Gastroesophageal reflux disease (GERD)

‫اآلية‬ ‫البقرة‬ ‫سورة‬32

The passage of gastric contents into the
esophagus (GER) is a normal physiologic
process that occurs in healthy infants,
children. Most episodes are brief and do not
cause symptoms, esophageal injury, or
result in other complications. In contrast,
gastroesophageal reflux disease (GERD)
occurs when the reflux episodes are
associated with complications such as
esophagitis or poor weight gain.

DEFINITIONS
 The term "uncomplicated” (GER) is used to
describe the normal physiologic process of
frequent regurgitation in the absence of
pathological consequences. The term,
(GERD), is used when the reflux has
pathological consequences, such as
esophagitis, nutritional compromise, or
respiratory complications.

Natural history: Gastroesophageal reflux
(GER) is extremely common in healthy
infants, in whom gastric fluids may reflux
into the esophagus 30 or more times daily.
The frequency of reflux decreases with
increasing age, such that physiologic
regurgitation or vomiting decreases
toward the end of the first year of life and
is unusual in children older than 18
months old. Pediatrics 1991; 88:834.

Prevalence
The prevalence of various symptoms
suggestive of gastroesophageal reflux
(GER) was 1.8 to 8.2 percent.
Arch Pediatr Adolesc Med 2000; 154:150.

CLINICAL MANIFESTATIONS
The most common symptoms of
gastroesophageal reflux (GER) and
gastroesophageal reflux disease (GERD)
vary according to age, although overlap may
exist:

Infants –Regurgitation is present in 50 to
70 percent of all infants, peaks at age four
months, and typically resolves by one year.
A small minority of infants with GER
develop other symptoms suggestive of
GERD, including feeding refusal,
irritability, hematemesis, anemia,
respiratory symptoms, and failure to
thrive.

Preschool age children with GERD may
present with intermittent regurgitation. Less
commonly, they may have respiratory
complications including persistent wheezing.
Decreased food intake or poor weight gain
without any other complaints may be a
symptom of esophagitis in young children.
All of these symptoms are nonspecific and
insufficient to make a definitive diagnosis of
GERD.

Older children and adolescents: The pattern
of GERD in older children and adolescents
resembles that seen in adults. The cardinal
symptoms are chronic heartburn and/or
regurgitation. Complications of GERD,
including esophagitis, strictures, Barrett's
esophagus, and hoarseness due to reflux
laryngitis, also may be seen. Older children
may complain of nausea, dysphagia and/or
epigastric pain.

 Sandifer syndrome is a paroxysmal
dystonic movement disorder occurring in
association with gastro-oesophageal reflux.
The onset usually occurs during infancy or
early childhood.
 The dystonic movements are characterised
by abnormal posturing of the head and
neck (torticollis) and severe arching of the
spine. The episodes usually last for between
1-3 minutes and can occur up to 10 times a
day. The prognosis for patients is good.

Oesophageal
 Strictures mainly in the distal oesophagus leading
to dysphagia.
 Long standing oesophagitis predisposes to
metaplastic epithelial changes in oesophagus
termed Barrett oesophagus which is a precursor
of oesophageal adenocarcinoma.
A

Nutritional
Failure to thrive because of caloric deficits.
Dental erosions
B

MULTICHANNEL INTRALUMINAL
IMPEDANCE (MII)

Surgery
Life Style
Dietary Management
Pharmacotherapy
Management
Complications
Wise Approach GERD
5 Stages Management
Lifestyle

Lifestyle Modification
Positions in infants

 Normalization of feeding techniques, volumes and
frequency if abnormal.
 Thickening of formulas results in fewer regurgitation
episodes
 A short trial of hypoallergenic milk may exclude milk
protein allergy before starting pharmacotherapy.

 Head elevation and lateral position may benefit.
 Prone position is acceptable if the infant is
observed and awake, particularly in the
postprandial period. Prone position may be
beneficial for children older than 1 year.

Position in Children
Daily activities modification
• Exercise:? Exercise induced reflux
• Overweight
• No snaking close to bed time

Surgery
Lifestyle
Dietary Management
Pharmacotherapy
Management
Complications
Wise Approach GERD
5 Stages Management
Dietary Management

Dietetic Management
Regurge with normal weight gain and
No Signs of GERD
1.Changing feeding schedule: burping, gently massage
abdomen and avoid tight diapers
2.Thickening feeds: precooked corn starch, one grain cereal,
carob, gower gum, rice starch??
3.Thickening of formula can be considered in addition to
parental education for management of GER in infants
[Quality of Evidence: A]
4.Trying solid foods if weaned

Persistent regurge signs of poor weight gain
esophagitis or respiratory symptoms
Consider cow milk with protein elimination
Re-evaluate (upper GI examination)
Trial of medication
Pharmacotherapy

Surgery
Lifestyle
Dietary Management
Pharmacotherapy
Management
Complications
Wise Approach GERD
5 Stages Management
Pharmacotherapy

Pharmacotherapy
II) Second line drugs
- Acid blocking drugs (neutralize or  stomach acidity)
1- Histamine H2RA: Ranitidine; removed from market.
2- Proton pump inhibitors PPI: Superior to H2 blockers in the
treatment of severe and erosive esophagitis e.g., Omeprazole,
Lansoprazole & Pantoprazole, Esomeprazole (Nexium) recently
approved.
I) First line drugs
- Gaviscon

I) First line drugs
Gaviscon
 Most commonly used and readily available over-the-
counter. Give rapid but transient relief. Gaviscon® was
non-inferior to Omeprazole in achieving a 24-h
heartburn-free period in moderate episodic heartburn
and is a relevant effective alternative treatment in
moderate GERD .

Approaches to
Acid-Reducing Therapy
 Begin treatment with PPI
 Maintain improvement with
PPI
 Switch to H2RA
Begin treatment with H2RA
Inadequate response  PPI
Inadequate response  ↑
PPI dose
Step Down
Step Up

•Tachyphylaxis: tolerance with prolonged use
in spite increasing dose
•Decreased absorption of Fe, Ca, Folic acid,
B12
Side effects of antacids:
• Stomach acid is a part of the body immune system Kills
pathological bacteria in the gut

Prokinetics (drugs that improve intestinal coordination)
They increase LES pressure ( most powerful anti-reflux ) & some
enhance the gastric emptying. Include : Metoclopramide and
Domperidone. Currently, (NASPGHAN) and (ESPGHAN) practice
guidelines concluded that there is insufficient evidence to justify the
routine use of prokinetic agents.
III)Third line drugs

Surgery
Lifestyle
Dietary Management
Pharmacotherapy
Management
Complications
Wise Approach GERD
5 Stages Management
Management
Complications

Management of
Supraesophageal Complications
Chronic sore throat
& hoarsness
Dental erosions
OM & Sinusitis
Wheezing
Asthma
Apnea
Bradycardia
Chronic cough
ALTE

• ALTE = acute life threatening event: apnea,
color change, chocking, gaging.
• 60% to 70% of infants with ALTE have
recurrent reguirge and abnormal esophageal pH
• Relationship between GER and obstructive or
mixed apnea most convincing when infant was:
Awake, Supine, Fed within past hour
GER and ALTE

Aspiration Syndromes
• Aspiration pneumonia &
pleural effusion
• Acid aspiration
pneumonitis
• Interstitial lung disease &
pulmonary fibrosis

• GER Asthma
• GER Asthma
• GER Asthma
• GER Asthma
Does GER Cause Asthma?

Surgery
Life Style
Dietary Management
Pharmacotherapy
Management
Complications
Wise Approach GERD
5 Stages Management
Surgery

Infants and Children:
• Dependence on aggressive or prolonged medical therapy
• Persistent asthma or recurrent pneumonia due to GERD
• Persistent vomiting with failure to thrive
• Esophageal stricture
• Apneic spells or chronic Pulmonary disease unresponsive to
2-3 months of medical therapy
• Documented Barrett Esophagus

Gastroesophageal reflux disease (GERD)

Gastroesophageal reflux disease (GERD)

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