Best practice in Pediatric GERD

Transcription

1 7 September 2017 Practice in Pediatric : Now and the Next Best practice in Pediatric GERD รศ.พญ.ศ กระวรรณ อ นทรขาว ภาคว ชาก มารเวชศาสตร คณะแพทยศาสตร มหาว ทยาล ยธรรมศาสตร

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3 Spectrums of GERD Extra-esophageal syndrome Esophageal syndrome

4 Definitions related to GERD in pediatrics GER GERD Troublesome symptoms Troublesome dysphagia Non-erosive reflux disease Reflux esophagitis Physiologic passage of gastric content into the esophagus Reflux of gastric contents causes troublesome symptoms and/or complications When GER symptoms have an adverse effect on the well-being of the pediatric patient When older children and adolescent need to alter eating patterns or report food impaction Absence of mucosal breaks during endoscopy Endoscopically visible breaks of the distal esophageal mucosa Sherman P, et al. Am J Gastroenterol 2009

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6 Sherman P, et al. Am J Gastroenterol 2009

7 Prevalence General pediatric population 2-25% 0.91/1000 person-years in children <5 yrs General adult population 10-20% Trend to over-diagnose GERD between Infant : 3.4% to 12.3% Increased by 30-50% in other age groups Nelson SP, et al. Arch Pediatr Adolesc Med.2000;154:150-4 Chitkara DK et al. Clin Gastroenterol Hepatol 2007;5: Dent J et al. Gut 2005;54:710-7 Nelson SP, et al. J Med Econ 2009;12:348-5

8 Nelson SP, et al. J Med Econ 2009;12:348-5

9 Nelson SP, et al. J Med Econ 2009;12:348-5

10 The prevalence of GERD peaks at age of 1 and again in adolescence Ruigomez A et al. Scand J Gastroenterol 2010;45(2):139-46

11 Pathophysiology

12 Lower esophageal sphincter; LES ( specialized smooth muscle) Crural part of diaphragm esophagus Angle of His Intra-abdominal esophagus stomach

13 - Impaired or decreased swallowing - Impaired esophageal clearance Protective mechanisms 1. anti-reflux barrier 2. Esophageal clearance 3. Esophageal mucosal resistance - Increased intragastric pressure - Delayed gastric emptying - Gastric distention Bile reflux ( duodeno-gastric reflux) Possible factors Genetic, exercise, posture, sleep state, allergy diet, alcohol, smoking, overweight, stress

14 Clinical manifestation

15 Irritability The Symptoms of GERD Manifestations Based on Age Feeding refusal Abdominal Pain Poor weight gain Recurrent regurgitation/vomiting Heartburn Dysphagia Infancy (Birth -1 year) School Age (5 15 yr) Adolescence (>15 21 yr) Martin el al. Pediatrics 2002;109:1061 Ashorn et al, Scand J Gastroenterol 2002;37:638

16 Clinical manifestation Esophageal Vomiting Regurgitation Heartburn Hematemesis/melena FTT Dysphagia/odynophagia Irritability in infants Food refusal Extra-esophageal Wheezing Recurrent pneumonia Stridor Chronic cough Hoarseness Apnea/ALTEs Sandifer s syndrome Dental erosion Laryngeal/pharyngeal inflammation Otitis media

17 Esophageal Complications Erosive esophagitis Esophageal stricture Barrett s Esophagus Adenocarcinoma

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19 Diagnostic approach Document the occurrence of GER Detect complications of GER Establish a causal relationship between GER and symptoms To evaluate therapy To exclude other causes of symptoms/signs Each test design to answer a particular question

20 Diagnostic tests Esophageal ph monitoring Combined Multiple Intraluminal Impedance and ph monitoring ( MII/pH ) Motility studies Endoscopy and Biopsy Barium Contrast Radiography Nuclear Scintigraphy Esophageal and Gastric Ultrasonography Test on Ear, Lung, and Esophageal Fluids Empiric Trial of Acid Suppression ESPGHAN / NASPGHAN JPGN 2009;49:

21 24 hrs- esophageal ph monitoring Reflux index 13.5 % DeMeester Score 55.4 Normal (< 95 percentile) < 14.72

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24 Treatment Lifestyle modification Infants Children/adolescent Pharmacotherapy H2RAs PPIs Prokinetics Other agents Surgical therapy

25 LSM in infant More frequent and small volume feeding Proper feeding technique Milk thickening agents/thickened formulas Position therapy

26 LSM in Children Avoid large meal Avoid caffeine, chocolate, spicy food, peppermint, orange juice, cigarette smoking, alcohol Do not lie down immediately after eating Lose weight, if obesity Position: left lateral +/- elevation the head of the bed

27 Goal of pharmacotherapy Control symptoms Promote healing Prevent complications Improve health-related quality of life Avoid adverse effect of treatment

28 Esophagitis management PPI for 3 months is recommended as initial therapy Increase PPI dose at 4 weeks if symptoms control is not adequate In most case efficacy can be monitored by extent of symptoms relief without routine endoscopic follow up Most patients require a once daily dose of PPI to relieve symptoms and healing esophagitis ESPGHAN / NASPGHAN JPGN 2009;49:

29 Esophagitis management Trial of dose reduction or withdrawal after 3-6 months of treatment PPIs should not be stopped abruptly, may need to be tapered Recurrence after repeated trials of PPI withdrawal : indicates chronic-relapsing GERD which require long term PPI treatment or anti-reflux surgery ESPGHAN / NASPGHAN JPGN 2009;49:

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31 PPIs control acid secretion by directly inhibiting the proton pump Proton pump Inhibition of proton pump H + Inhibition of acid secretion Gastric gland Activation Concentration Parietal cell Canalicular space PPI (inactive) Blood

32 Summary of medical management H2RAs : relief of symptoms and mucosal healing PPIs : superior to H2RAs in relieving symptoms and healing esophagitis Insufficient support to justify the routine use of motility agents for GERD ESPGHAN / NASPGHAN JPGN 2009;49:

33 Who is candidate for anti-reflux surgery? Fail medical therapy Dependent on aggressive/ prolonged medical therapy Significantly non-adherent with medical therapy Persistent asthma or recurrent pneumonia due to GERD Has life threatening complications of GERD ESPGHAN / NASPGHAN JPGN 2009;49:

34 Surgery and Therapeutic Endoscopic Procedures Nissen fundoplication Laparoscopic Nissen fundoplication Esophagogastric separation Endoscopic gastroplasty ( Endocinch system) Radiofrequency delivery at cardia (Stretta system) Injection therapy ( Enteryx procedure)

35 Groups at increase risk for severe, chronic GERD Neurologic impairment Obesity Esophageal anatomic disorders and achalasia Chronic respiratory disorders Lung transplantation Premature infant ESPGHAN / NASPGHAN JPGN 2009;49:

36 ผ ป วยรายท 1 ผ ป วยเด กชายไทย อาย 8 ว น มาพบแพทย ด วยอาการแหวะ นม ส ารอกบ อย และม อาเจ ยนมาต งแต แรกเก ด คลอดปกต ครบกาหนด น าหน กแรกเก ด 3254 กร ม ก นนมแม ท ก 2 ชม. นาน10-15 นาท และม นมผสม 1ม อ (30 ml) Physical examination BW 3,155 gm, Lt 58 cm, HC 39 cm and others were unremarkable.

37 GER vs GERD?

38 Question? What is the most proper management? A. 24-hr ph monitoring B. Barium contrast study C. prokinetics D. proton pump inhibitor E. Life style modification

39 Start lansoprazole 1 MKD

40 Differential Diagnosis of vomiting GI causes Gastrointestinal obstruction Other gastrointestinal disorders Achalasia, gastroparesis, gastroenteritis, peptic ulcers, food allergy, IBD, etc. Extra GI causes Infectious neurologic Metabolic & endocrine disorders Renal Toxic Cardiac

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42 Upper GI study Advantages Useful to detecting anatomic abnormalities Disadvantages Cannot discriminate between physiologic and pathologic GER episodes In this girl : 2 episodes of gastroesophageal reflux during 5 minutes course of examination

43 PPI in infant More evidence that PPIs do not reduce GER symptoms in infant decrease infant crying and irritability Davidson G, et al. J Pediatr2013;163:692-8 Van der Pol RJ, et al. Pediatr 2011;127: Gieruzczak-Bialek D, et al. J Pediatr 2015;166:767-70

44 Progression อาย 15 ว น ย งม อาการแหวะนมเท าๆเด ม ซ กประว ต เพ มเต ม : ม ยายเป น ภ ม แพ น าเป นหอบห ด ไม ม ผ นตามใบหน าหร อลาต วมาก อน BW 3,365 gm ( increment wt 30 gm/day) management off PPI consider of history of atopy in family then cannot rule out CMPA : maternal avoid diary product

45 Clinical course Age at 4 months no regurgitation nor vomiting normal weight gain no symptoms/signs of atopy Last visit at age of 1 year-old BW 9300 gm, and others are unremarkable

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47 Check list for infant with regurgitation Assess historical risk factors for GERD Assess physical signs that may indicate a systemic condition ( CMPA, cerebral palsy) Assess the effect of the symptoms on the emotional state of care taker and family Assess alarming symptoms Provide comfort : educate, reassure, ensure continuity of care LSM, re-evaluate symptoms ( presence of alarming) and impact on the family

48 Natural evolution of regurgitation in healthy infants Acta Paediatr 2009;98:

49 Prevalence (%) Regurgitation in Thai children day/wk 4-6 day/wk daily Months Osatakul S, et al. JPGN 2002;34:63

50 Clinical Practice Guideline Gastroesophageal Reflux Disease

51 Infant with regurgitation/vomiting Alarm symptoms yes no Complications of GER* Investigations for other diagnosis no GER yes GERD Reassure** Life style modification Resolved by 18 month of age yes no Physiologic GER Consider UGI study Acid suppression Rx Modified from Thai Ped GERD Guideline 2004

52 ESPGHAN / NASPGHAN JPGN 2009;49:

53 Warning signals in infants with regurgitation/vomiting Bilious vomiting Gastrointestinal bleeding Consistently forceful vomiting Onset of vomiting > 6 monthold Failure to thrive Diarrhea Constipation Fever Lethargy Hepatosplenomegaly Bulging fontanel Macro/microcephaly Seizures Abdominal tenderness/ distention Documented or suspected genetic/metabolic syndrome ESPGHAN / NASPGHAN JPGN 2009;49:

54 Conclusions Increasing of prevalence than previously Pediatric GERD can present with variable symptoms GERD may be lifelong, chronic condition Approach to diagnosis and treatment depended on presenting symptoms and signs Good history and clinical judgment are important for optimal evaluation and management

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