  25. Candidate for AntirefluxSurgery in Childhood • Fails medical therapy due to GERD • Is dependent on aggressive or prolonged medical therapy • Has persistent asthma or recurrent pneumonia due to GERD

  26. Principles of Antireflux Surgery Restore intraabdominal segment of esophagus Approximate diaphagmatic crurae Reduce hiatal hernia when present Wrap fundus around LES to reinforce antireflux barrier

  27. Summary • GER is common in healthy infants • Pediatric GERD can present with variable symptoms • Currently available tests often do not conclusively demonstrate a relationship between GER and specific symptoms • Good history and clinical judgment are important for optimal evaluation and management • Antisecretory agents are the most effective pharmacological therapy

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