GERD

Question 1

What is LES …?

Answer 1

The LES, defined as a high-pressure zone by manometry, is supported by the crura of the diaphragm at the gastroesophageal junction, together with valve-like functions of the esophagogastric junction anatomy, form the antireflux barrier

Question 2

What is transient LES relaxation

Answer 2

Transient LES relaxation (TLESR) is the primary mechanism allowing reflux to occur, and is defined as simultaneous relaxation of both LES and the surrounding crura.

TLESRs occur independent of swallowing, reduce LES pressure to 0-2 mm Hg (above gastric), and last 10-60 sec; they appear by 26 wk of gestation.

Question 3

Regulation of TLESR ……. And main stimulus

Answer 3

A vagovagal reflex, composed of afferent mechanoreceptors in the proximal stomach, a brainstem pattern generator, and efferents in the LES, regulates TLESRs.

Gastric distention (postprandially, or from abnormal gastric emptying or air swallowing) is the main stimulus for TLESRs.

Question 4

GERD is caused by the ?????

Answer 4

Whether GERD is caused by a higher frequency of TLESRs or by a greater incidence of reflux during TLESRs is debated; each is likely in different persons

Question 5

Other factors influencing gastric pressure–volume dynamics………

Answer 5

Increased movement, 
straining, obesity, 
large-volume or hyperosmolar meals, 
gastroparesis, 
a large sliding hiatal hernia, and 
increased respiratory effort (coughing, wheezing) can have the same effect

Question 6

Infant reflux and Happy spitters…….

Answer 6

Infant reflux becomes evident in the first few mo of life, peaks at 4 mo, and resolves in up to 88% by 12 mo and in nearly all by 24 mo.

Happy spitters are infants who have recurrent regurgitation without exhibiting discomfort or refusal to eat and failure to gain weight

Question 7

Signs of esophagitis ……..

Answer 7

Irritability, arching, choking, gagging, feeding aversion), and resulting failure to thrive

Question 8

Sandifer syndrome……..

Answer 8

Occasional children with GERD present with food refusal or neck contortions (arching, turning of head) designated Sandifer syndrome

Question 9

Respiratory symptoms associated with GERD………

Answer 9

The respiratory presentations are also age dependent: GERD in infants may manifest as obstructive apnea or as stridor or lower airway disease in which reflux complicates primary airway disease such as laryngomalacia or bronchopulmonary dysplasia.

Otitis media, sinusitis, lymphoid hyperplasia, hoarseness, vocal cord nodules, and laryngeal edema have all been associated with GERD.

Question 10

Airway manifestations in older children with GERD …..

Answer 10

More commonly related to asthma or to otolaryngologic disease such as laryngitis or sinusitis

Question 11

Symptoms That May Be Associated With Gastroesophageal Reflux

Answer 11

Recurrent regurgitation with or without vomiting 
Weight loss or poor weight gain 
Irritability in infants 
Ruminative behavior 
Heartburn or chest pain 
Hematemesis 
Dysphagia, odynophagia 
Wheezing Stridor Cough Hoarseness

Question 12

Signs That May Be Associated With Gastroesophageal Reflux

Answer 12

Esophagitis 
Esophageal stricture 
Barrett esophagus 
Laryngeal/pharyngeal inflammation 
Recurrent pneumonia 
Anemia 
Dental erosion 
Feeding refusal 
Dystonic neck posturing (Sandifer syndrome) 
Apnea spells 
Apparent life-threatening events

Question 13

the I-GERQ, and its derivative, the I-GERQ-R……….?

Answer 13

The history may be facilitated and standardized by questionnaires (e.g., the Infant Gastroesophageal Reflux Questionnaire, the I-GERQ, and its derivative, the I-GERQ-R),

which also permit quantitative scores to be evaluated for their diagnostic discrimination and for evaluative assessment of improvement or worsening of symptoms.

Question 14

The important differential diagnoses to consider in the evaluation of an infant or a child with chronic vomiting……….

Answer 14

Milk and other food allergies, eosinophilic esophagitis, pyloric stenosis, intestinal obstruction (especially malrotation with intermittent volvulus), non esophageal inflammatory diseases, infections, inborn errors of metabolism, hydronephrosis, increased intracranial pressure, rumination, and bulimia.

Question 15

Contrast (usually barium) radiographic study of the esophagus and upper gastrointestinal tract….. importance

Answer 15

Is to evaluate for achalasia, esophageal strictures and stenosis, hiatal hernia, and gastric outlet or intestinal obstruction

It has poor sensitivity and specificity in the diagnosis of GERD as a result of its limited duration and the inability to differentiate physiologic GER from GERD

Question 16

Drawbacks of contrast study in GERD

Answer 16

Contrast radiography neither accurately assesses mucosal inflammation nor correlates with severity of GERD.

Question 17

Extended esophageal pH monitoring of the distal esophagus……….

Answer 17

No longer considered the sine qua non of a GERD diagnosis, provides a quantitative and sensitive documentation of acidic reflux episodes, the most important type of reflux episodes for pathologic reflux

Question 18

Placement of probe in esophagus for pH monitoring

Answer 18

Placed at a level corresponding to 87% of the nares-LES distance,
based on regression equations using the patient’s height,

on fluoroscopic visualization, or

on manometric identification of the LES

Question 19

Normal pH of esophagus…….

Answer 19

Normal values of distal esophageal acid exposure (pH <4) are generally established as <5 to 8% of the total monitored time

Question 20

T he most important indications for esophageal pH monitoring are for……..

Answer 20

Assessing efficacy of acid suppression during treatment,

evaluating apneic episodes in conjunction with a pneumogram and perhaps impedance, and

evaluating atypical GERD presentations such as chronic cough, stridor, and asthma.

Question 21

Endoscopy in GERD…..

Answer 21

Diagnosis of erosive esophagitis and complications such as strictures or Barrett esophagus;

esophageal biopsies can diagnose histologic reflux esophagitis in the absence of erosions while simultaneously eliminating allergic and infectious causes.

Endoscopy is also used therapeutically to dilate reflux-induced strictures.

Question 22

Empirical antireflux therapy…….?

Answer 22

Empirical antireflux therapy, using a time-limited trial of high-dose proton pump inhibitor (PPI), is a cost-effective strategy for diagnosis in adults;

although not formally evaluated in older children, it has also been applied to this age group.

Failure to respond to such empirical treatment, or a requirement for the treatment for prolonged periods, mandates formal diagnostic evaluation

Question 23

Dietary measures for GERD………

Answer 23

Normalisation of any abnormal feeding techniques, volumes, and frequencies.

Thickening of feeds or use of commercially prethickened formulas increases the percentage of infants with no regurgitation, decreases the frequency of daily regurgitation and emesis, and increases the infant’s weight gain.

Question 24

Non pharmacological measures for GERD…….

Answer 24

Older children should be counseled to avoid acidic or reflux-inducing foods (tomatoes, chocolate, mint) and beverages (juices, carbonated and caffeinated drinks, alcohol).

Weight reduction for obese patients and elimination of smoke exposure are other crucial measures at all ages.

Question 25

Positioning measures in GERD……..

Answer 25

Seated position worsens infant reflux and should be avoided in infants with GERD.

Esophageal pH monitoring demonstrates more reflux episodes in infants in supine and side positions compared with the prone position,

but evidence that the supine position reduces the risk of sudden infant death syndrome

Question 26

Reflux is low in which position…….

Answer 26

When the infant is awake and observed, prone position and upright carried position can be used to minimize reflux.

Question 27

Provocative positions for GER…….

Answer 27

Lying in the flat supine position and semi-seated positions (e.g., car seats, infant carriers) in the postprandial period

Question 28

Most common anti reflux medication……

Answer 28

Antacids are the most commonly used antireflux therapy

They provide rapid but transient relief of symptoms by acid neutralization.

The long-term regular use of antacids cannot be recommended because of side effects of diarrhea (magnesium antacids) and constipation (aluminum antacids) and rare reports of more serious side effects of chronic use.

Question 29

Histamine-2 receptor antagonists

Answer 29

Histamine-2 receptor antagonists (H2RAs: cimetidine, famotidine, nizatidine, and ranitidine) are widely used antisecretory agents that act by selective inhibition of histamine receptors on gastric parietal cells.

There is a definite benefit of H2RAs in treatment of mild-to-moderate reflux esophagitis

Question 30

PPIs…….

Answer 30

PPIs (omeprazole, lansoprazole, pantoprazole, rabeprazole, and esomeprazole) provide the most potent antireflux effect by blocking the hydrogen–potassium adenosine triphosphatase channels of the final common pathway in gastric acid secretion.

Question 31

H2 receptors blocker V/S PPI…

Answer 31

H2RAs have been recommended as first-line therapy because of their excellent overall safety profile, but they are superseded by PPIs in this role, as increased experience with pediatric use and safety, FDA approval, and pediatric formulations and dosing are available.

PPIs are superior to H2RAs in the treatment of severe and erosive esophagitis

Question 32

Drawback of PPI….

Answer 32

An important systematic review of the efficacy and safety of PPI therapy in pediatric GERD reveals no clear benefit for PPI over placebo use in suspected infantile GERD (crying, arching behavior).

Limited pediatric data are available to draw definitive conclusions about potential complications implicated with PPI use, such as respiratory infections, Clostridium difficile infection, bone fractures (noted in adults), hypomagnesemia, and kidney damage.

Question 33

Name the pro kinetic agents…..

Answer 33

metoclopramide (dopamine-2 and 5-HT3 antagonist),

bethanechol (cholinergic agonist), and

erythromycin (motilin receptor agonist).

Question 34

Surgical management of GERD …..

Answer 34

Surgery, usually fundoplication, is effective therapy for intractable GERD in children, particularly those with refractory esophagitis or strictures and those at risk for significant morbidity from chronic pulmonary disease.

It may be combined with a gastrostomy for feeding or venting.

Question 35

Complications of Gastroesophageal Reflux Disease……

Answer 35

ESOPHAGEAL: ESOPHAGITIS AND SEQUELAE—STRICTURE, BARRETT ESOPHAGUS, ADENOCARCINOMA

Question 36

Barrett esophagus………

Answer 36

Long-standing esophagitis predisposes to metaplastic transformation of the normal esophageal squamous epithelium into intestinal columnar epithelium, termed Barrett esophagus,

A precursor of esophageal adenocarcinoma.