Best practice in Pediatric GERD - home.kku.ac.th · Modified from Thai Ped GERD Guideline 2004....

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Best practice in Pediatric GERD 7 September 2017 รศ.พญ.ศุกระวรรณ อินทรขาว ภาควิชากุมารเวชศาสตร์ คณะแพทยศาสตร์ มหาวิทยาลัยธรรมศาสตร์ Practice in Pediatric : Now and the Next”

Transcript of Best practice in Pediatric GERD - home.kku.ac.th · Modified from Thai Ped GERD Guideline 2004....

Best practice in Pediatric GERD

7 September 2017

รศ.พญ.ศกระวรรณ อนทรขาวภาควชากมารเวชศาสตรคณะแพทยศาสตร มหาวทยาลยธรรมศาสตร

“Practice in Pediatric : Now and the Next”

Spectrums of GERD

Esophageal syndromeExtra-esophagealsyndrome

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

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

Nelson SP, et al. J Med Econ 2009;12:348-5

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

Pathophysiology

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

Clinical manifestation

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.

GER vs GERD ?

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?

Start lansoprazole 1 MKD

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

Acta Paediatr 2009;98:1189-93

Natural evolution of regurgitation in healthy infants

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

(%

)

Clinical Practice GuidelineGastroesophageal Reflux Disease

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

ESPGHAN / NASPGHAN

JPGN 2009;49:498-547

• 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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