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  • 1. Issues in diagnosis management ofGERD in children PRESENTED BY: Virendra Gupta GUIDED BY: Dr. B. S. Sharma Sir
  • 2. DefinitionsGER Passage of gastric contents into the esophagus with or without regurgitation or vomiting. NASPGHAN GUIDELINES 2009;49:498-547. Retrograde movement of gastric contents across the lower esophageal sphincter (LES) into the esophagus. Nelson textbook of pediatric_19th e- Regurgitation (spitting-up) - Effortless movement of stomach contents into the esophagus and mouth. Nelson textbook of pediatric_19th e-
  • 3. DefinitionsGERDPresence of troublesomesymptoms and/or complicationsof persistent GER. NASPGHAN GUIDELINES 2009;49:498-547 orGER becomes pathologicalwhen it causes troublesomesymptoms and physicalcomplications, hence the termgastro esophageal reflux disease(GERD). Nelson textbook of pediatric_19th e-
  • 4. GERD-EPIDEMIOLOGY• GERD – One of the commonest gastrointestinal diagnoses in pediatric practice in the West• Prevalence of an abnormal quantity of GER in infants- 8% Vandenplas et al ,Pediatrics 1991;88:834-840
  • 5. GERD-EPIDEMIOLOGY• 10 % of babies from a well baby clinic(62 / 602 babies) had symptoms of GER De S et al Trop Gastroenterol. 2001 ; 22(2):99-102• GER - 35% of cases with respiratory symptoms (recurrent bronchopneumonia, reactive airway disease and chronic cough) Jain A et al, J Trop Ped.2002;48:39-42
  • 6. Prevalence of GERD in Asthmatic Children• A significant no. of childhood asthmatic patients experience GERD• 25-75% have abnormal intra esophageal pH• Only 50% have esophageal symptoms of GERD Pediatr Drugs.2005;7:177-186 : J Pediatr Gastroenterol Nutr 2001; 32 S1
  • 7. CONDITIONS WITH HIGHER PREVALENCE• Cerebral palsy• Mentally challenged• TEF• Obesity
  • 8. GER- NATURAL COURSEInfant reflux• 1st few months of life - Becomes evident• 4 month of life - Peaks• 12 month of life - Resolves in up to 88%• 24 month of life - Resolves nearly allolder children• Tend to be chronic, waxing and waning• 50% completely resolves• 50% resembles adult patterns of GER
  • 9. PREVALENCE OF GER IN INFANCY > 1 time a day 70 60 % of infants 50 40GER is common in infants and most of them outgrow it by 1 year of age 30 20 10 0 0-3 months 4-6 months 7-9 months 10-12 months Age (months) Arch Pediatr Adolescent Med 1997:151-159
  • 10. AETIOLOGY OF GERD• Genetic predisposition• Environmental factors – Food habit – Eating fast – Obesity – Stress – Exposure to tobacco smoke• Nerologically impaired children
  • 11. ESOPHAGUS• Exposed to a variety of potentially noxious substances.• Major challenge to the integrity of esophageal function is GER
  • 12. ESOPHAGEAL DEFENSES: THREE TIERS• Anti reflux barrier - Lower esophageal sphincter, The diaphragmatic pinchcock and Angle of His• Esophageal clearance - Limit the duration of contact between luminal contents and esophageal epithelium• Esophageal mucosal resistance - Comes into play when reflux contact time is prolonged
  • 13. LES • High pressure zone-Length 3-6 cm & Pressure of about 20 mmHg • Pressure < than 6 mmHg favors GER • 20% of all reflux episodes occur in relation to a decreased basal low resting LES pressure (Cadiot et al Gut 1997)
  • 14. INTRA-ABDOMINAL ESOPHAGUS• Rt & Lt crus of diaphragm produces a pinch cock action to constrict esophagus at the hiatus• Length of the intra abdominal esophagus- >2cm
  • 15. ANGLE OF HIS•An acute angle betweenthe greater curvature of the stomach and the esophagus•If the angle is obtuse as in hiatal hernia this favorsGER episodes.
  • 16. PATHOPHYSIOLOGY OF GERD• Transient LES relaxation• Reduced esophageal body peristalsis
  • 17. Gastric Overfeeding distension overweight increased abdominal pressure Vagally mediated Low basal LES tone abnormal Defective LES motilityneural control of LES Increased TLESRs Haital hernia obtuse angle of His Increase in GER Impaired pH neutralization Delayed acid clearance GERD Poor mucosal resistance
  • 18. symptomsNeonates/Infants Older Children/AdolescentsRegurgitation- Early morning nauseaespecially postprandially Abdominal discomfortSigns Of Esophagitis- Burps that burn(irritability, arching, choking, Sub sternal paingagging, feeding aversion) Heartburnfailure to thrive Recurrent vomiting •Sandifer syndrome-Poor weight gain neck contortions (arching, turning of head)
  • 19. Non GI Manifestations of GERD Extra-esophageal symptomsPulmonary Otorhinolaryngeal• Asthma • Chronic otitis media• Recurrent pneumonias • Hoarseness• Chronic Cough • Globus sensation• Apnoea • Persistent cough • Sore throat
  • 20. Non GI Manifestations of GERD Extra-esophageal symptoms• Acute life threatening events •Excessive coughing, (ALTE) •Irritability• Bradycardia •Sleep disturbances• Abnormal posturing / arching •Poor appetite (Sandifer’s syndorme)• Dental erosions / waterbrash
  • 21. COMPLICATIONS• Erosive esophagitis• Stricture• Barrett esophagus• Adenocarcinoma• Weight loss• Failure to thrive• Progressive pulmonary fibrosis• Adenoidal enlargement• Otitis media
  • 22. Asthma & GERDDoes GERD cause Asthma ? Does asthma cause GERD? Asthma GERD Asthma + GERDCoexistence seems to be more frequent than would be expected for a chance occurrence.
  • 23. Does Asthma Trigger GERD? Proposed Mechanisms Coughing Asthma Medications IncreaseIntraabdominal Pressure Increasing Lower LESPressure Gradient Across The LES GERD Pressure
  • 24. Does GERD Trigger Asthma? Reflux TheoryDirect contact between gastric refluxate and lung tissues Inflammation of the airway Bronchial smooth muscle reactivity Am J Med 2001; 111: 37S
  • 25. Does GERD Trigger Asthma? Reflex Theory Esophagus and bronchial tree have identical embryological derivation Share common innervation (via vagus nerve) and common reflexes Stimulation of receptors in distal esophagus by refluxate Leads to vagal reflux Producing bronchial constriction and/or cough Moser et al, Gastroenterology 1991; 101: 1512 Tuchman et al, Gastroenterology 1984; 87: 872
  • 26. GER& ASTHMA• Medical therapy does not consistently improve pulmonary function, asthma symptoms or need of asthma medication• Approach to GER related asthma should be individualized• Selected subgroup of asthmatics benefit from anti reflux therapy Cochrane Systematic Review
  • 27. Naspghan’s RecommendationsWork up and /or initiation of empiric therapy for GERDin the child with asthma should be considered in thefollowing situations:-  Asthma exacerbations despite compliance with asthma therapy sth ma torya  Frequent episodes of nocturnal asthma or nocturnal cough ref rac re  Two or more courses of systemic corticosteroids per year Sev e despite maintenance asthma medication use.All patients with severe refractory asthma should undergo oesophgeal pH monitoring to evaluate the presence of GERD.
  • 28. When to suspect GERD associated Asthma?• Associated typical symptoms of GERD• Nocturnal cough• Difficult to control asthma
  • 29. GER & Chronic cough• GERD is currently considered the third leading cause of chronic cough affecting an estimated 20 % of patients• Most patients do not have heartburn or regurgitation• Anti reflux therapy combined with lifestyle changes have reported cough resolution in 70- 100% of patients
  • 31. • GERD is diagnosed on basis of history & clinical features• An empiric trial of PPI therapy is a widely used diagnostic test
  • 32. GERD symptoms questionnaire• Developed for infants and young children• Individual symptom score calculated as the product of symptom frequency and severity score• Useful in distinguishing symptomatic GERD from healthy children Deal L et al JPGN 2005
  • 33. INVESTIGATIONS FOR GERDGoal Investigation1-Documenting reflux 1-24 hr pH monitoring -Scintiscan2-Documenting tissue 2-Endoscopy, Occult blood damage3-Establishing GER as in stool etiology of episodic 3-pH monitoring symptoms4-Documenting Anatomical deficiency 4-Barium study
  • 34. DIFFERENTIALSEsophageal motility disordersEosinophilic esophagitisCrohns disease
  • 35. 24 HOUR ESOPHAGEAL PH MONITORING•Most quantitative and sensitive method•Cumbersome & not easily available•Used to correlate symptoms with refluxepisode•Probe inserted acc to length calculatedby strobel’s formula {5+ 0.252x length incm}•All medications discontinued 72hrsbefore test•Reflux episode: ph <4•Reflux index : % of time when esophagealph is <4•Mild- 5- 10%•Moderate -10-20%•Severe >20%•Now wireless capsules are available
  • 36. INDICATIONS FOR ESOPHAGEAL PH MONITORING1. For assessing efficacy of acid suppression during treatment2. Evaluating apneic episodes in conjunction with a pneumogram and perhaps impedance3. Evaluating atypical GERD presentations such as chronic cough, stridor, and asthma
  • 37. CONTRAST RADIOGRAPHIC STUDY(USUALLY BARIUM)Performed in children with vomiting and dysphagia Evaluate for- Achalasia Esophageal Strictures Stenosis Hiatal Hernia Gastric Outlet Intestinal Obstruction It has poor sensitivity and specificity in the diagnosis of GERD
  • 38. ENDOSCOPY•In most of patients normal sonot useful for GERD•To identify complicationslike ulcers, strictures,barrett’s esophagus•Biopsies can be obtained forearly diagnosis of barrett’s &cancers•Biopsies can differentiateother causes of esophagitislike eosinophilic esophagitis
  • 39. MULTICHANNEL INTRALUMINALIMPEDANCE (MII)• Both for diagnosing GERD and for understanding esophageal function• Cumbersome test• Multiple sensors and a distal ph sensor• Document acidic reflux, weakly acidic reflux, and weakly alkaline reflux• An important tool in respiratory symptoms• Determination of nonacid reflux
  • 40. LARYNGOTRACHEOBRONCHOSCOPYEvaluates for-• Visible airway signs a/w extra esophageal GERD Posterior laryngeal inflammation Vocal cord nodules• Diagnosis of silent aspiration• Evaluation for dysmotility
  • 41. EMPIRICAL ANTIREFLUX THERAPY(THERAPEUTIC TRIAL)•Using of high-dose proton pump inhibitor (PPI)•useful in adolescent and adults•Diagnosis most of time clinical•Response to treatment is considered as confirmed diagnosisPitfalls•Does not include diagnostic tests•Gastritis & peptic ulcers presents & responds similarly•20% may have placebo effects
  • 42. NUCLEAR SCINITISCAN•Helpful in diagnosing delayed gastric emptying•Low radiation hazard•Useful when fundoplication is considered
  • 44. GERD Investigations• To establish a cause and effect relationship between reflux and symptoms such as irritability, heart burn , coughing, choking etc.• To exclude exacerbating causes such as gastric emptying delay, anatomical abnormalities• To document damage due to reflux and to exclude associated conditions-esophageal strictures, Barret,s esophagus etc.
  • 45. Management of GERD
  • 46. Treatment Goals of GERD
  • 48. POSITIONING• Head end elevation about 30 degree• Left lateral positioning• Prone positioning• <1yr not recommended, can be done in awake state as during sleep risk of SIDS outweigh the benefits• Don’t use soft bed during prone positioning
  • 49. DIETARY MODIFICATIONS• Small feed with increase in frequency• Increase proportion of solids or semisolids• Avoid spicy foods, tea, coffee, cola & late evening meals alcohol & tobacco• Avoid acid containing foods like citrus juices, carbonated beverages, and tomato juices• Chewing gum is useful as it increases production of bicarbonate containing saliva & increases rate of swallowing and promote acid clearance
  • 50. PHARMACOTHERAPY ACID REDUCING AGENTS• H2 receptor antagonists• Proton pump inhibitors• Antacids PROKINETICS• Metaclopromide• Bethanechol• Erythromycin• Baclofen• Cisapride
  • 51. Mode of Action K+,Cl- K+,Cl- HCl H+ H+ Histamine Proton pump K+ K+H2 receptors Proton pump Antacidsantagonists inhibitors Thus PPIs block the final step in gastric acid secretion.
  • 52. ANTACIDS• Good for symptomatic relief as are short acting• Best to take app. 1 hr after meal or before symptoms of reflux• Calcium containing antacids should be avoided as promote gastrin secretion• Use antacids containing both aluminum & magnesium
  • 53. HISTAMINE ANTAGONISTS• Selective inhibition of histamine receptors on gastric parietal cells• Best taken 30 minutes before meals as blood levels peaks when stomach is producing acid actively• Effects last for 6 hrs• Used for uncomplicated GERD• Tachyphylaxis or diminution of response after long term used• CIMETIDINE 40mg/kg /day TID• RANITIDINE 1-2 mg/kg /day BD• FAMOTIDINE1 mg/kg day BID• NIZATIDINE 10 mg/kg /day BID
  • 54. PROTON PUMP INHIBITOR• Shuts off acid production more completely and for longer period of time• Especially useful for complications or inadequate response by histamine receptor antagonists• Available as capsules containing enteric coated granules that can be emptied in soft foods or liquids• Should be taken30 minutes before meals for maximal effect• No PPI is approved for use in infants• OMEPRAZOLE 0.3-3.5mg/kg /day BD• LANSOPRAZOLE<10KG 7.5 MG OD, 10-30 KG 15 MGOD >30KG 30MG OD[0.73-1.66mg/kg/day]• PANTOPRAZOLE[0.5 -1 mg /kg/day]• ESOMEPRAZOLE 1.0 mg/kg QD
  • 55. PRO MOTILITY DRUGS• Increase pressure in LES & strengthen peristalsis of esophagus , speeds up gastric emptying• None affects the frequency of TLESRs• Most effective when 30 min before meals• Reserved for non responders or to enhance other treatments of GERD• METOCLOPROMIDE 0.4-0.8 mg/kg / day QID[5,10 MG,5MG/5ML] (dopamine-2 and 5-HT3 antagonist)• BETHANECHOL (cholinergic agonist)• ERYTHROMYCIN (motilin receptor agonist)• BACLOFEN (centrally acting γ-aminobutyric acid (GABA) agonist )• CISAPRIDE 0.8 mg/ kg/day QID[1MG/ML,10 MG, 20MG](serotonergic agent)• MOSAPRIDE 0.5-0.8 mg/kg/day QID
  • 56. FOAM BARRIERS• Composed of an antacid and a foaming agent• Forms physical barrier to reflux• Best taken after meals• Available as magaldrate with alginate
  • 60. Take Home Message• A common childhood problem• More common in select pediatric populations• Diagnosis is essentially clinical , based on high index of suspicion• Trial of therapy is justified in patient with high degree of suspicion• Investigations required in individualized cases