GERDKhaled Saad

The passage of gastric contents into the esophagus (GER) is a normal physiologic process that occurs in healthy infants, children. Most episodes are brief and do not cause symptoms, esophageal injury, or result in other complications. In contrast, gastroesophageal reflux disease (GERD) occurs when the reflux episodes are associated with complications such as esophagitis or poor weight gain.

DEFINITIONS  The term "uncomplicated” (GER) is used to

describe the normal physiologic process of frequent regurgitation in the absence of pathological consequences. The term, (GERD), is used when the reflux has pathological consequences, such as esophagitis, nutritional compromise, or respiratory complications.

Natural history: Gastroesophageal reflux (GER) is extremely common in healthy infants, in whom gastric fluids may reflux into the esophagus 30 or more times daily. The frequency of reflux decreases with increasing age, such that physiologic regurgitation or vomiting decreases toward the end of the first year of life, and is unusual in children older than 18 months old. Pediatrics 1991; 88:834.

Although the problem usually resolves by the end of infancy, there is a weak association with GERD later in life. As an example, frequent regurgitation during infancy and a history of GERD in the mother (but not the father) both predict the risk of reflux-related symptoms during childhood. Pediatrics 2002; 109:1061.

Prevalence 

The prevalence of various symptoms suggestive of gastroesophageal reflux (GER) was 1.8 to 8.2 percent.

Arch Pediatr Adolesc Med 2000; 154:150.

CLINICAL MANIFESTATIONS

The most common symptoms of gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) vary according to age, although overlap may exist:

Infants –Regurgitation is present in 50 to 70 percent of all infants, peaks at age four months, and typically resolves by one year.

A small minority of infants with GER develop other symptoms suggestive of GERD, including feeding refusal, irritability, hematemesis, anemia, respiratory symptoms, and failure to thrive.

Preschool age children with GERD may present with intermittent regurgitation. Less commonly, they may have respiratory complications including persistent wheezing. Decreased food intake or poor weight gain without any other complaints may be a symptom of esophagitis in young children. All of these symptoms are nonspecific and insufficient to make a definitive diagnosis of GERD.

Older children and adolescents – The pattern of GERD in older children and adolescents resembles that seen in adults. The cardinal symptoms are chronic heartburn and/or regurgitation. Complications of GERD, including esophagitis, strictures, Barrett's esophagus, and hoarseness due to reflux laryngitis, also may be seen. Older children may complain of nausea, dysphagia and/or epigastric pain.

Surgery

Life Style

Dietary Management

Pharmacotherapy

Management Complications

Wise Approach GERDWise Approach GERD

5 Stages Management5 Stages Management

Life Style

Life Style ModificationLife Style ModificationPositions in infantsPositions in infants

Position in ChildrenPosition in Children

Daily activities modificationDaily activities modification•Exercise:? Exercise induced reflux•Overweight•No snaking close to bed time

•Exercise:? Exercise induced reflux•Overweight•No snaking close to bed time

Surgery

Life Style

Dietary Management

Pharmacotherapy

Management Complications

Wise Approach GERDWise Approach GERD

5 Stages Management5 Stages Management

Dietary Management

Dietetic ManagementDietetic Management

Regurge with normal weight gain and No Signs of GERD

1.Changing feeding schedule: burping, gently massage abdomen and avoid tight diapers

2.Use pacifiers: saliva and neutralize acid

3.Thickening feeds: precooked corn starch, one grain cereal, carob, gower gum, rice starch??

4.Using special AR formulas

5.Trying solid foods if weaned

1.Changing feeding schedule: burping, gently massage abdomen and avoid tight diapers

2.Use pacifiers: saliva and neutralize acid

3.Thickening feeds: precooked corn starch, one grain cereal, carob, gower gum, rice starch??

4.Using special AR formulas

5.Trying solid foods if weaned

Persistent regurge signs of poor weight gain esophagitis or respiratory symptoms

Consider cow milk with protein eliminationConsider cow milk with protein elimination

Re-evaluate (upper GI examination)Re-evaluate (upper GI examination)

Trial of medicationTrial of medication

N.B. - Probiotics-

Homeotherapy

N.B. - Probiotics-

Homeotherapy

Surgery

Life Style

Dietary Management

Pharmacotherapy

Management Complications

Wise Approach GERDWise Approach GERD

5 Stages Management5 Stages Management

Pharmacotherapy

PharmacotherapyPharmacotherapy

II) Second line drugsII) Second line drugs

- Acid blocking drugs (neutralise or stomach acidity)- Acid blocking drugs (neutralise or stomach acidity)

1- Histamine H2RA Ranitidine

2- Proton pump inhibitors PPI

Omeprazole

1- Histamine H2RA Ranitidine

2- Proton pump inhibitors PPI

Omeprazole

I) First line drugsI) First line drugs

- Mylicon

- Gaviscon

- Mylicon

- Gaviscon

Prokinetics (drugs that improve intestinal coordination)

1- Cisapride (propalsid) abnormal heart rate

2- Erythromycin side effect is an advantage

III)Third line drugsIII)Third line drugs

Approaches toAcid-Reducing Therapy

Begin treatment with PPI Maintain improvement with

PPI Switch to H2RA

Begin treatment with PPI Maintain improvement with

PPI Switch to H2RA

Begin treatment with H2RA Inadequate response PPI Inadequate response ↑ PPI

dose

Begin treatment with H2RA Inadequate response PPI Inadequate response ↑ PPI

dose

Step DownStep Down

Step UpStep Up

• Tachyphylaxis: tolerance with prolonged use inspite increasing dose

• Decreased absorption of Fe, Ca, Folic acid, B12

• Tachyphylaxis: tolerance with prolonged use inspite increasing dose

• Decreased absorption of Fe, Ca, Folic acid, B12

Side effects of antacids:Side effects of antacids:

• Stomach acid is a part of the body immune system Kills pathological bacteria in the gut

• Stomach acid is a part of the body immune system Kills pathological bacteria in the gut

Surgery

Life Style

Dietary Management

Pharmacotherapy

Management Complications

Wise Approach GERDWise Approach GERD

5 Stages Management5 Stages Management

Management Complications

Management of Supraesophageal Complications

Management of Supraesophageal Complications

Chronic sore throat & hoarsness

Dental erosions

OM & Sinusitis

Wheezing Asthma

Apnea Bradycardia

Chronic cough

ALTE

• ALTE = acute life threatening event

apnea, color change, chocking gaging

• 60% to 70% of infants with ALTE have recurrent regurge and abnormal esophageal pH

• Relationship between GER and obstructive or mixed apnea most convincing when infant was:

Awake, Supine, Fed within past hour

• ALTE = acute life threatening event

apnea, color change, chocking gaging

• 60% to 70% of infants with ALTE have recurrent regurge and abnormal esophageal pH

• Relationship between GER and obstructive or mixed apnea most convincing when infant was:

Awake, Supine, Fed within past hour

GER and ALTEGER and ALTE

Aspiration SyndromesAspiration Syndromes

• Aspiration pneumonia &pleural effusion

• Acid aspiration pneumonitis

• Interstitial lung disease & pulmonary fibrosis

• Aspiration pneumonia &pleural effusion

• Acid aspiration pneumonitis

• Interstitial lung disease & pulmonary fibrosis

• GER Asthma

• GER Asthma

• GER Asthma

• GER Asthma

• GER Asthma

• GER Asthma

• GER Asthma

• GER Asthma

Does GER Cause Asthma?Does GER Cause Asthma?

Surgery

Life Style

Dietary Management

Pharmacotherapy

Management Complications

Wise Approach GERDWise Approach GERD

5 Stages Management5 Stages Management

Surgery

Infants and Children:• Failure of medical therapy

• Dependence on aggressive or prolonged medical therapy

• Persistent asthma or recurrent pneumonia due to GERD

Infants and Children:• Failure of medical therapy

• Dependence on aggressive or prolonged medical therapy

• Persistent asthma or recurrent pneumonia due to GERD