Pedi Gasro Osophogeal Reflux Presentation

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Pediatric RefluxPediatric Reflux

Frederick S. Rosen, MD

Norman R. Friedman, MDOctober 25, 2000


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Pediatric RefluxPediatric Reflux

! FunctionalGastroesophagealReflux

!GERD

! SecondaryGastroesophagealReflux


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Lower Esophageal SphincterLower Esophageal Sphincter

! Pinch-Cock Action

! Intraabdominal Esophagus

! Angle of His

!Mucosal Rosette! High Pressure Zone

! Abdominal Pressure


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Reflux events in infantsReflux events in infants

!Maturation of LES at 5-7 weeks of life,regardless of gestational age

! Esophagitis and

TLESRs a viciousCycle

! Acid & Pepsin,

Bile Acids and Trypsin


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Typical presentation of GERDTypical presentation of GERD

! Crying/Irritability

! Poor feeding

! Regurgitation

! Epigastric pain

! FTT/weight loss

! Sore throat

! Waterbrash

! Hematemesis! Anemia


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Atypical presentation of GERDAtypical presentation of GERD

! Apnea/Bradycardia

! ALTEs

!Wheezing/Asthma

! Stridor! Recurrent

pneumonia

! Chronic cough

! Sandiferssyndrome

! Hoarseness/

Laryngitis!Otalgia

! Sinusitis


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GERD UntreatedGERD Untreated

! Resolves by 2years of age in60% of GERD

! Persists until age 4in 30%

! stricture, malnutrition


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GERD in OtolaryngologyGERD in Otolaryngology

!Chronic Sinusitis avoid FESS!Chronic Cough

!

Globus Pharyngeus- osteophytes,FB, cricopharyngeus, tonsils, goiter,web, cervical lad, mass

!Dysphagia


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!Otitis Media?


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! Vocal cordgranuloma

! Laryngomalacia

!

Pseudolaryngomalacia

! Subglottic

stenosis! Sandifers Synd.


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Apnea &Apnea & ALTEsALTEs

! 7-15% SIDS

! At least 53% of ALTEs

! Esophagolaryngeal Adductor Reflex

obstructive apnea! Laryngeal Chemoreflex Central Apnea

! Seizure and Reflux?


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AsthmaAsthma

! Vicious Cycle

!Macroaspiration

!Microaspiration

! Esophagitis vagal reflex

!


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Differential diagnosisDifferential diagnosis

!Food allergy (cow milk)

! Infection

! Increased intracranial pressure

(tumor)!Hydronephrosis

!

Intestinal obstruction!Metabolic Disorders (uremia)


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Diagnosing GERDDiagnosing GERD


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! Upper GI

! Esophageal biopsy

! DL and Bronch

! pH probe! Scintigraphy

!Modified Bernstein

Test!Manometry


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Treatment of GERDTreatment of GERD


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Treatment of GERDTreatment of GERD

!Appropriate feeds

!Caffeine, chocolate, and tobacco

!Positioning

!Thickening feeds

!Small, frequent feeds

!Continuous feeding via NGT


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Medical Treatment of GERDMedical Treatment of GERD

!Prokinetics

!Cisapride Prolonged QT interval,Torsades, and heart block

Risk of death 1/250,000Avoid macrolides, azoles, &grapefruit juice; cytochrome P450

!Metoclopramide EPS in 24-48 hr


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Surgical Treatment of GERDSurgical Treatment of GERD


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! Nissen 2/3

!360 degree wrap

!Gas bloat

!

Thal 1/3!180 degree wrap

!Long intraabd,

fixation, restoresangle of His


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! Indications

!Failure ofmedical tx

!Stricture

!Pulmonary Dz

!Quality of Life

!Esophagealatresia


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! Indications in children < 2 yo

!Neurologic impairment

!BPD/RDS

!Apneic Episodes

!Congenital anomalies (hiatal

hernia, esophageal atresia)


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!Outcomes

!More effective in children

!Good outcomes: 94% NN, 85% NI

!Complications: 4.2% NN, 12.8% NI

!Reoperation: 3.6% NN, 11.8% NI

!Mortality: 0.07%!TLESRs and Fundoplication


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ConclusionConclusion

!Similar incidence of GERD in infantsand adults

!Patients < 2 yo: A question of

motility!Reflux and Otolaryngology

Pedi Gasro Osophogeal Reflux Presentation

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