Gastroesophageal reflux disease Case presentation as seen in UCTH Calabar.

1. GERD CASE MANAGEMENT
PRESENTATION
BY
DR EFFIOM, VICTOR E.
HO
Pediatrics

2. BIODATA
 C.C.G
 3 Months
 Male
 No. 4 Asari Iso Layout Street, Calabar.
 Hails from Imo state, Igbo Tribe.
 Christian
 Admission: Via CHER
 Informant: Mother (Reliable)

3. History
 PC:
-Vomiting since birth
-Swelling on the left Forearm x 1/52
-Fever x 4/7
-Passage of watery stools X 3/7
-Cough and catarrh x 1/7

4. History Of Presenting Complaint (A).
 Vomiting was noted since 1st day of life.
 Non-projectile, non-forceful, persistent, post-prandial, non-
bilious, usually from immediately after meals to 30 mins.
post feeding.
 Quantity depended on quantity of breast milk intake. There
was no associated history of loss of appetite as child was
always eager to suckle at breast.
 Color is that of breast milk, not blood stained and not
offensive.
 Episodes of vomiting mostly averaged 10x per day. Had
vomited 6x already prior to presentation at CHER.
 Nil abdominal swelling.

5. HISTORY OF PRESENTING COMPLAINT
 Swelling on left forearm was initially small in size measuring
about the size of a peanut.
 Swelling had progressively enlarged but did not discharge any
purulent effluents.
 No differential warmth. Mild tenderness. Not fixed to underlying
tissue.
 No preceding trauma or injury

6.  Fever started 4/7 prior to presentation at
CHER.
 Was high-grade and continuous.
 Nil convulsions, nil excessive crying or crying
during micturition
 Nil tugging of the ears
 Subsides with administration of tabs PCM and
tepid sponging.

7. HISTORY OF PRESENTING COMPLAINT
CONTD.
 Passage of watery stools noticed 3/7 days prior
to presentation
 Sudden onset
 Occurred on an average almost 8x in a day
 Non-mucoid, not blood stained, non-copious.
 no curling up or crying to show abdominal pain

8.  Cough: Non-paroxysmal.
 Nil difficulty in breathing, nil fast breathing,
 Had no variation with time of the day (Not worse at night)
 Occasionally associated with post prandial vomiting.
 Nil hx. of force feeding
 No known aggravating or relieving factors.
 no bluish discoloration of lips and extremities.

9.  For the above set of complaints, baby and mother
presented at the CHER for expert management.
PAST MEDICAL HX.
 Baby was admitted during neonatal period on account
of jaundice and was treated with phototherapy.

10. Prenatal, Natal and Post Natal History.
 Spontaneous conception & desired
 Received 2 doses of TT & IPTp.
 Was placed on Haematinics and vitamin C through out
duration of pregnancy.

11.  Investigations done for RVS, HBsAg, HCV were all
negative.
 Not a known HEADS0
 Delivery via Elective Caesarean section
 Outcome live male Neonate, Wt: 3.2kg.
 Baby cried immediately after birth
 Exclusive breastfeeding/immunised for age.
 Puerperium was uneventful.

12. DIETARY AND NUTRITIONAL
HISTORY.
 Predominant breastfeeding x 2months
 Currently supplementing by adding guinea corn, millet
and NAN 3x daily. Recently introduced another milk
2/52 with no improvement.

13. Immunization Hx.
 Has been immunized for age
Developmental History:
- No Neck control, sustained grasp of objects.

14. FAMILY AND SOCIAL HISTORY
• Patient is third in a family of 3, (2 males and 1
female, all alive and well).
• Both parents are alive and well.
• Mother is a 23 year old graduate, unemployed.
• Father is a ? old plumber, self employed with
secondary level of education.

15. SUMMARY
I have presented the case of C.C.G a 3 months old infant
who presented at the Children emergency clinic with
complaints of Vomiting since birth, Swelling on the left
Forearm x 1/52, Fever x 4/7, Passage of watery stools X 3/7
and Cough and catarrh x 1/7.

16.  PHYSICAL EXAMINATION
o A conscious, Small for age, afebrile (36.70C), not pale,
anicteric, acyanosed, not dehydrated, not in respiratory
distress, no peripheral Lymphadenopathy, nil pedal edema,
no dysmorphic features.
o Anthropometry
*OFC: 39cm (Adequate)
*Weight: 3.6kg (~60th pecentile)
*Length: 54cm (75th percentile)
 .

17. o ABD: full, moved with respiration, soft.
Liver was palpated about 2cm below the costal
margin, firm, smooth and non-tender.
 RESPIRATORY SYSTEM
o RR – 44 cpm,
o Vesicular breath sounds, nil crepitations.

18.  CARDIOVASCULAR SYSTEM
o PR - 140 b.p.m, regular, normal volume.
o BP – no appropriate cuff.
o heart sounds: S1, S2 only. No murmurs
MSS: Mass on left forearm measuring 2.5cm by 2cm. Firm, no
differential warmth.
CNS: Conscious and alert, AF: flat and normotensive, no
neck control, nil signs of meningeal irritation, normal tone in
all limbs.

19. Working Diagnosis (CHER)
 1. Partial Intestinal obstruction ? Cause r/o Congenital
hypertrophic pyloric Stenosis
 2. Sepsis (furunculosis, diarrheal disease + URTI)

20. Treatment
①Admitted to CHER.
②Carry out following investigations; MP,
Abdominal USS, FBC, Barium meal and follow
through, E,U,Cr.

21.  ORS Plan A 50-100/mls per loose stool.
 Started on IV Ampiclox 180mg every 6hrs till reviewed
 Tabs Zinc 10mg daily x 2/52
 Vitamin A 100,000IU dly x 2days, then 1 dose 2weeks
later.

22. Investigations:
 Retrieved on 2nd day of admission.
 FBC
a. PCV: 42%
b. WBC: 7.8 X 109/L
c. Neutrophils = 28%
d. Eosinophil = 1%
e. Lymphocyte = 71%
f. Monocytes = 0%
 MP
Trophozoites of P. Falciparum + seen.

23.  E/U/Cr
1. Urea: 3.0 mmol/l
2. Na+: 137mmol/l
3. K+: 3.6 mmol/l
4. HCO3: 25mmol/l
5. Cl--: 98mmol/l
6. Creatinine: 102umol/l.

24.  On the 4th day of admission, patient was no more passing
watery stools. Has had 6 episodes of vomiting over past 24
hours.
 Vital signs had been stable since admission and child was
sucking well at breast.
 Swelling over the anterolateral part of the L. forearm had
become fluctuant in consistency.
 Plan was initiated to
• Do an Incision and drainage for abscess. Consult was sent
to the PSU.
• Introduction of syrup P-Alaxin 7.5mls dly x 3/7 following MP
result.
• Continue breastfeeding and present medications (Ampiclox,
zinc)

25. On the 8th day of admission,
ABD USS: no abnormality detected.
Barium swallow meal and follow through: Normal.
Current weight: 3.7kg
::: A diagnosis of Gastroesophageal Reflux Disease

26. Plan
 Counseling the mother
 Commencement of cereal and infant formula
 Put patient to lie prone
 Alternate day weighing
 Keep feeding/vomitus chart
 Small frequent feeds (cereal and infant formula) @
30mls 2hrly x 24hrs and then further reduced to 10mls
hourly.

27.  On the 9th day of admission, regurgitation had reduced
in frequency since the commencement of NAN 1 and
patient is also lying prone.
 Weight on day 9 of admission was 3.9kg
 Abscess had reduced drastically in size.
 Vital signs remained stable.
 Was to complete 7 days of IV Ampiclox.

28.  Patient continued to improve clinically.
 Vomiting little quantity.
 Mother admits to child’s improved clinical state
and requests discharge home.
 Weight was 4.05kg
 Patient was discharged home on mothers
request.

29.  Continue oral tabs zinc 10mg daily.
 Feed 10mls hourly.
 Nurse prone and keep upright for 30mins after feeding.
 See in clinic in 3/7.

30. FOLLOW UP VISIT 1.
 Age: 4 months 5 days.
 Weight: 4.5kg
 RR: 40cpm
 Patient is gaining weight (gained 0.45kg in 3 days)
 Tolerating frisco rice with NAN 1
 Regurgitation reducing in volume and frequency.
 Neck control is improving.
 Mother happy with infant’s improvement.
 Mother advised to continue small, frequent feeds and keep
upright for at least 30mins after feeding. Infant to lie prone.
 To see in clinic in 2/52.

31. Follow up visit 2
 Age: 4 months
 Wgt was 5kg. (83% of EWA)
 OFC=41cm
 Length=60cm
 Chest is clear.
 Doing well.
 Vomiting had reduced in frequency and volume.
 Had attained neck control.
 Nil fresh complaints.

32.  Continue with feeding as prescribed
 See in 1/12.

33. Thank you…