Gastroesophageal Reflux Disease in Infants and Children

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1 Gastroesophageal Reflux Disease in Infants and Children 4 Marzo 2017 Drssa Chiara Leoni Drssa Valentina Giorgio pediatriagastro@gmail.com valentinagiorgio1@gmail.com

2 Definitions: GER GER is the passage of gastric contents into the esophagus with or without regurgitation and vomiting GER is a normal physiologic process in healthy infants and children Most episodes of GER last < 3 minutes, occur in the postprandial period, and cause few or no symptoms Resolves spontaneously in most healthy infants by 12 to 24 months of age. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines:

3 Definitions: GER Disease GERD (Gastroesophageal Reflux Disease) is present when GER causes troublesome symptoms and/or complications

4 Symptoms and signs Symptoms Recurrent regurgitation with/without vomiting Weight loss or poor weight gain Irritability in infants Ruminative behavior Heartburn or chest pain Hematemesis Dysphagia Wheezing Stridor Cough Signs Esophagitis Esophageal stricture Barrett esophagus Laryngeal/pharyngeal inflammation Recurrent pneumonia Feeding refusal Dystonic neck posturing (Sandifer syndrome) Apnea spells Apparent life-threatening events TYPICAL ATYPICAL

5 Empiric trial as a diagnostic test Empiric Trial of Acid Suppression as a Diagnostic Test In an older child (> 8years) or adolescent with typical symptoms suggesting GERD, an empiric trial of PPI is justified for up to 4 weeks

6 Radiologic tests Nuclear Scintigraphy and Esophageal and Gastric US: These tests are not recommended for the routine evaluation of GERD in children. There may be a role for nuclear scintigraphy to diagnose aspiration in patients with chronic refractory respiratory symptoms Barium Contrast Radiography: is not useful for the diagnosis of GERD but is useful to confirm or rule out anatomic abnormalities of the upper gastrointestinal tract that may cause symptoms similar to those of GERD

7 Endoscopy and Motility study Endoscopy and biopsy Endoscopically-visible breaks in the distal esophageal mucosa are the most reliable evidence of reflux esophagitis Biopsy is important to identify or rule out other causes of esophagitis, to diagnose and monitor Barrett esophagus and its complications. Endoscopic biopsy cannot determine whether esophagitis, if present, is due to reflux Motility Studies Esophageal manometry may be abnormal in patients with GERD It may be useful in the differential diagnosis (achalasia) and to diagnose a motility disorder in patients who have failed acid suppression and who have a normal endoscopy (surgery treatment?)

8 Esophageal Ph Monitoring: features is a valid quantitative measure of esophageal acid exposure may be useful to correlate symptoms (eg, cough, chest pain) with acid reflux episodes

9 Esophageal Ph Monitoring: limits GER episodes are indirectly detected by acidification of the lumen surrounding the ph sensor (this is especially problematic in infants, in whom frequent feeding and subsequent buffering of stomach contents) Non-Acid GER not detected

10 MII and Ph Monitoring Combined Multiple Intraluminal Impedance and ph Monitoring It detects acid, weakly acid, and nonacid reflux episodes It is superior to ph monitoring alone for evaluation of the temporal relation between symptoms and GER

11 Catheters ph- Multichannel Intraluminal Impedance ph metry