GERD Brandon Hoff. What is GERD? Gastroesophageal Reflux Disease Acid Reflux Disease.
Gastroesophageal Reflux Disease
Transcript of Gastroesophageal Reflux Disease
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Seoul National University Children’s Hospital Pediatric Gastroenterology, Hepatology and
NutritionFellow. Sang Hee, Cho
Gastroesophageal Reflux Disease
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Gastroesophageal reflux (GER) : passage of gastric contents into the esophagusGER disease (GERD) : symptoms or complications of GER
Infancy GER- 50% of infants in the first three months of life- 67% of four month old infants- 5% of 10~12 month old infants : resolves spontaneously in nearly all of these infants: small minority of infants develop GERD with symptoms - anorexia, irritability, hematemesis,- dysphagia (difficulty swallowing), - odynophagia (painful swallowing), - arching of the back during feedings, - anemia, failure to thrive
Colin D. Rudolph et al. Pediatric GE Reflux Clinical Practice Guidelines. JPGN, 2001;32:S1-S31
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History and Physical Examination
Barium Contrast Radiography
Esophageal pH Monitoring
Multichannel Intraluminal Impedance
Endoscopy and Biopsy
Scintigraphy
Empiric Therapy
Diagnostic Approaches
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History and Physical Examination
Barium Contrast RadiographyUpper gastrointestinal series : useful to detect anatomic abnormalities : pyloric stenosis, malrotation, hiatal hernia,
esophageal stricture : sensitivity (31-86%), specificity (21-83%), positive predictive value (80-82%) : brief duration of the upper GI series false negative results
: frequent occurrence of non-pathhological reflux false positive results
Diagnostic Approaches
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Reflux index : percentage of the total time - esophageal pH is <4- the most valid measure of reflux - reflects the cumulative exposure of the esophagus to
acidSensitivity : 87-93.3%, Specificity : 92.9-97%Mean upper limit of normal of the reflux index
: 11.7% in infants 0 to 11 months: 5.4% in children 0 to 9 years old: approximately 6% in 432 normal adults
upper limit of normal of the reflux index : up to 12% in the first year of life and up to 6% there-
after
Esophageal pH Monitoring
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Esophageal pH Monitoring
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Multichannel Intraluminal Im-pedance
Michiel P. et al. Role of the MCII Technique in Infants and Children. JPGN, 2009;48(1):2-12
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New diagnostic tool for GERD Combination with manometry : determination of the relation
between esophageal pressures and esophageal bolus flow Symptom Index (SI) = No. of reflux-related symptom/total No. of symptom (positive when above 50%)Symptom Sensitivity Index (SSI) = No. of reflux-related symptom/total No. of reflux (abnormal when higher than 10%)Symptom association probability score (SAP) : statistical means of calculating the probability that the
symptoms and GER episodes found are unrelated : calculated as (1.0-P) * 100%
Multichannel Intraluminal Im-pedance
Michiel P. et al. Role of the MCII Technique in Infants and Children. JPGN, 2009;48(1):2-12
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Impedance(electrical resis-tance)
: resistance to electrical current flow between two electrodes
: impedance being inversely proportional to ionic concen-trations of luminal contents
: bolus with relatively low ionic contents (eg, air) : higher im-pedance measurements com-pared with a bolus with rela-tively high ionic contents (eg, saline, refluxate)
Multichannel Intraluminal Im-pedance
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Multichannel Intraluminal Im-pedance
Michiel P. et al. Role of the MCII Technique in Infants and Children. JPGN, 2009;48(1):2-12
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Multichannel Intraluminal Im-pedance
Limitation : Poor reproducibility, no normal range, costly and time-consuming technique
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Multichannel Intraluminal Im-pedance
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Endoscopy and Biopsypresence and severity of esophagitis, stric-
tures and Barrett's esophagus,exclude other disorders, such as Crohn's
disease, webs and eosinophilic or infectious esophagitis
Diagnostic Approaches
Lundell. et al. Endoscopic assessment of oesophagitis. Gut. 1998;45;172
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Lifestyle Changes-Feeding Changes in Infants-Positioning Therapy for Infants
Pharmacological TherapiesAcid Suppressants
-Histamine-2 receptor antagonists (H2RAs) -Proton Pump Inhibitors-Antacids
Prokinetic TherapySurface Agents
Surgical Treatment
Treatment Options
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Pharmacological Thera-pies
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Rome III crite-ria
Paul E. et al. Childhood Functional Gastrointestinal Disorders. Gastroenterol-ogy. 2006;130:1519-26
Must include all of the following in otherwiseHealthy infants 3 weeks to 12 months of age:1. Regurgitation 2 or more times
per day for 3 or more weeks2. No retching, hematemesis,
aspiratioin, apnea, failure to thrive, feeding or swallowing difficulties, or abnormal pos-turing
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Bilious vomitingGI bleeding : he-
matemesis, hema-tochezia
Forceful vomitingOnset of vomiting after
6 months of lifeFailure to thriveDiarrheaConstipationFeverLethargy
Hep-atosplenomegaly
Bulging fontanelleMacro/microcephalySeizuresAbdominal tender-
ness, distentionGenetic disorder
(eg:Trisomy21)Other chronic disor-
ders(eg:HIV)
Warning Signals in the vomiting infant
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Colin D. Rudolph et al. Pediatric GE Reflux Clinical Practice Guidelines. JPGN, 2001;32:S1-S31
Management of an infant with uncomplicated GER(the “happy spit-ter”)
Algorithm
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Colin D. Rudolph et al. Pediatric GE Reflux Clinical Practice Guidelines. JPGN, 2001;32:S1-S31
Algorithm
Management of an infant with vomiting and poor weight gain
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THANK YOU!!!
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Consisted of 14 items – maximum possible score of 31Characteristics of regurgitation : frequency, volumeFeeding refusalWeight gainIrritabilityCrying : daily frequency and correlation with mealHiccupsArching backRespiratory symptomsPosture
Score 7 : value usually indicated as the threshold limit over which the presence of GERD is a possible risk
Infant Gastroesophageal Reflux Question-naire