GER GERD

GER – GASTROESOPHAGEAL REFLUX passive return of gastric contents retrograde into the oesophagus

GERD – GASTROESOPHAGEAL REFLUX DISEASE –

GERD definition: Gastroesophageal reflux disease which causes adverse signs and symptoms

GERD

Gastroesophageal reflux disease which causes adverse signs and symptoms

GERD - pathophysiology

• transient lower oesophageal sphincter (LES) relaxation unassociated with swallowing

• delayed gastric emptying

• increased acid secretion

• hiatal hernia

DISEASES ASSOCIATED WITH INCREASED RISK OF GERD IN CHILDREN

• cerebral palsy• Down syndrome• oesophageal atresia with repair• hiatal hernia• asthma• bronchopulmonary dysplasia• cystic fibrosis• obesity

GERD in children

GERD in full-term infants

GERD in children olderthan 1 year

FACTORS PREDISPOSING TO FUNCTIONAL GER IN INFANTS

• short oesophagus• low pressure of LES• supine position • small gastric volume and compliance• fluid diet • high volume of meals

(150 ml per kg per 24h)

GER IN INFANTS

• Functional GER (physiological uncomplicated reflux) 30% of infantsReffers to healthy infants „happy spitters” with regurgitation

• Pathogenic GER (GERD) 1:300Infants with complications: symptoms of esophagitis, respiratory or neurobehavioral problems

GERD-SYMPTOMS IN INFANCY

SIGNS OF OESOPHAGITIS• loss of apetite• poor weight gain• iron deficiency anemia• hematemesis

CHANGES IN BEHAVIOUR• irritability• sleeping problems• Sandifer’s syndrome

RESPIRATORY SYMPTOMS• chronic cough (often

nocturnal)• recurrent infection

of lower and upper respiratory tract

• wheezing• apnea

SANDIFER’S SYNDROME

Arching or twisting of the neck or back in infants and small children with severe acid GERD (1%)

The head positioning is the mecha nism to protect the airways and reduce discomfort associated with acid reflux

SANDIFER’S SYNDROME

GERD - SYMPTOMS IN ELDER CHILDREN

• vomiting• chestpain• epigastric pain • waterbrush• dysphagia• odynophagia• loss of apetite

• chronic cough• hoarseness and/or laryngitis• sore throat• dental erosions• halitosis

GERD - DIAGNOSTIC EVALUATION

• trial of acid–supressing drugs (PPI 2-4 weeks)

• oesophageal 24h pH probe monitoring /multichannelintraluminal impedance monitoring

• gastroscopy with esophageal biopsy

• barium radiography

ESOPHAGEAL pH-PROBE MONITORING

• pH probe placed in distal oesophagus measures the severity and frequency of acid reflux (numer and duration of reflux episodes with esophageal pH<4)

• Usefull in demostrating an association between acid reflux and atypical symptoms (cought, apnea, stridor)

MULTICHANNEL INTRALUMINAL IMPEDANCE MONITORING

detects movements of both acidic and nonacidic fluids, solids and air in the oesophagus

Combined pH/MII monitoring is a test of choice to diagnose non specific symptoms

GASTROSCOPY WITH ESOPHAGEAL BIOPSY

reflux esophagitismucosal damage (erosions, ulcer) at the lower part

of the oesophagus

BARIUM RADIOGRAPHY(UPPER GI TRACT SERIES)

• usefull for evaluating anatomic abnormalities of g.i. tract:hiatal herniaesophageal/duodenal stricture malrotation

• not usefull for evaluating GERD

BARIUM RADIOGRAPHY

MANAGEMENT OF GER IN INFANTS „Happy spitters”

• reduce the feeding volume /increase the frequency of feedings

• thickened feedings with cereals• upright position after feeding• parenteral reassurance on therapeutic course

In most cases of GER no diagnostic study is requiredReflux resolves spontaneusly in 85% infants

by 12 month of age

THICKENING FEEDINGS

• potato starch• rice• carob (sain’t John’s bread)

Formulas for infants with GER

AR – Anti Regurgitationem

CAROB TREE AND FRUITS

REFLUX BOARD

REFLUX BOARD

MANAGEMENT OF GERD IN INFANTS

• lifestyle modifications

• exclusion of cows-milk allergy

• farmacological treatment

• surgery (?)

2 weeks milk-free diet with extensively hydrolised milk formulaand milk challenge

GERD IN INFANTS DIFFERENCIAL DIAGNOSIS

• food allergy (cow’s milk allergy)• congenital anomalies of gastrointestinal tract • urinary tract infections• hydrocephalus, increased intracranial pressure• metabolic disorders

MANAGEMENT OF GERD IN ELDER CHILDREN

• lifestyle modificationsavoidance carbonated drinks, chocolate, caffeine, foodcontaining high amount of fat, spices and acid (citrus juices)

• pharmacological treatmentacid suppresants (PPIs, H2RAs)antiacidsprokinetic agents

• surgery (?)

GERD PHARMACOLOGICAL TREATMENT

• antiacids

• proton pomp inhibitors

• H2- blockers

• prokinetics

ANTIACIDS

- directly buffer acid in oesophagus and stomach- heal mucosal inflammation- less effective than PPIs- adverse effects: aluminium toxicity- on demand

• alginates• sucralfat• aluminium and magnesium salts• hyaluronic acid• sodium bicarbonate

PROTON PUMP INHIBITORS

• omeprazole 1 mg/per kg/day for 6 weeks -3 months• lansoprazole• esomeprazole• dexlansoprasole

administration: 30 minutes before meals (1-2 dose/day)safe, fewer side effectsdexlansoprasole – may be given after meals

H2-BLOCKERS

- decrease the secretion of acid by inhibiting histamine-2 receptor - less effective than PPIs- effect of tachyphylaxis

• ranitidine (5-10 mg/kg/d divided in 2-3 doses)

PROKINETICS

- increase lower esophageal sphincter pressure- improve gastric emptying- administration 3-4 times/day before meals- adverse effects: cisapride-cardiac arrhytmia, diarrhoea

• cisapride (serotonin receptor agonist)• domperidone (metoclopramide derivate)• itopride >16y (dopamine receptor antagonist)

PRECAUTIONS IN THE USE OF CISAPRIDE

• Total dose should not exceed 0.8 mg/kg per/day Avoid concomitant use of macrolides, such as erythromycin, azithromycin and clarithromycin and azole antifungals such as ketoconazole

• Do not use in patients with a previous history of dysrhythmias or electrolyte disturbances.

• Use with caution in premature infants with immature cytochrome P450 3A4 activity

• ECG monitoring during treatment is required Parental education about proper dosing and drug interactions

NISSEN FUNDOPLICATION

Stomach (gastric fundus) is wrapped around the lower part of the esophagus restoring the function of LES

ANTIREFLUX SURGERY

Severe symptoms unresposive to medications• Persistent vomiting with failure to thrive• severe oesophagitis or oesophageal stricture• life threatening apneis spells• large hiatal hernia• neurological handicap• chronic pulmonary dis. unresponsive to treatment

ULCER DISEASE

• Ulcer – disruption in the mucosal layer of the stomach or duodenum

• Erosion – superficial ulcer (disruption of the epithelium)

• Gastritis –inflammation of the gastric mucosa without disruption of the mucosa (may be confirmed only by histologic examinatiotion)

ULCER DISEASE

DEFENSIVE FACTORS

• mucous gel layer• local production

of bicarbonate• regulation of gastric acid

secretion• adequate mucosal blood flow

OFFENSIVE FACTORS

• Helicobacter pylori infection • acid-pepsin environment• mucosal ischemia• Bile• NSAID

Helicobacter pylori

• spiral gram negative bacteria

• colonizes mucus adhering gastric mucosa

• produces urease, catalase, cytotoxins, lipopolysaccharase

• urease converts urea to ammonium and bicarbonate

Helicobacter pylori-prevalence

• Prevalence in Poland: 30% children 84% adults

• 80-90% patients H. pylori positive is asymptomatic• 10-15% develop ulcer disease/antral gastritis• 0,1% - risk of neoplasm in future (gastric lymphoma and

adenocarcinama)

ULCER DISEASE - SYMPTOMS

• abdominal pain - epigastric area or righ upper quadrant, worsened at night and after the meals

• vomiting, nausea• loss of apetite • poor growth• iron deficiency anaemia• upper GI bleeding

ULCER DISEASE - COMPLICATIONS

• acute bleeding (neonates)• iron deficiency anaemia (chronic bleeding)

• perforation

• gastric outlet obstruction (duodenal and pyloric channel ulcers)

ULCER DISEASE - DIAGNOSIS

• Gastroduodenoscopy- diagnostic aim- therapeutic aim for acute bleeding-urease test- biopsy with hematoxylin and eosin staining

• 13C-urea breath test

• H. pylori antigen in stool (cheap, sensitive, noninvasive)

• serum antibodies against H. pylori (not reliable, usefull for epidemiological reserch)

H. pylori infection in childrenantral nodular gastritis (nodular gastropathy)

Helicobacter pylori–associated peptic ulcer in the duodenal bulb

ULCER DISEASE -TREATMENT

PROTON PUMP INHIBITORS (6-8 weeks)1 mg/per kg/day (0,5-3,3)

• omeprazole • lansoprazole• pantoprazole • esomeprasole• dexlansoprasole

Recommended options for first-line therapy for H pylori infection

H pylori antimicrobial susceptibility

Known• Susceptible to CLA and to MET PPI-AMO-CLA 14d with

standard dose• Resistant to CLA, susceptible to MET PPI-AMO-MET 14d or

bismuth-based• Resistant to MET, susceptible to CLA PPI-AMO-CLA 14d or

bismuth-based• Resistant to CLA and to MET PPI-AMO-MET 14d with high

dose for amoxicillin or bismuth-based

Unknown• High-dose PPI-AMO-MET 14d or bismuth-based

Helicobacter pylori eradicationsecond-line treatment

quadriple therapy

I Amoxicillin + Metronidazole + bismuth salts +PPI or

II Amoxicillin + Metronidazole + Tetracyclin +PPI (children > 11y)

biopsy with culture and susceptibility testing

H. pylori treatment (drugs and doses)

• PPI: 1-2 mg/kg/d (high dose 2-2,5 mg/kg/d)• Amoxicillin: 50mg/kg/d (high dose 60-100mg/kg/d)• Claritromycine : 20 mg/kg/d• Metronidazole: 20 mg/kg/d• Bismuth salts: 8 mg/kg/d

Indications for the treatment of Helicobacter pylori infection in children

• active or previous gastric and duodenal ulcer• chronic gastritis • long term NSAID’s treatment or immunosupressive

treatment

• iron deficiency anaemia resistant to treatment• idiopathic thrombocytopenia