Post on 30-Apr-2018
Best practice in Pediatric GERD
7 September 2017
รศ.พญ.ศกระวรรณ อนทรขาวภาควชากมารเวชศาสตรคณะแพทยศาสตร มหาวทยาลยธรรมศาสตร
“Practice in Pediatric : Now and the Next”
GER
GERD
Troublesome symptoms
Troublesome dysphagia
Non-erosive reflux disease
Reflux esophagitis
Physiologic passage of gastric content into the esophagus
Reflux of gastric contents causes troublesome symptoms and/or complications
When GER symptoms have an adverse effect on the well-being of the pediatric patient
When older children and adolescent need to alter eating patterns or report food impaction
Absence of mucosal breaks during endoscopy
Endoscopically visible breaks of the distal esophageal mucosa
Definitions related to GERD in pediatrics
Sherman P, et al. Am J Gastroenterol 2009
Prevalence
• General pediatric population 2-25%
• 0.91/1000 person-years in children <5 yrs
• General adult population 10-20%
• Trend to over-diagnose GERD between 2000-2005
• Infant : 3.4% to 12.3%
• Increased by 30-50% in other age groups
Nelson SP, et al. Arch Pediatr Adolesc Med.2000;154:150-4
Chitkara DK et al. Clin Gastroenterol Hepatol 2007;5:186-91
Dent J et al. Gut 2005;54:710-7
Nelson SP, et al. J Med Econ 2009;12:348-5
Ruigomez A et al. Scand J Gastroenterol 2010;45(2):139-46
The prevalence of GERD peaks at age of 1 and again in adolescence
Angle of His
Crural part of diaphragm
Lower esophageal sphincter; LES ( specialized smooth muscle)
esophagus
stomachIntra-abdominal esophagus
Protective mechanisms
1. anti-reflux barrier
2. Esophageal
clearance
3. Esophageal mucosal resistance
Bile reflux ( duodeno-gastric reflux)
- Impaired or
decreased swallowing
- Impaired esophageal
clearance
Possible factors
Genetic, exercise,
posture, sleep state,
allergy diet, alcohol,
smoking, overweight, stress
- Increased intragastric
pressure
- Delayed gastric emptying- Gastric distention
The Symptoms of GERDManifestations Based on Age
Recurrent regurgitation/vomiting
Irritability Poor weight gain
Feeding refusal Abdominal Pain
Heartburn
Dysphagia
Infancy
(Birth -1 year)School Age(5 – 15 yr)
Adolescence(>15 – 21 yr)
Martin el al. Pediatrics 2002;109:1061
Ashorn et al, Scand J Gastroenterol 2002;37:638
Clinical manifestation
• EsophagealVomiting
Regurgitation
Heartburn
Hematemesis/melena
FTT
Dysphagia/odynophagia
Irritability in infants
Food refusal
• Extra-esophagealWheezing
Recurrent pneumonia
Stridor
Chronic cough
Hoarseness
Apnea/ALTEs
Sandifer’s syndrome
Dental erosion
Laryngeal/pharyngeal inflammation
Otitis media
Esophageal Complications
Erosive esophagitis Esophageal stricture Barrett’s Esophagus
Adenocarcinoma
Diagnostic approach
• Document the occurrence of GER
• Detect complications of GER
• Establish a causal relationship between GER and symptoms
• To evaluate therapy
• To exclude other causes of symptoms/signs
• Each test design to answer a particular question
Esophageal pH monitoringCombined Multiple Intraluminal Impedance and pH monitoring
( MII/pH ) Motility studiesEndoscopy and BiopsyBarium Contrast RadiographyNuclear ScintigraphyEsophageal and Gastric UltrasonographyTest on Ear, Lung, and Esophageal FluidsEmpiric Trial of Acid Suppression
Diagnostic tests
ESPGHAN / NASPGHAN
JPGN 2009;49:498-547
24 hrs- esophageal pH monitoring
Reflux index 13.5 % DeMeester Score 55.4Normal (< 95 percentile) < 14.72
Treatment
• Lifestyle modification Infants
Children/adolescent
• Pharmacotherapy
H2RAs
PPIs
Prokinetics
Other agents
• Surgical therapy
LSM in infant
More frequent and small volume feeding
Proper feeding technique
Milk thickening agents/thickened formulas
Position therapy
LSM in Children
• Avoid large meal• Avoid caffeine, chocolate, spicy food,
peppermint, orange juice, cigarette smoking, alcohol
• Do not lie down immediately after eating
• Lose weight, if obesity• Position: left lateral +/- elevation the
head of the bed
Goal of pharmacotherapy
• Control symptoms
• Promote healing
• Prevent complications
• Improve health-related quality of life
• Avoid adverse effect of treatment
Esophagitis management
• PPI for 3 months is recommended as initial therapy
• Increase PPI dose at 4 weeks if symptoms control is not adequate
• In most case efficacy can be monitored by extent of symptoms relief without routine endoscopic follow up
• Most patients require a once daily dose of PPI to relieve symptoms and healing esophagitis
ESPGHAN / NASPGHAN
JPGN 2009;49:498-547
• Trial of dose reduction or withdrawal after 3-6 months of treatment
• PPIs should not be stopped abruptly , may need to be tapered
• Recurrence after repeated trials of PPI withdrawal : indicates chronic-relapsing GERD which require long term PPI treatment or anti-reflux surgery
Esophagitis management
ESPGHAN / NASPGHAN
JPGN 2009;49:498-547
PPIs control acid secretion by directly inhibiting the proton pump
Inhibition
of acid
secretion
Parietal
cell
Canalicularspace
Proton pump
Inhibition of proton pump
Activation
Concentration
PPI(inactive)
H+
Blood
Gastric gland
Summary of medical management
• H2RAs : relief of symptoms and mucosal healing
• PPIs : superior to H2RAs in relieving symptoms and healing esophagitis
• Insufficient support to justify the routine use of motility agents for GERD
ESPGHAN / NASPGHAN
JPGN 2009;49:498-547
Who is candidate for anti-reflux surgery?
• Fail medical therapy
• Dependent on aggressive/ prolonged medical therapy
• Significantly non-adherent with medical therapy
• Persistent asthma or recurrent pneumonia due to GERD
• Has life threatening complications of GERD
ESPGHAN / NASPGHAN
JPGN 2009;49:498-547
Surgery and Therapeutic Endoscopic Procedures
• Nissen fundoplication
• Laparoscopic Nissen fundoplication
• Esophagogastric separation
• Endoscopic gastroplasty ( Endocinch system)
• Radiofrequency delivery at cardia (Stretta system)
• Injection therapy ( Enteryx procedure)
Groups at increase risk for severe, chronic GERD
• Neurologic impairment
• Obesity
• Esophageal anatomic disorders and achalasia
• Chronic respiratory disorders
• Lung transplantation
• Premature infant
ESPGHAN / NASPGHAN
JPGN 2009;49:498-547
ผปวยรายท 1
ผปวยเดกชายไทย อาย 8 วน มาพบแพทยดวยอาการแหวะนม ส ารอกบอย และมอาเจยนมาตงแตแรกเกด คลอดปกตครบก าหนด น าหนกแรกเกด 3254 กรมกนนมแมทก 2 ชม. นาน10-15 นาท และมนมผสม 1มอ(30 ml)
Physical examination BW 3,155 gm, Lt 58 cm, HC 39 cm and others were unremarkable.
What is the most proper management?
A. 24-hr pH monitoring
B. Barium contrast study
C. prokinetics
D. proton pump inhibitor
E. Life style modification
Question?
Differential Diagnosis of vomiting
GI causes
• Gastrointestinal obstruction
• Other gastrointestinal disorders
Achalasia, gastroparesis, gastroenteritis, peptic ulcers, food allergy, IBD , etc.
Extra GI causes
• Infectious
• neurologic
• Metabolic & endocrine disorders
• Renal
• Toxic
• Cardiac
Upper GI study
Advantages Disadvantages
Useful to detecting anatomic abnormalities
Cannot discriminate between physiologic and pathologic GER episodes
In this girl : 2 episodes of gastroesophageal reflux during 5 minutes course of examination
PPI in infant
• More evidence that PPIs do not
reduce GER symptoms in infant
decrease infant crying and irritability
Davidson G, et al. J Pediatr2013;163:692-8
Van der Pol RJ, et al. Pediatr 2011;127:925-35Gieruzczak-Bialek D, et al. J Pediatr 2015;166:767-70
Progression
• อาย 15 วน ยงมอาการแหวะนมเทาๆเดม ซกประวตเพมเตม : มยายเปนภมแพ นาเปนหอบหด ไมมผนตามใบหนาหรอล าตวมากอน
BW 3,365 gm ( increment wt 30 gm/day)
• management
off PPI
consider of history of atopy in family then cannot rule out CMPA : maternal avoid diary product
Clinical course
• Age at 4 months
no regurgitation nor vomiting
normal weight gain
no symptoms/signs of atopy
• Last visit at age of 1 year-oldBW 9300 gm, and others are unremarkable
Check list for infant with regurgitation
• Assess historical risk factors for GERD
• Assess physical signs that may indicate a systemic condition ( CMPA, cerebral palsy)
• Assess the effect of the symptoms on the emotional state of care taker and family
• Assess alarming symptoms
• Provide comfort : educate, reassure, ensure continuity of care
• LSM, re-evaluate symptoms ( presence of alarming) and impact on the family
Regurgitation in Thai children
0
10
20
30
40
50
60
70
80
90
100
1-3 day/wk4-6 day/wkdaily
1 2 4 6 8 10 12 Months
Osatakul S, et al. JPGN 2002;34:63
Pre
va
lence
(%
)
Infant with regurgitation/vomiting
Alarm symptoms Investigations for other diagnosis
Complications of GER*
GER GERD
no
no yes
yes
Resolved by 18 month of age
yes
Reassure**
Life style modification
no
Physiologic GERConsider UGI study Acid suppression Rx
Modified from Thai Ped GERD Guideline 2004
• Bilious vomiting
• Gastrointestinal bleeding
• Consistently forceful vomiting
• Onset of vomiting > 6 month-old
• Failure to thrive
• Diarrhea
• Constipation
• Fever
• Lethargy
• Hepatosplenomegaly
• Bulging fontanel
• Macro/microcephaly
• Seizures
• Abdominal tenderness/ distention
• Documented or suspected genetic/metabolic syndrome
Warning signals in infants with regurgitation/vomiting
ESPGHAN / NASPGHAN
JPGN 2009;49:498-547
Conclusions
• Increasing of prevalence than previously
• Pediatric GERD can present with variable symptoms
• GERD may be lifelong, chronic condition
• Approach to diagnosis and treatment depended on presenting symptoms and signs
• Good history and clinical judgment are important for optimal evaluation and management
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