Gastroesophageal reflux disease Flashcards
Definition GER
the involuntary passage of gastric contents into the
esophagus
- Physiologic reflux episodes commonly occur during
meals or in the immediate postprandial period and
are associated with the absence of symptoms
- Is present when reflux of gastric contents is the cause
symptoms and/or complications (esophageal or extra esophageal –ex respiratory, ENT) with/without esophagitis (ERD/NERD)
Symptoms
General
* Discomfort/irritability
* Failure to thrive
* Feeding refusal
* Sandifer Syndrome
Gastrointestinal
* Regurgitation/ vomiting
* Heartburn / chest pain
* Epigastric pain
* Hematemesis
* Dysphagia/Odynophagia
Airway
* Wheezing
* Stridor
* Cough
* Hoarseness
Signs
General
* Dental erosions
* Anemia
* Gastrointestinal
* Esophagitis
* Esophageal stricture
* Barrett’’s esophagus
Airway
* Apnea
* Brief resolved unexplained events
* Asthma
* Recurrent pneumonia
* Recurrent otitis
Alarm signs
1.General
*Weight loss
*Letargy
*Fever
*Excessive irritability/ pain
*Dysuria
*Onset after 6 months or increasing in intensity after 12-18 months
2.Neurological
*Bulging fontanel/ rapidly increasing of head circumference
*Seizures
*Macro/microcephaly
3.Gastrointestinal
*Persistent forceful vomiting
*Nocturnal vomiting
*Bilious vomiting
*Hematemesis
*Chronic diarrhea
*Rectal bleeding
*Abdominal distension
Differential diagnosis of GERD
1.Gastrointestinal obstruction
2.Neurological disease
3.Metabolic/endocrine
4.Cardiac disease
5.Other gastrointestinal
disorders
6.Infectious
7.Renal
8.Other
Gastrointestinal
obstruction
- Pyloric stenosis
- Malrotation with volvulus
- Intussusception
- Hirschsprung disease
- Foreign body
- Incarcerated hernia
- Superior mesenteric
artery syndrome
Neurological disease
- Hydrocephaly
- Subdural hematoma
- Intracranial hemorrhage
- Intracranial mass
Renal
- Obstructive uropathy
- Renal insufficiency
Other
- Munchausen by proxy syndrome
- Child neglect or abuse
- Voluntary induced vomiting
- Cyclic vomiting syndrome
- Rumination syndrome
- Toxic (lead poising/ other poising)
Metabolic/endocrine
- Galactosemia
- Hereditary fructose intolerance
- Urea cycle defects
- Amino/ organic acidemias
- Fatty acid oxidationdisorders
- Metabolic acidosis
- Congenital adrenal hyperplasia/ adrenal crisis
Cardiac disease
- Heart failure
- Vascular rings
- Autonomic disfunction
Other gastrointestinal
disorders
- Achalasia
- Gastric paresis
- Gastroenteritis
- Peptic ulcer
- Eosinophilic esophagitis
- Food allergy /intolerance
- Inflammatory bowel disease
- Pancreatitis
- Appendicitis
Infectious
- Sepsis
- Meningitis
- Urinary tract infection
- Respiratory infections
- Otitis media
- Hepatitis
Diagnostic tests
- Esophageal pH monitoring
- Combined MII-pH monitoring (multichannel intraluminal impendance = MII)
- Upper endoscopy and biopsy
- Esophageal manometry
- Upper GI tract series
- Gastroesophageal scintigraphy
- Echo
ESOPHAGEAL PH MONITORING
Use for:
– Identified pathological acid reflux
– Correlation between acid reflux and symptoms
– Identified adequate doses for PPI
Indications
Esophageal pH monitoring
- Infant with critically symptoms (ALTE, apnea)
- Infant with typical symptoms, with failure to thrive
- Infant with recurrent respiratory symptoms not responders at specific therapy: recurrent wheezing, recurrent pneumonia, chronic cough
- Child non responder at PPI
- Pre surgical evaluation
- Post surgical evaluation in symptomatic children
Combined MII-pH monitoring
( multichannel intraluminal impendance - MII)
- a relatively new technique that can measure the movements of liquids, solids and air in the esophagus independently of their acid contents
- is able to detect acid, weakly acid and non acid reflux episodes
- a better evaluation of temporal association between symptoms and reflux episodes
- the height that the reflux material reaches, thus giving important information about the possible relationship between GERD and respiratory
symptoms, types of reflux (liquid, mixt or gaseous)
Combined MII-pH monitoring
- disadvantages
- Variability between expert’s analysis and between manually analysis and
automatically analysis - Time consuming (>60 min)
- Expensive
- Normal values for infants – expert’s consensus
Upper endoscopy and biopsy
- It is used for the diagnosis of reflux esophagitis defined by the presence of
visible breaks in the mucosa of the esophagus and, combined with biopsy, - it is important to rule out other causes of
esophagitis and the occurrence of complications in the presence of prolonged and severe GERD (strictures and presence of esophageal metaplasia)
Upper endoscopy and biopsy
- Histopathological examination
can show microscopic changes of the esophageal mucosa when macroscopic alterations are not visible by endoscopy as in patients with NERD
* Epidemiological paediatrics studies: NERD is at least as frequency as ERD
Upper GI tract series
- Upper GI tract series was once recommended as a screening test for GERD but because of its lack of sensitivity and specificity, it is no longer considered as a routine test in the evaluation of GERD
- The test consists in obtaining a series of fluoroscopic images of swallowed barium until the ligament of Treitz is visualized
- Barium esophagogram may produce false negative results due to its brief duration and false-positives due to the frequent occurrence of non pathologic reflux episodes during the examination that cannot be distinguished from pathologic GER
- Upper GI tract series was once recommended as a
screening test for GERD but because of its lack of sensitivity and specificity, it is no longer considered as a routine test in the evaluation of GERD - The test consists in obtaining a series of fluoroscopic
images of swallowed barium until the ligament of Treitz is
visualized - Barium esophagogram may produce false negative results due to its brief duration and false-positives due to the frequent occurrence of non pathologic reflux episodes during the examination that cannot be distinguished from pathologic GER
Esophageal manometry
- Esophageal manometry is most useful for the
evaluation of dysmotility and has only limited
utility in the evaluation of GERD. - Esophageal manometry consent:
– Lower and upper esophageal sphincter
measurement
– Evaluate esophageal peristaltasi
– Functional esophageal coordination during the
deglutition - The role of manometry in the evaluation of GERD
remains limited to preoperative testing for
exclusion of significant motility disorders such as
achalasia or scleroderma (clear contraindications
to anti-reflux surgery) as well as for assisting in
proper positioning of transnasal pH probes. - This test is not recommended for the diagnosis of
GERD. - GERD may asses with motility disorders - resolves
after treatment
Gastroesophageal scintigraphy
- Gastroesophageal scintigraphy scanning is a test that consists in the ingestion of food or formula labeled with 99technetium and in the scanning for their reflux into the esophagus or lungs.
- It is able to detect reflux episodes occurring after meals and aspiration of gastric content into the lungs.
- Because of the lack of standardized techniques and of age specific normal values, the usefulness of this test is limited and it is not recommended in the routine diagnosis and management of GERD
Abdominal ultrasound
- Is not recommended in GERD diagnosis
- Limited method:
– Short registration
– The lack of a standard meal
– The lack of a parameters
– Operator dependent the lack of a correlation with
another diagnosis method (pH monitoring)
Supplementary methods
- The presence of pepsin in middle ear exudate
- The presence of lactosis, pepsin, or lipidSimilarly
the presence of lactose, pepsin or a lipid laden macrophages in broncho-alveolar aspiration - Are not recommended in GERD diagnosis
Treatment
Lifestyle modifications
Positioning and environmental changes
Feeding management
* Reducing feeding volume and increase feeding frequency
* Modifying mother diet
* Thickening formula feedings with cereals
* Anti Regurgitant formula (AR)
* Hydrolysate formula
Treatment
Medications
– H2 antagonist
– IPP
– Alginate
– Domperidon – no in all countries
– Erythromycin
Gastritis
inflammatory injury
Gastrophaty
gastric mucosal damage
without inflammatory cells
Erosions
mucosal breaks – do not breach the
muscularis mucosa
Ulcerations
penetrate to the submucosa
Primary gastritis
H pylori
– Idiopatic?
Causes of secondary gastritis
- Stress gastropathy
- Neonatal
- Prolapse gastropathy/Mallory Weiss traumatic gastropathy
- Chemical
– NSAID
– Bile
– Another medication: steroids - Corticosteroids
- Celiac
- IBD
- Exercise induced gastropathy
- Eosinophilic
- Menetrier’s
- Autoimmune
- Zollinger Elison syndrome
- Uremic gastropathy
- Portal hypertension gastropathy
Sydney system
Gastritis is graded according to the Sydney System
– severity of inflammation (0-3)
– the level of activity (the degree of polymorph
neutrophil inflammation) (0-3)
– the presence of atrophy and of intestinal metaplasia
– the density of H pylori infection was also semi
quantitatively classified on a scale from 0 to 3 (mild, moderate, and marked).
Helicobacter pylori gastritis
- Gastritis
– Majority are asymptomatic
– Histological lymphocytic infiltrate and presence of lymphoid follicles is highly specific
– Antral gastritis is more associated with increased gastric acid and duodenal ulceration
– Gastritis of the body is associated with chronicity, atrophic gastritis, future carcinoma risk, gastric erosions and ulcers - Peptic ulcer disease (PUD)
- MALT –lymphoma (mucosa-associated lymphoid
tissue) lymphoma
Helicobacter pylori - disease manifestations
- Dyspepsia
- Refractory iron deficiency anemia
- Decreased growth
- Idiopathic thrombocytopenic purpura
- Periodontitis
- Otitis media
H pylori diagnosis
- Invasive
– Rapid urease test
– Histology
– Culture - Noninvasive
– Breath test C13
– H pylori stool antigen
– Serology
H pylori – treatment
First line
- First line
– Amoxicillin, claritromycin, PPI for 2 weeks (10 days)
– Amoxicillin, metronidazole, PPI for 2 weeks
– Bismuth, Amoxicillin, metronidazole for 2 weeks
– Sequential therapy - 5 days Amoxicillin and PPI
- Then 5 days , claritromycin , metronidazole and PPI
- Recurrence - claritromycin or metronidazole resistance (up to 20%)
H pylori – treatment
- Secondary line:
Quadruple therapy
– PPI+metronidzole+amixicillin+bismuth
– PPI+Levofloxacin+amoxicillin
– Sequential therapy
