Transcript GERD - Inovapeds.org

GERD
Objectives

Discuss the prevalence and significance of
GERD in the pediatric population
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Discuss the diagnostic evaluation of the child
with suspected GERD
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Review the management of GERD
CONTINUITY CLINIC
Epidemiology: GER Iceberg
Infants
Adults
Referral
Referral
2%
2%
Visit MD within
the year
10 %
10 %
Visit MD within the
year
Regurgitate > 2
times per day
50 %
50 %
Heartburn > 1 times
per month
CONTINUITY CLINIC
Prevalence of Regurgitation in
Infancy
70
60
50
% of
infants 40
>1 time per day
>4 times per day
30
20
10
0
0-3 mos
4-6 mos
CONTINUITY CLINIC
7-9 mos 10-12 mos
The Antireflux Barrier
Esophagus
Angle of His
LES
Crural
Diaphragm
CONTINUITY CLINIC
Stomach
CONTINUITY CLINIC
Esophageal Capacitance
30 cm; 2x3 cm diam
- Shorter esophagus (11 cm; 5 mm diam)
- Smaller capacity
Adult
Infant
Gravity
CONTINUITY CLINIC
Factors Predisposing to GERD
Increased gastric volume:
Large meals
Delayed gastric emptying
Duodenogastric reflux
Decreased resistance:
Inadequate LES tone
Inappropriate LES relaxation
Inadequate supporting structures
Increased pressure:
- Tonic (e.g. obesity,
slouched posture)
- Phasic (e.g. cough,
sneeze, strain)
CONTINUITY CLINIC
Presenting Symptoms
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Recurrent vomiting in
infant
Recurrent vomiting and
poor weight gain in
infant
Recurrent vomiting and
irritability in infant
Recurrent vomiting in
older child
CONTINUITY CLINIC
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Heartburn in child or
adolescent
Dysphagia or feeding
refusal
Apnea or ALTE
Asthma
Recurrent pneumonia
Upper airway symptoms
Chronic cough
Warning Signals Suggestive of
a Non-GER Diagnosis
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Recurrent vomiting
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History and PE
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Are there warning
signs?
CONTINUITY CLINIC
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Bilious or forceful
vomiting
Hematemesis or
hematochezia
Vomiting or diarrhea
Abdominal tenderness or
distention
Onset of vomiting after 6
months of life
Fever, lethargy,
hepatosplenomegaly
Macrocephaly,
microcephaly, seizures
Signs of Complicated GERD
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Poor weight gain
Excessive crying or irritability
Feeding problems
Respiratory problems, including:
wheezing
 stridor
 recurrent pneumonia
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CONTINUITY CLINIC
What approach do you take in
suspected GERD?
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History and physical examination
Upper GI series
Upper endoscopy and biopsy
Esophageal pH or impedance monitoring
Empirical medical therapy
* Most common 1st steps listed by pediatricians
CONTINUITY CLINIC
Upper GI
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ADVANTAGES
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LIMITATION
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CONTINUITY CLINIC
Useful for detecting
anatomic abnormalities
Cannot discriminate
between physiologic and
nonphysiologic GER
episodes
Radiographs of Diagnoses that
can Mimic GERD
Pyloric stenosis
CONTINUITY CLINIC
Malrotation
Upper Endoscopy with Biopsy
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ADVANTAGES
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LIMITATIONS
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CONTINUITY CLINIC
Enables visualization and
biopsy of esophageal
epithelium
Determines presence of
esophagitis, other
complications
Discriminates between reflux
and non-reflux esophagitis
Need for sedation or
anesthesia
Generally not useful for
extraesophageal GERD
Examples of Endoscopic Findings
Erosive Esophagitis
CONTINUITY CLINIC
Eosinophilic Esophagitis
Esophageal pH Monitoring
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ADVANTAGES
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LIMITATIONS
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CONTINUITY CLINIC
Detects episodes of reflux
Determines temporal association
between acid GER and symptoms
Determines effectiveness of
esophageal clearance mechanisms
Assesses adequacy of H2RA or PPI
dosage in unresponsive patients
Cannot detect nonacidic reflux
Cannot detect GER complications
associated with “normal” range of
GER
Not useful in detecting association
between GER and apnea unless
combined with other techniques
When would it be USEFUL to
obtain esophageal pH monitoring?
To establish a relationship
between occult GER and
chronic symptoms:
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Upper respiratory sx
Chest pain
Recurrent pneumonia
Apnea/Cyanosis
Irritability
Intractable asthma
CONTINUITY CLINIC
To monitor efficacy of
medical or surgical
therapy:
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Acid blockers
Prokinetic agents
Following fundoplication
Treatment Options
Surgical Tx
Medication
Lifestyle
Changes
CONTINUITY CLINIC
Conservative Therapy
INFANTS
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OLDER KIDS
Normalize feeding volume
and frequency
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Consider thickened formula
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Consider non-prone
positioning during sleep
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Consider trial of
hypoallergenic formula
CONTINUITY CLINIC
Avoid large meals
Do not lie down immediately
after eating
Lose weight, if obese
Avoid caffeine, chocolate,
and spicy foods that provoke
symptoms
Eliminate exposure to
tobacco smoke
Thickened Formula
CONTINUITY CLINIC
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Unthickened ready-to
use infant formula =
20 cal/oz
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Thickened formula 1
tablespoon rice cereal
per ounce = ~34
cal/oz
% of
Patients
Comparison of Drug Therapies For
Healing Erosive Esophagitis in Adults
100
90
80
70
60
50
40
30
20
10
0
Placebo
Sucralfate
Cisapride
H2 Blocker
PPI
Endoscopic
Improvement
CONTINUITY CLINIC
Heartburn relief
PPIs in Infants and
Children With GERD
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Pharmacologic studies with omeprazole and
lansoprazole showing benefit
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No randomized placebo-controlled trials
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Multiple case series of children refractory to
H2RA showing benefit
CONTINUITY CLINIC
Recommended Oral H2RA Dosages
Generic
Name
Brand Name
Typical Peds Dose
Ranitidine
Zantac
4-10 mg/kg/day
divided BID-TID
for ages 1 month or
older up to 40 mg
BID
150 mg
BID
150 & 300 mg
tablets; 25 mg
Efferdose tablet;
15 mg/ml syrup
Famotidine
Pepcid
Pepcid AC
0.5 mg/kg/day
divided BID up to
40 mg BID for ages
1-17 years
20 or 40
mg QDBID
10, 20, 40 mg
tablets; 40 mg/5
ml liquid; 10 & 20
mg OTC tablets
CONTINUITY CLINIC
Typical
Adult
Dose
Formulations
Oral PPI Dosages for GERD
Generic
Brand
Pediatric Doses
Adult Doses
Formulations
Lansoprazole
Prevacid < 30 kg 15 mg QD
> 30 kg 30 mg QD for 117 years
15 or 30 mg
QD-BID
15 & 30 mg
capsules; 15 & 30
mg Solutab
Omeprazole
Prilosec
20 or 40 mg
QD-BID
10, 20 & 40 mg
capsules
Esomeprazole Nexium
10 or 20 mg QD for 2-16
years
10 or 20 mg QD age 1-11; 20 or 40 mg
20 or 40 mg QD 12-17 yo QD-BID
20 & 40 mg
capsules; 10 & 20
mg liquid
Pantoprazole
Protonix No FDA approval
20 or 40 mg
QD-BID
20 & 40 mg
tablets; 40 mg oral
suspension
Rabeprazole
Aciphex No FDA approval
20 or 40 mg
QD-BID
20 mg tablet
CONTINUITY CLINIC
Candidate for Antireflux
Surgery in Childhood
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Fails medical therapy due to GERD
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Is dependent on aggressive or prolonged
medical therapy
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Has persistent asthma or recurrent pneumonia
due to GERD
CONTINUITY CLINIC
Principles of Antireflux Surgery
Restore
intraabdominal
segment
of esophagus
Approximate
diaphagmatic
crurae
CONTINUITY CLINIC
Reduce
hiatal hernia
when
present
Wrap fundus
around LES to
reinforce
antireflux barrier
Summary
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GER is common in healthy infants
Pediatric GERD can present with variable symptoms
Currently available tests often do not conclusively
demonstrate a relationship between GER and specific
symptoms
Good history and clinical judgment are important for
optimal evaluation and management
Antisecretory agents are the most effective
pharmacological therapy
CONTINUITY CLINIC