Gastroesophageal reflux disease

PPT on GERD. Including basics from Nelson textbook of Pediatrics. useful for MD/DCH /DNB Pediatrics exams.

1. Gastroesophageal Reflux Disease Dr.Himanshu S Dave Dept of Pediatrics NRCH, New Delhi

2. Retrograde movement of gastric contents across the lower esophageal sphincter (LES ) into the esophagus , which occurs physiologically every day in all infants, older children, and adults . Physiologic GER is exemplified by the effortless regurgitation of normal infants.

3. The phenomenon becomes pathologic GERD in infants and children who manifest or report bothersome symptoms because of frequent or persistent GER, producing esophagitis -related symptoms, or extra esophageal presentations , such as respiratory symptoms or nutritional effects.

4. Pathophysiology Factors determining the esophageal manifestations of reflux include : the duration of esophageal exposure (a product of the frequency and duration of reflux episodes ), the causticity of the refluxate , and the susceptibility of the esophagus to damage.

5. The frequency of reflux episodes is increased by : Insufficient LES tone, by abnormal frequency of LES relaxations, and by hiatal herniation that prevents the LES pressure from being proportionately augmented by the crura during abdominal straining.

6. Transient LES relaxation (TLESR) is the primary mechanism allowing reflux to occur, and is defined as simultaneous relaxation of both LES and the surrounding crura . TLESRs occur independent of swallowing, reduce LES pressure to 0-2 mm Hg (above gastric), and last 10-60 sec; they appear by 26 wk of gestation.

7. A vagovagal reflex, composed of afferent mechanoreceptors in the proximal stomach, a brainstem pattern generator, and efferents in the LES, regulates TLESRs.

8. Gastric distention ( postprandially , or from abnormal gastric emptying or air swallowing) is the main stimulus for TLESRs.

9. Epidemiology Infant reflux becomes evident in the first few mo of life, peaks at 4 mo, and resolves in up to 88% by 12 mo and in nearly all by 24 mo. Happy spitters are infants who have recurrent regurgitation without exhibiting discomfort or refusal to eat and failure to gain weight. Symptoms of GERD in older children tend to be chronic, waxing and waning, but completely resolving in no more than half, which resembles adult patterns.

10. Clinical Features Infantile reflux manifests more often with regurgitation (especially postprandially ), signs of esophagitis (irritability , arching, choking, gagging, feeding aversion), and resulting failure to thrive ; symptoms resolve spontaneously in the majority of infants by 12-24 mo.

11. Older children can have regurgitation during the preschool years; this complaint diminishes somewhat as children age, and complaints of abdominal and chest pain supervene in later childhood and adolescence. Occasional children present with food refusal or neck contortions (arching, turning of head) designated Sandifer syndrome .

12. The respiratory presentations are also age dependent : GERD in infants may manifest as obstructive apnea or as stridor or lower airway disease in which reflux complicates primary airway disease such as laryngomalacia or bronchopulmonary dysplasia.

13. Symptoms Recurrent regurgitation with or without vomiting Weight loss or poor weight gain Irritability in infants Ruminative behavior Heartburn or chest pain Hematemesis Dysphagia , odynophagia Wheezing Stridor Cough Hoarseness

14. Signs Esophagitis Esophageal stricture Barrett esophagus Laryngeal/pharyngeal inflammation Recurrent pneumonia Anemia Dental erosion Feeding refusal Dystonic neck posturing (Sandifer syndrome ) Apnea spells Apparent life-threatening events

15. DIAGNOSIS For most of the typical GERD presentations, particularly in older children, a thorough history and physical examination suffice initially to reach the diagnosis .

16. The clinician should be alerted to the possibility of other important diagnoses in the presence of any alarm or warning signs : bilious emesis, frequent projectile emesis, gastrointestinal bleeding , lethargy, organomegaly , abdominal distention , micro- or macrocephaly , hepatosplenomegaly , failure to thrive, diarrhea , fever, bulging fontanelle , and seizures .

17. Contrast (usually barium) radiographic study of the esophagus and upper gastrointestinal tract is performed in children with vomiting and dysphagia to evaluate for achalasia , esophageal strictures and stenosis , hiatal hernia, and gastric outlet or intestinal obstruction.

18. Extended esophageal pH monitoring of the distal esophagus , no longer considered the sine qua non of a GERD diagnosis, provides a quantitative and sensitive documentation of acidic reflux episodes, the most important type of reflux episodes for pathologic reflux.

19. Endoscopy allows diagnosis of erosive esophagitis and complications such as strictures or Barrett esophagus ; esophageal biopsies can diagnose histologic reflux esophagitis in the absence of erosions while simultaneously eliminating allergic and infectious causes. Endoscopy is also used therapeutically to dilate reflux-induced strictures. Radionucleotide scintigraphy using technetium can demonstrate aspiration and delayed gastric emptying when these are suspected.

20. Laryngotracheobronchoscopy evaluates for visible airway signs that are associated with extraesophageal GERD, such as posterior laryngeal inflammation and vocal cord nodules.

21. Empirical antireflux therapy , using a time-limited trial of high-dose proton pump inhibitor (PPI), is a cost-effective strategy for diagnosis in adults; although not formally evaluated in older children, it has also been applied to this age group .

22. MANAGEMENT Conservative therapy and lifestyle modifications that form the foundation of GERD therapy. Dietary measures for infants include normalization of any abnormal feeding techniques, volumes, and frequencies.

23. A combination of modified feeding volumes, hydrolyzed infant formulas, proper positioning, and avoidance of smoke exposure satisfactorily improve GERD symptoms in 24–59% of infants with GERD.

24. Older children should be counseled to avoid acidic or reflux-inducing foods (tomatoes , chocolate, mint) and beverages (juices, carbonated and caffeinated drinks , alcohol). Weight reduction for obese patients and elimination of smoke exposure are other crucial measures at all ages.

25. Positioning measures are particularly important for infants, who cannot control their positions independently. Seated position worsens infant reflux and should be avoided in infants with GERD. When the infant is awake and observed, prone position and upright carried position can be used to minimize reflux.

26. PHARMACOTHERAPY Pharmacotherapy is directed at ameliorating the acidity of the gastric contents or at promoting their aboral movement and should be considered for those symptomatic infants and children who are either highly suspected or proven to have GERD.

27. Antacids are the most commonly used antireflux therapy and provide rapid but transient relief of symptoms by acid neutralization. The long-term regular use of antacids cannot be recommended because of side effects of diarrhea ( magnesium antacids ) and constipation ( aluminum antacids) and rare reports of more serious side effects of chronic use.

28. Histamine-2 receptor antagonists (H2RAs: cimetidine, famotidine, nizatidine , and ranitidine) are widely used antisecretory agents that act by selective inhibition of histamine receptors on gastric parietal cells.

29. PPIs ( omeprazole , lansoprazole , pantoprazole , rabeprazole , and esomeprazole ) provide the most potent antireflux effect by blocking the hydrogen–potassium adenosine triphosphatase channels of the final common pathway in gastric acid secretion. PPIs are superior to H2RAs in the treatment of severe and erosive esophagitis .

30. Prokinetic agents : Available in the United States include metoclopramide (dopamine-2 and 5-HT3 antagonist), bethanechol (cholinergic agonist), and erythromycin ( motilin receptor agonist ). Most of these increase LES pressure; some improve gastric emptying or esophageal clearance. None affects the frequency of TLESRs

31. Surgery, usually fundoplication , is effective therapy for intractable GERD in children , particularly those with refractory esophagitis or strictures and those at risk for significant morbidity from chronic pulmonary disease. It may be combined with a gastrostomy for feeding or venting.

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