GERD

Question 1

How is pathological reflux different from physiological reflux?

Answer 1

Pathological is greater in quantity and frequency – and may cause complications

Question 2

What common drugs of abuse lower tone in the lower esophageal sphincter?

(2)

Answer 2

Nicotine

 &

Narcotics

Question 3

Which endocrine-related medications are known to decrease tone at the lower esophageal sphincter?

(3)

Answer 3

1.  Estrogen
2.  Prostaglandin
3.  Somatostatin

Question 4

What respiratory complications has reflux been linked to?

5

Answer 4

1.  Reactive airway disease
2.  Pneumonia
3.  Chronic cough
4.  Stridor
5.  Laryngitis

Question 5

What medical therapies are primarily used to treat GE reflux?

(2 general categories)

Answer 5

Prokinetic medications

    &

Acid-reducing agents

Question 6

What is the first-line treatment for pathological GE reflux?

Answer 6

Diet modification

(small, frequent feeds & thickening of formula

Question 7

How rapidly do infants outgrow GER?

Answer 7

Forty percent of healthy infants have spitting or regurgitation more than once a day; mild reflux does not represent disease. As a rule, in those infants who have more significant primary GER (about 12% of total), 25% to 50% resolve by 6 months of age, 75% to 85% by 12 months of age, and 95% to 98% by 18 months of age. GER in older children may be more widespread than appreciated. Surveys of parents of children and adolescents (3 to 17 years) revealed that symptoms of heartburn regurgitation were relatively common (2% to 8% of patients)

Question 8

How effective are nonpharmacologic agents as treatments for suspected GER?

Answer 8

• Switching formula-fed infants to semi-elemental formula thickened with rice cereal
• If breastfeeding, the mother should eliminate cow milk and soy products from her diet
• Avoiding seated and supine positioning as much as possible for the infant, especially after feeding
• Eliminating tobacco smoke because of its association with increased GERD

Question 9

An infant with known GER who periodically arches his or her back may have what syndrome?

Answer 9

Sandifer syndrome is paroxysmal dystonic posturing with opisthotonus and unusual twisting of the head and neck (resembling torticollis) in association with GER. Typically, an esophageal hiatal hernia is also present.

Question 10

What is a Nissen fundoplication?

Answer 10

Nissen fundoplication is the most commonly performed antireflux surgical procedure. It involves wrapping a portion of the gastric fundus 360 degrees around the distal esophagus in an effort to tighten the gastroesophageal junction.

Question 11

Which patients are candidates for fundoplication?

Answer 11

Most infants with developmental GER do not require fundoplication. It is indicated in patients with recurrent aspiration , refractory or Barrett esophagitis , reflux-associated apnea , and reflux-associated FTT that is refractory to medical therapy. Patients with severe reflux and psychomotor retardation should be evaluated for fundoplication if a feeding gastrostomy is contemplated.

Question 12

A teenage girl has symptoms of swallowing difficulties improved by positional head and neck changes, nocturnal regurgitation, and halitosis. What is the leading diagnosis?

Answer 12

Achalasia , which is a motor disorder of the esophagus characterized by loss of esophageal peristalsis, increased lower esophageal sphincter (LES) pressure, and absent or incomplete relaxation of LES with swallowing. Most cases are sporadic, and patients can present at any age from birth until the ninth decade of life. Suspected causes include autoimmune, infectious, and environmental triggers.

Question 13

What are treatment options for achalasia?

Answer 13

Treatment options include pneumatic dilations (via therapeutic endoscopy), corrective laparoscopic surgery, botulinum toxin injection at the lower esophageal sphincter, and pharmacologic therapies. Pneumatic dilation is relatively well tolerated, but it often needs to be repeated if symptoms recur. Regardless of treatment modality used, patients continue to be at increased risk for aspiration secondary to pooling of food and saliva in the esophagus after meals. Many have complications of reflux esophagitis, which require ongoing surveillance.

Question 14

What are the common symptoms of gastroparesis?

Answer 14

Gastroparesis is a disorder of gastric motility characterized by impairment of gastric contraction and emptying. Common symptoms include bloating, early satiety, nausea, vomiting (especially of undigested food eaten many hours before), and abdominal discomfort in the absence of mechanical obstruction.

Question 15

In what clinical settings should gastroparesis be suspected?

Answer 15

• Preterm infants with immature GI tract
• Infants with cow milk protein allergy
• Postinfectious, including viral (rotavirus, Epstein-Barr virus [EBV], cytomegalovirus [CMV]) and Mycoplasma infection
• Postsurgical, including vagal nerve injury in upper abdominal surgery such as fundoplication or bariatric surgery
• Cystic fibrosis
• Type 1 diabetes mellitus
• Chronic intestinal pseudo-obstruction
• Muscular dystrophy
• Systemic autoimmune disorders, such as scleroderma

Question 16

How is postinfectious gastroparesis diagnosed?

Answer 16

Patients will commonly present with persistent vomiting for days, weeks, or even months after a viral illness. Often the acute illness has passed, and the offending pathogen cannot be isolated. Diagnosis is mainly clinical, but can be confirmed with a delayed gastric emptying scan.

Question 17

A 12-year-old who presents with weight loss and a history of effortlessly and involuntarily regurgitating many meals has what likely diagnosis?

Answer 17

Rumination syndrome. This is a functional gastrointestinal motility disorder characterized by repetitive effortless regurgitation of recently swallowed food from the stomach into the mouth within 30 minutes of ingesting the meal. When the stomach contents reach the mouth, it is either reswallowed or expelled. In infants and young children, rumination is commonly seen in patients with neurologic impairment or developmental delay. Adolescents are typically healthy. Children who have rumination typically do not retch and do not complain of dyspeptic/heartburn symptoms. Rumination syndrome can be difficult to diagnose. Differential diagnoses include bulimia nervosa and gastroparesis. The most effective treatments involve biofeedback and relaxation techniques.