Pediatrics Gastroenterology

Gastroesophageal reflux disease (GERD)

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10 أقسام

شرح المدرسين

د. رناد العجارمة

د. رناد العجارمة

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Summary

Gastroesophageal reflux disease (GERD) occurs when transient inappropriate relaxation of the lower esophageal sphincter (LES) allows acidic gastric contents to reflux into the esophagus, causing mucosal injury and symptoms. It is one of the most common gastrointestinal conditions encountered in both primary care and exam settings.

The hallmark symptoms are substernal burning (heartburn) and acid regurgitation, typically worsening after meals and when lying supine. GERD also has important extraesophageal manifestations — chronic cough, hoarseness, and wheezing — which may occur even without classic heartburn ("silent GERD").

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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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