Gastro- oesophageal reflux

Transcription

1 The George Abbott Symposium Christchurch 2015 Gastro- oesophageal reflux A/Prof Peter Lewindon Paediatric Gastroenterologist Former Director Mo?lity Service Lady Cilento Children s Hospital, Brisbane Defini?on Incidence Overview Medical assessments Medical treatments The role of the Gastroenterologist Diminishing for GOR Increasing for eosinophilic oesophagi?s 1

2 What is GOR / GER? - Terminology GOR involuntary transfer gastric contents (gas, liquid, solid) into oesophagus REGURGITATION VOMITING effortless return of ingested material into the mouth gastric contents emited from mouth with assistance of raised intra - abdominal pressure What is GOR? Normal physiological phenomenon (a means by which intra-gastric pressure is relieved eg belching) AND A term used for a symptom complex (regurgitation, heartburn, nausea - ADULTs) AND A term used for a Disease state 2

3 When does GOR become GORD? NASPGHAN Guidelines Oesophageal injury (Oesophagi?s) Failure to thrive Severe Respiratory disease NASPGHAN / ESPGHAN Guidelines When reflux causes symptoms sufficient to interfere with normal life Common Parlance Silent reflux Infant Misery / Feeding problems Evidence Based Consensus GERD Defini?on in Children Am J Gastroenterol, 2009 GERD is present when reflux of gastric contents causes troublesome symptoms and / or complica@ons, but defini?on complicated by unreliable repor?ng of symptoms in children under the age of ~ 8 years Histology has limited use in establishing or excluding a diagnosis of GERD; its primary role is to exclude other condi?ons Extra- oesophageal condi@ons may be associated with GERD, but for most of these condi?ons causality remains to be established 3

4 How common is overt infant GOR? 948 Caucasian parents interviewed Regurgita?on > 1 per day 50% infants < 3 months 70% infants 4-6 months 20% infants at 7 months 5% infants at 12 months (Nelson, 1997) 1997 Davidson & Dent Physiology of GOR Lower Oesophageal Sphincter (LOS) relaxa?on unrelated to swallowing is main mechanism for involuntary reflux of gastric contents = NOT weak sphincter! = Physiological Majority TLOSRs occur during and aoer meals? GOR responsible for post prandial misery? 4

5 5

6 Physiology or Pathology? Severity of GOR Frequency (func?on of TLOSRs) Composi?on (gas, liquid, acidity, bile) Data only good/valid in adults! How the Oesophagus deals with it Clearance (peristal?c ac?vity) Buffering (saliva) Mucosal protec?on (reduced with inflamm ) Afferent Nerve Sensi@vity (Vagal) (Func@onal) Why do normal infants reflux more than older children /adults? Body Posi3on increased horizontal / supine posi?on increased slouching (gastric pressure) Feed composi3on rela?ve increase liquid intake (equiv 7-8 litres milk) Lower Oesophageal Sphincter increased Transient LOS Relaxa?ons - ANY DIS- EASE Shorter Oesophagus any reflux more likely to appear 6

7 Special for GOR Barium Meal Anatomy (Not Δ Physiol/Path) Video swallow (MBS) Examine Oropharynx mechanisms Ambulatory Intra-oesophageal ph studies quantifies amount Acid Reflux vs Normal data poor/no correlation of ph index and oesophagitis symptom correlation with Acid reflux Ambulatory Oesophageal Impedance Gold standard for occurrence of oesophageal transit Upper GI Endoscopy Insensitive for GER Gold standard for OESOPHAGITIS Medical treatments Pharmacological PPI Nutri?onal Con?nuous feeds (gastric / transpyloric) Surgical Fundoplica?on v effec?ve v high risk complica?on Other Posi?oning upright, side- lying Thickening feeds 7

8 PPI therapies reduce acid exposure but do not reduce frequency of bolus reflux in infants Number of episodes p< Acidic reflux Weakly acidic reflux Non-acidic reflux Total bolus reflux Baseline Week 1 Number of episodes Baseline Week Liquid reflux Gas reflux Mixed reflux Efficacy of PPI vs Placebo 162 Infants Symptoms of GOR - Is it Acid reflux? 8

9 Prevalence PPI use by year among insured infants age <12 months (U.S.A) The prescription of PPI s is going through the roof!! Position control Therapy? Left side positioning for 2 hours following feeding 9

10 Position and GOR Right Lateral Left Lateral Ewer. Arch Dis Child Fetal Neo1999 These data suggest that PCT and PPI used in combination will have a more powerful effect on 24h reducing ph-impedance the overall burden monitoring of reflux than data PCT or PPI alone. Left Positioning Corvaglia et al. Pediatrics.2007 Episodes/24h ALL GOR Supine p<0.05 ALL GOR Left % GOR Episodes Acid Supine Nonacid Nonacid Acid Left PPI (0.5mg/kg Nexium) p<0.01 NEC 2 Trial Episodes/24h ALL GOR Baseline ALL GOR PPI % GOR Episodes Acid Baseline Nonacid Nonacid Acid PPI 10

11 Video Camera Sleep System Impedance System Combined Impedance, Video and Physiological Monitoring System Body Posi?on in Infants with Misery and Symptom associa?on for GOR Much misery was associated with GOR event Nothing par?cular about the GOR Height, volume, clearance Infant response to the episode Leo lateral posi?on Reduced overall severity frequency/ height GOR No difference to overall severity of misery Loots C, JPGN

12 Feeding, nutri?on, growth concerns Reduced energy intake Dysphagia less common Feed aversion increasingly common Energy losses Vomi?ng Increased energy requirements Irritability, crying, back arching, not sleeping Treatment Empiric poor evidence base / pragma?c NGT/Gastrostomy/G Jejunostomy/ Fundoplica?on SURGERY for GOR - Fundoplica?on Using capacitance part Cuff around GOJ Effec?ve reducing GOR? effec?ve for GOR High rate complica?ons Dysphagia Gas bloat Dumping Unpopular 12

13 Gastro-oesophageal reflux disease vs Allergic / Eosinophilic Esophagitis Eosinophilic oesophagitis, previously confused with esophageal inflammation due to GOR, has recently begun to be distinguished from it. (Orenstein, am J Gast, 2000) Histopathological differentiation with important clinical implications GORD - Basal hyperplasia, few eosinophils (LP) Eosinophilic esophagi?s (LP) 13

14 Oesophagitis reflux irritation or allergy? Severity of (mucosal) eosinophilia predicts response to conventional GOR therapy Maximum Eosinophil Count >7 hpf 86% PPV for treatment failure Maximum Eosinophil Count < 7 hpf 85% PPV for treatment success Rucelli, Pediatr Dev Pathol, 1999 Atopy of the Oesophagus Gut mucosa starts GOJ or Z line Oesophageal mucosa squamous epithelium cf respiratory mucosa EE strongly related to Allergic Rhinitis /Asthma Allergic Rhinitis commonest diagnosis in world Every community and culture Prevalence 9% - 42% US 19 million people 14

15 EE - On the increase? Paediatric Oesophageal Biopsies Using cut off > 40 eosinophils phpf /10,000 paediatric population /10,000 paediatric population x increase finding eosinophilic infiltration in paediatric oesophageal biopsies Forbes et al; Arch Dis Child, Dec

16 Presenting Symptoms among 103 Children with EE (Noel, et al Lancet, 2004) Symptom Median Age (%) Feeding Disorder 2 years (1 6) 14% Vomiting 8 years (3-12) 27% Abdominal Pain 12 years (10-15) 27% Dysphagia 13 years (10-16) 28% Food impaction 16 years (13-20) 7% Eosinophilic esophagitis - Treatment? 1 st Steroids 1998 Liacouras Treated 20 children with persistent GOR symptoms despite PPI AND - mucosal Eosinophils >20 hpf (mean 34) 1.5mg/kg/day Prednisolone 4 weeks 19/20 complete symptom resolution 20/20 Eosinophil / Oesophagitis resolution 10/19 sustained improvement at one year Liacouras, J Pediatr Gastroenterol Nutr,

17 RCT Swallowed Fluticasone Propionate for EE 36 Children mcq (9 x 50mcg or 2 puffs x 220mcg) FP swallowed, twice daily 15 2 puffs placebo swallowed, twice daily ONE MONTH of Treatment Complete remission (Eos < 1phpf) + symptom resolution Fluticasone 50% Placebo 9% Compete + Partial Remission (Eos < 6 phpf) in 55% Konikoff et al, Gastro 2006 Treatment 146 Children with EE by Specific Food Elimination Diet Combined Skin Prick (IgE) /Skin Patch (non-ige) Testing 39/146 Food Antigens Identified Egg, Cow s Milk, Soy commonest on Skin PRICK testing Corn, Soy, Wheat, commonest on Skin PATCH testing Normalisation histology on elimination EE recurrence on dietary reintroduction 73/146 on Restricted Diet Elemental Formula 8 weeks with boiled sweets normalisation of histology Total 112/146 (77%) improved with Elimination Diets 17

18 EE where to from here Long term morbidity? Oesophageal remodelling / Food bolus impac?on Most don t resolve with?me How long to treat? How ooen to Endoscope? Many asymptoma?c pa?ents have ac?ve mucosal inflamma?on How high to go with steroid dosage Impac?on Final height 1cm down? Summary GOR In Infants - GOR is frequent and physiological In many infants GOR elicits dysfunc?onal response Treatments cannot greatly reduce GOR Leo lateral posi?on reduces GOR PPI reduces acidity of refluxate Neither improves infant misery Fundoplica?on reduces GOR but high complica?on Eosinophilic oesophagi?s is increasing Treatment endpoints not worked out 18

19 Issues Silent reflux poor feeding a big problem How to manage No Endoscopy, rarely do for infant feeding problems rarely for misery rarely for vomi?ng always normal/ Older children? EE s?ll majority normal unless very atopic. NOT a GE problem NOT about managing reflux Pragma?c management Nutri?on PPI in infants Effect on ph /impedance Number of episodes PPI therapies reduce acid exposure but do not reduce the frequency of bolus reflux p< Baseline Week 1 0 Acidic reflux Weakly acidic reflux Non-acidic reflux Total bolus reflux 19

20 PPI and ph/impedance GOR - Infants Number of episodes Week Liquid reflux Gas reflux Mixed reflux Skin Prick Testing for Environmental Allergens (including dietary) IgE mediated response 20

21 Skin Patch Testing for Environmental Allergens (T cell, or Non IgE mediated Response) Gastro- oesophageal Reflux No longer main province of Paed GE Endoscopy litle role in INFANT reflux Evidence for role of GOR in Infant disease poor Infant Misery + Infant Feeding problems Rarely helped by GE interven?on Unless need for pragma?c solu?ons Gastrostomy? Later Fundoplica?on? Neurolog impaired Aspira?on or pep?c oesophagi?s Gastrostomy? Fund 21