Managing Upper GI Tract Disease. Michael Herzlinger, MD Pediatric Gastroenterology 7/2018
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1 Managing Upper GI Tract Disease Michael Herzlinger, MD Pediatric Gastroenterology 7/2018
2
3 Puke Happens Too Managing Upper GI Tract Disease Michael Herzlinger, MD Pediatric Gastroenterology 7/2018
4 Objectives Common causes Worrisome causes Diagnosis Management
5 None Disclosures
6 Case 15 year old girl with intermittent epigastric abdominal pain, vomiting, dysphagia. Functioning intact Growth: reassuring Exam: well appearing Vitals: normal
7 Differential Diagnosis Non-acute Non-worrisome Upper GI tract process
8 Next step? A. Labs B. H. pylori C. Imaging D. Acid suppression E. GI referral
9 Screening labs CBC LFTs ESR/CRP TTG, IgA BMP UA Upreg Lipase
10 Celiac disease Jericho et al. JPGN
11 Celiac disease - 1 st degree relatives - Autoimmune diseases - Iron deficiency anemia Rubio-Tapia et al. AJG
12 Celiac screening Sensitivity (%) Specificity (%) TTG IgA Endomysial IgA Gliadin IgA 2,3, Gliadin IgG 2,3, ) Turner. DDS ) Hill et al. Gastroenterology ) Hill et al. JPGN ) Lagerqvist C et al. JPGN
13 Next step? A. Labs B. H. pylori
14 H. Pylori
15 H. Pylori
16 H. Pylori
17 H. pylori Doesn t cause symptoms Low rate of cancer Miss other diseases Distract from functional disease High reinfection rate NASPGHAN 2017
18 H. pylori Atherton + Blaser 2009
19 H. Pylori Non-invasive testing Sensitivity (%) Specificity (%) Serum IgG Breath* Stool* *Unreliable in setting of acid suppression 1) De Oliveira et al. JPGN ) Koletzko et al. NASPGHAN ) Gisbert et al. Am J Gastro 2006.
20 Next step? A. Labs B. H. pylori
21 Next step? A. Labs B. H. pylori C. Imaging
22 UGI series
23 Esophageal disorders Case courtesy of Dr Hani Salam, Radiopaedia.org, rid: 9585 Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rid: 14538
24 Malrotation Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rid: 12548
25 Corkscrew sign
26 Constipation + fecal impaction
27 Next step? A. Labs B. H. pylori C. Imaging (UGI) D. Acid suppression
28 Acid peptic disease Stomach ulcer Duodenal ulcer Gastritis GERD
29 Acid peptic disease PPI 1 2 mg/kg 2-4 weeks 2 months Stop Tums and ranitidine PRN
30 Acid peptic disease Stomach ulcer Duodenal ulcer Gastritis GERD Eosinophilic esophagitis
31 Allergic + Immune Diseases Bach et al. NEJM
32 600 EoE 2010 Bach et al. NEJM Hruz et al. 2011
33 EoE Clinicopathologic syndrome Chronic Immune/antigen-mediated Esophageal dysfunction 33
34 Symptoms Infants/Toddlers Teens/Adults FTT Feeding aversion Vomiting Abdominal Pain Cough Dysphagia Heartburn Chest pain Food impaction
35 Predisposition M > F 10% 1st degree family 75% Atopy Connective tissue diseases Genes Abonia et al. J Allergy Clin Immunol Abonia et al. J Allergy Clin Immunol
36 Antigen Exposure Pathogenesis Eosinophil Eosinophilic infiltration and degranulation 36
37 Definition The eczema of the esophagus Like esophageal reflux but caused by an allergy, not acid.
38 Diagnosis Exclude other causes of eosinophilia GERD PPI x 8 weeks Impedance / ph monitoring
39 Acid and EoE relationship Acid Permeability Dysmotility - Predisposition + - Vomiting - GERD Antigen exposure Inflammation
40 Acid Permeability PPI Dysmotility Antigen exposure Inflammation
41 Next step? A. Labs B. H. pylori C. Imaging D. Acid suppression
42 Next step? A. Labs B. H. pylori C. Imaging D. Acid suppression E. GI referral
43 15 year old girl with intermittent epigastric abdominal pain, vomiting, dysphagia Cyclic vomiting Circadian rhythm
44 Circadian rhythm / Sleep deprivation D. J. Levinthal; K. Bielefeldt. Experimental Brain Research 2014
45 15 year old girl with intermittent epigastric abdominal pain, vomiting, dysphagia Cyclic vomiting Circadian rhythm Functional GI disease Marijuana induced hyperemesis Increased intracranial pressure Hepatobiliary disease Renal disease Pregnancy
46 In sum A. Labs B. H. pylori C. Imaging D. Acid suppression E. GI referral
47 In sum A. Labs B. H. pylori C. Imaging UGI series Abd US Brain MRI
48 In sum A. Labs B. H. pylori C. Imaging = UGI series, Abd US, Brain MRI D. Acid suppression PPI x 1-2 months
49 In sum A. Labs B. H. pylori C. Imaging = UGI series, Abd US, Brain MRI D. Acid suppression = PPI x 1-2 months E. GI referral Upper Endoscopy
50 Thanks
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