Seminar On

“APPROACH TO GERD IN CHILDREN”Presented by

Vijay kr. SinghDNB PGT (Pediatrics)Under guidance of

Dr T K MAITY MD(PEDIATRICS)

Consultant physician M R Bangur HospitalDate 23rd march 2013

VenueDNB Seminar hall M R Bangur hospital Kolkata-33

APPROACH TO GERD IN

CHILDREN

ANATOMY AND PHYSIOLOGY

Esophagus begins at lower border of cricoids cartilage.

It develops from foregut and is recognizable by third week of gestation.

Food or fluid delivered from the esophagus to the stomach, swallowing must be accompanied by a coordinated wave of peristaltic contractions

It is lined by four layersMucosa- stratified squamous non

keratinized epitheliumSub mucosa- mucous glands and

lymphoid tissueMuscularis externa Adventitia

Lower esophageal sphincter

It is not a true anatomical sphincter.The lower 3-4 cm smooth circular muscle

fibers form LES.Its remain tonic activity prevent reflux of

gastric contain into stomach.The tone of LES is under control of

parasympathetic neural control.The tone of LES is also under influenced of

gastric hormone

Mechanism which prevent gastro esophageal reflux

Tonic activity of LESValve like mechanism of short portion of

esophagus that extend into the diaphragmFibres of crural portion of diaphragm

surround esophagus at the lower end which prevent reflux

Introduction

Gasrtroesophageal reflux disease is the most common esophageal disorder in children.

Gastroesophageal reflux signified the retrograde movement of gastric contents across the lower esophageal sphincter .

The regurgitation is normal in infant, The phenomenon becomes pathological GERD in

children who have more frequent and persistent. It produce esophageal symptoms or have respiratory

symptoms.

Prevalence

Infant reflux becomes evident in the 1st few months of life.

Peaks at 4months, at 12 months it resolves upto 88% and nearly all up to 24 months.

Prevalence of GERD in the infant range from 1 to 8%.

85% of premature infant have GERD, with upto 10% of them having extra intestinal manifestations like bradicardia and apnea.

Path physiology of reflux

A well- coordinated relaxation of the lower esophageal sphincter is essential for the transport of food into stomach.

Basal LES pressure is maintained above 4mmHg to prevent reflux.

Pressure theory is disproved by many pressure studies.

Reflux is primarily due to Transient LES relaxation.TLESR occur independent of swallowing, reduce LES

pressure to 0-2mm Hg and last for>10 seconds, and they appears by 26 wks of gestation.

A vaso vagal reflex, composed of afferent mechanoreceptors in the proximal stomach, a brain stem pattern generated, and efferent in the LES, regulates TLESRs.

Gastric distention the main stimulus for TLESRs.The pathogenesis of reflux in premature infant is

not well understood.

Symptoms and manifestationIn InfantVomiting

Poor weight gainIrritabilityFeeding refusalRecurrent pneumoniaAsthma or any upper respiratory tracts

symptomsApnea

childrenHeartburn and retrosternal chest pain.Dysphasia.Regurgitation.Asthma and chronic cough.Recurrent pneumonia.Anemia and haemetemesis.Sandifer’s syndrome.

Conditions predisposing to severe GERDObesity Neurological impairmentRep. aired trachea- esophageal fistulaCongenital diaphragmatic hernia Chronic lung diseaseSignificant prematurity

Diagnostic approach to GERD

History and physical examination suffice the diagnosis.

Evaluation aims to identify the positive support of the diagnosis.

The history standardized by ORENSTIEN’S questionnaireI-GERQ and its derivatives I-GERQ-R

Esophageal pH monitoring

Ph monitoring help to establish the presence of acid reflux Ph <4.

It assess the efficacy of treatment. It is non-invasive and done in any age group. It does not measure the non –acid and

weakly acidic reflux.

Multichannel intraluminal -impedance measurement

It detect the change in the electrical resistance that occur during the passage of a bolus of gas or liquid .

This study detects both acid and non acid reflux and direction of reflux.

The limitation of the procedure is – high cost, limited availability

Endoscopy

Upper GI endoscopy is the best method of detecting esophagitis.

Normal endoscopy does not rule out GERD.

This type of GERD is called non-erosive reflux.

Advantages of endoscopy

It gives direct information about the presence of esophagitis.

Detects complications like ulcer, stricture, Barrett’s esophagitis.

Endoscopic biopsy help to exclude other cause of esophagitis.

Histology is more sensitive than endoscopy in the early stage. Erosive esophagitis is the most definite evidence of GERD on endoscopy.

Barium UGI series

This test is useful to detect anatomical abnormalities but it is not useful in diagnosis of GERD.

The sensitivity and specificity is less than 50%.

Nuclear scintigraphy

Nuclear scintigraphy has poor sensibility and specificity.

Used in recurrent aspiration pneumonia. Retention of radioactivity in lung beyond 24

hours suggests GERD . Nuclear scintigraphyis not recommended for

the routine evaluation.

MANAGEMENT

GER in infant (Happy splitters)Counseling and natural history of GER in

infant to be explained to the parents or care givers.

It is advised to give small and frequent feeding .

Thickening of feed.

GERD in childrenAcid suppressants- GERD need acid

suppression therapy for 12weeks. Proton pump inhibiter is more potent than H2

blocker.Neutralizing agent- Useful in symptomatic

relief of heartburn. Not for long term due to risk of side effects.

Prokinetics

There is insufficient evidence to justify the role of prokinetics in management of GERD.

It is only indicated in GERD associated with gastro paresis.

Duration of therapyPPI therapy is recommended for at least

12weeks . Taper over 2 to 3 months to prevent rebound

hyperacidity . If there is no improvement in 4 weeks then

the dose of PPI need to be increased.

Surgery

Nissen fundoplication may be of beneficial in children with confirmed GERD who have failed optimal medical therapy.

Bronchial asthma and GERD

The clinical association of bronchial asthma and GERD is very strong.

Causal relationship between these two entities has no yet established.

Persistent asthma with symptomatic GERD

It can be treated with a clear explanation given to the parents.

Reflux symptoms will improve but chance of improvement of asthma is remote.

GERD in neurologically impaired children

Prevalence of GERD in neurological impaired children is 50% higher than normal child .

The prevalence of erosive esophagitis about 30 to 70%.

This group of children needs prolonged treatment and often surgery.

ConclusionGER is common in infant.Most infant have physiological reflux and need

minimal intervention. Symptoms resolve by 18 months of age.No gold standard test for GERD diagnosisMedical therapy with PPI is very effective and safe. Surgical therapy is not recommended because of

its morbidity and often fails in those who need it most.

THANK YOU