SeminarOn“APPROACH TO GERD IN CHILDREN”Presented byVijay kr. SinghDNB PGT (Pediatrics)Under guidance ofDr T K MAITYMD(PEDIATRICS)Consultant physician M R Bangur HospitalDate 23rd march 2013VenueDNB Seminar hall M R Bangur hospital Kolkata-33
ANATOMY AND PHYSIOLOGY Esophagus begins at lower border of cricoidscartilage. It develops from foregut and is recognizable bythird week of gestation. Food or fluid delivered from the esophagus to thestomach, swallowing must be accompanied by acoordinated wave of peristaltic contractions
It is lined by four layersMucosa- stratified squamous nonkeratinized epitheliumSub mucosa- mucous glands andlymphoid tissueMuscularis externaAdventitia
Lower esophageal sphincter It is not a true anatomical sphincter. The lower 3-4 cm smooth circular musclefibers form LES. Its remain tonic activity prevent reflux ofgastric contain into stomach. The tone of LES is under control ofparasympathetic neural control. The tone of LES is also under influenced ofgastric hormone
Mechanism which prevent gastroesophageal reflux Tonic activity of LES Valve like mechanism of short portion ofesophagus that extend into the diaphragm Fibres of crural portion of diaphragm surroundesophagus at the lower end which preventreflux
Introduction Gasrtroesophageal reflux disease is the most commonesophageal disorder in children. Gastroesophageal reflux signified the retrogrademovement of gastric contents across the loweresophageal sphincter . The regurgitation is normal in infant, The phenomenon becomes pathological GERD in childrenwho have more frequent and persistent. It produce esophageal symptoms or have respiratorysymptoms.
Prevalence Infant reflux becomes evident in the 1st few monthsof life. Peaks at 4months, at 12 months it resolves upto88% and nearly all up to 24 months. Prevalence of GERD in the infant range from 1 to8%. 85% of premature infant have GERD, with upto 10%of them having extra intestinal manifestations likebradicardia and apnea.
Path physiology of reflux A well- coordinated relaxation of the loweresophageal sphincter is essential for thetransport of food into stomach. Basal LES pressure is maintained above4mmHg to prevent reflux. Pressure theory is disproved by many pressurestudies.
Reflux is primarily due to Transient LES relaxation. TLESR occur independent of swallowing, reduce LESpressure to 0-2mm Hg and last for>10 seconds, andthey appears by 26 wks of gestation. A vaso vagal reflex, composed of afferentmechanoreceptors in the proximal stomach, a brainstem pattern generated, and efferent in the LES,regulates TLESRs. Gastric distention the main stimulus for TLESRs. The pathogenesis of reflux in premature infant is notwell understood.
Symptoms and manifestationIn Infant Vomiting Poor weight gain Irritability Feeding refusal Recurrent pneumonia Asthma or any upper respiratory tracts symptoms Apnea
childrenHeartburn and retrosternal chest pain.Dysphasia.Regurgitation.Asthma and chronic cough.Recurrent pneumonia.Anemia and haemetemesis.Sandifer’s syndrome.
Diagnostic approach to GERD History and physical examination suffice thediagnosis. Evaluation aims to identify the positivesupport of the diagnosis. The history standardized by ORENSTIEN’SquestionnaireI-GERQ and its derivatives I-GERQ-R
Esophageal pH monitoring Ph monitoring help to establish the presenceof 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 weaklyacidic reflux.
Multichannel intraluminal -impedance measurementIt detect the change in the electricalresistance that occur during the passageof a bolus of gas or liquid .This study detects both acid and non acidreflux and direction of reflux.The limitation of the procedure is – highcost, limited availability
EndoscopyUpper GI endoscopy is the best methodof detecting esophagitis. Normal endoscopy does not rule outGERD.This type of GERD is called non-erosivereflux.
Advantages of endoscopy It gives direct information about the presence ofesophagitis. Detects complications like ulcer, stricture, Barrett’sesophagitis. Endoscopic biopsy help to exclude other cause ofesophagitis. Histology is more sensitive than endoscopy in theearly stage. Erosive esophagitis is the most definiteevidence of GERD on endoscopy.
Barium UGI seriesThis test is useful to detect anatomicalabnormalities but it is not useful indiagnosis of GERD.The sensitivity and specificity is lessthan 50%.
Nuclear scintigraphyNuclear scintigraphy has poor sensibility andspecificity.Used in recurrent aspiration pneumonia. Retention of radioactivity in lung beyond 24hours suggests GERD .Nuclear scintigraphyis not recommended forthe routine evaluation.
GER in infant (Happy splitters)Counseling and natural history of GER in infantto be explained to the parents or care givers.It is advised to give small and frequentfeeding . Thickening of feed.
GERD in childrenAcid suppressants- GERD need acidsuppression therapy for 12weeks.Proton pump inhibiter is more potent than H2blocker.Neutralizing agent- Useful in symptomaticrelief of heartburn.Not for long term due to risk of side effects.
ProkineticsThere is insufficient evidence to justify therole of prokinetics in management of GERD. It is only indicated in GERD associated withgastro paresis.
Duration of therapyPPI therapy is recommended for at least12weeks .Taper over 2 to 3 months to prevent reboundhyperacidity . If there is no improvement in 4 weeks thenthe dose of PPI need to be increased.
SurgeryNissen fundoplication may be ofbeneficial in children with confirmedGERD who have failed optimal medicaltherapy.
Bronchial asthma and GERDThe clinical association of bronchialasthma and GERD is very strong. Causal relationship between these twoentities has no yet established.
Persistent asthma withsymptomatic GERDIt can be treated with a clear explanation givento the parents. Reflux symptoms will improve but chance ofimprovement of asthma is remote.
GERD in neurologically impairedchildrenPrevalence of GERD in neurological impairedchildren is 50% higher than normal child .The prevalence of erosive esophagitis about30 to 70%.This group of children needs prolongedtreatment and often surgery.
Conclusion GER is common in infant. Most infant have physiological reflux and needminimal intervention. Symptoms resolve by 18 months of age. No gold standard test for GERD diagnosis Medical therapy with PPI is very effective and safe. Surgical therapy is not recommended because of itsmorbidity and often fails in those who need it most.