Pediatrics Gastroenterology

Gastroesophageal reflux disease (GERD)

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10 أقسام

Summary

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Introduction

  • Gastroesophageal reflux (GER) is the normal physiologic state in which stomach contents move retrograde into the esophagus.
  • Gastroesophageal reflux disease (GERD) is characterized by transient inappropriate decrease in lower esophageal sphincter tone which allows excessive gastric refluxate to enter the esophagus and even the oropharynx.
  • GERD presents as heartburn, regurgitation, and dysphagia.
  • This condition is also associated with respiratory symptoms such as chronic cough, hoarseness and it may exacerbate asthma.
  • Complications include erosive esophagitis, strictures, and Barrett esophagus.
Gastroesophageal Reflux Disease (GERD)
Pathophysiology
  • Decreased tone or excessive transient relaxation of LES
  • Anatomic disruption to gastroesophageal junction (e.g., hiatal hernia)
  • Increased risk with obesity, pregnancy, smoking, and alcohol intake
Manifestations
  • Regurgitation of acidic material in mouth
  • Heartburn
  • Odynophagia (often indicates reflux esophagitis)
  • Extraesophageal syndrome (e.g., cough, laryngitis, wheezing)
Complications
  • Erosive esophagitis
  • Strictures
  • Barrett’s esophagus (premalignant for adenocarcinoma)
Initial Treatment
  • Lifestyle (e.g., weight loss) and dietary changes
  • Histamine 2 receptor blocker or proton pump inhibitor

 

Barrett Esophagus
Definition
  • Specialized intestinal metaplasia (replacement of nonkeratinized stratified squamous epithelium with intestinal epithelium which is nonciliated columnar with goblet cells)
Location
  • Distal esophagus
Etiology
  • Chronic gastroesophageal reflux disease (GERD)
Associations
  • Increased risk of esophageal adenocarcinoma

      

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Epidemiology

  • GERD is one of the most common gastrointestinal disorders (approximately 20% of adults).
  • This condition presents higher in girls compared with boys.
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Etiology

  • Impaired lower esophageal sphincter (LES) function and transient lower esophageal sphincter relaxations (TLESRs)
  • Acidic refluxate from the stomach enters the esophagus and oropharynx.
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Presentation of physiologic reflux (GER)

  • Infants are often termed “happy spitters” (they are without reflux-associated symptoms).
  • Emesis is benign.
  • Education and reassurance of parents are important (to avoid aimless formula changes, early weaning, medications or remedies).
  • Emesis from physiology reflux resolves by 6-12 months of age.
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Presentation of pathological reflux (GERD)

  • Presentation of pathological reflux is different based on the age of the child affected.
Difference in Presentation of Gastroesophageal Reflux Disease Based on Age
Infants Older Children
  • Emesis is the most common presentation
  • Feeding refusal with irritability (may indicate esophagitis; esophagus might be painful which may negatively reinforce feeding)
  • Constant hunger (desiring the buffering action of milk to reduce acid irritation)
  • Mid-epigastric pain (“heartburn”) temporarily relieved with food or antacids, exacerbated by fatty foods, caffeine, and being in the supine position
  • Nausea, hoarseness, halitosis, and wheezing
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Diagnosis

  • pH probe measurement (the gold standard for diagnosis)
  • Barium upper gastrointestinal study
  • Gastric emptying study
  • Endoscopy with biopsy (detects inflammation)
  • Bronchoscopy with alveolar lavage (when aspiration is suspected)

          

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Differential diagnosis

  • Milk protein allergy
  • Pyloric stenosis
Differential Diagnosis of Regurgitation and Vomiting in Infants
Diagnosis Clinical Features Management
Gastroesophageal Reflux
  • Physiologic: asymptomatic, happy spitter
  • Reassurance
  • Positioning therapy
  • Pathological (GERD): failure to thrive, significant irritability
  • Thickened feeds
  • Antacid therapy
  • If severe, esophageal pH probe monitoring and upper endoscopy
Milk Protein Allergy
  • Regurgitation/vomiting
  • Eczema
  • Bloody stools
  • Elimination of dairy and soy protein from diet
Pyloric Stenosis
  • Projectile nonbilious vomiting
  • Olive-shaped abdominal mass
  • Dehydration, weight loss
  • Abdominal ultrasound
  • Pyloromyotomy

 

Infantile Hypertrophic Pyloric Stenosis
Risk Factors
  • First born boy
  • Azithromycin and Erythromycin (particularly for infants exposed during the first 2 weeks of life)
  • Formula/bottle feeding
  • Decreased production of nitric oxide synthase
Clinical Presentation
  • Projectile nonbilious emesis
  • Poor weight gain
  • Dehydration
  • “Olive-shaped” abdominal mass
Associations
  • Duodenal atresia
  • Tracheoesophageal fistula
  • Trisomy 18
Laboratory Findings
  • Hypochloremic metabolic alkalosis
Diagnostic Studies
  • Thickened pylorus on abdominal ultrasound
Treatment
  • Intravenous rehydration
  • Pyloromyotomy

 

Protein Intolerance Leading to Malabsorption
Epidemiology
  • Protein intolerance occurs in up to 8% of children
  • Cow’s milk allergy is the most common type
  • Other causes include soy and egg proteins
Clinical Features
  • Diarrhea, vomiting, colicky abdominal pain that occurs after exposure to dietary protein
Diagnosis
  • Resolution of acute symptoms within a few days after complete withdrawal of the suspected antigen
  • Chronic symptoms usually resolve within 1–2 weeks
Management
  • Withdrawal and avoidance of the suspected dietary protein
  • Most protein intolerance is transitory and resolves by 1–2 years of age
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Treatment

  • Conservative management
    • Positioning in an upright or sitting position (raise the head of the bed after feeding or when asleep)
    • Dietary recommendations (frequent small meals and thickening of feeds)
    • Acid inhibition with antacids, histamine 2 receptor blockers, and proton pump inhibitors
  • Surgical management
    • Nissen fundoplication (wrapping the fundus of the stomach around the distal esophagus)
    • Pyloroplasty (to improve gastric emptying)
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Complications

  • Upper and lower airway disease may be induced or worsened by GERD (acidic refluxate induces bronchopulmonary constriction and can also lead to frank aspiration or microaspiration)
  • Chronic laryngitis, hoarseness, wheezing and the development of vocal cord nodules.
  • Failure to thrive
  • Esophageal strictures
  • Barrett esophagus
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