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Gerd in children and its treatment


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  • 1. 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
  • 3. 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
  • 4. It is lined by four layersMucosa- stratified squamous nonkeratinized epitheliumSub mucosa- mucous glands andlymphoid tissueMuscularis externaAdventitia
  • 5. 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
  • 6. 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
  • 7. 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.
  • 8. 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.
  • 9. 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.
  • 10.  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.
  • 11. Symptoms and manifestationIn Infant Vomiting Poor weight gain Irritability Feeding refusal Recurrent pneumonia Asthma or any upper respiratory tracts symptoms Apnea
  • 12. childrenHeartburn and retrosternal chest pain.Dysphasia.Regurgitation.Asthma and chronic cough.Recurrent pneumonia.Anemia and haemetemesis.Sandifer’s syndrome.
  • 13. Conditions predisposing to severeGERDObesity Neurological impairmentRep. aired trachea- esophageal fistulaCongenital diaphragmatic hernia Chronic lung diseaseSignificant prematurity
  • 14. 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
  • 15. 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.
  • 16. Multichannel intraluminal -impedance measurementIt 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
  • 17. EndoscopyUpper GI endoscopy is the best methodof detecting esophagitis. Normal endoscopy does not rule outGERD.This type of GERD is called non-erosivereflux.
  • 18. 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.
  • 19. Barium UGI seriesThis test is useful to detect anatomicalabnormalities but it is not useful indiagnosis of GERD.The sensitivity and specificity is lessthan 50%.
  • 20. Nuclear scintigraphyNuclear 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.
  • 22. 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.
  • 23. GERD in childrenAcid 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.
  • 24. ProkineticsThere is insufficient evidence to justify therole of prokinetics in management of GERD. It is only indicated in GERD associated withgastro paresis.
  • 25. Duration of therapyPPI 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.
  • 26. SurgeryNissen fundoplication may be ofbeneficial in children with confirmedGERD who have failed optimal medicaltherapy.
  • 27. Bronchial asthma and GERDThe clinical association of bronchialasthma and GERD is very strong. Causal relationship between these twoentities has no yet established.
  • 28. Persistent asthma withsymptomatic GERDIt can be treated with a clear explanation givento the parents. Reflux symptoms will improve but chance ofimprovement of asthma is remote.
  • 29. GERD in neurologically impairedchildrenPrevalence 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.
  • 30. 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.