Case 1

2. 4 month baby boy • Wt on 9thcentile • Spitting after food (described as vomiting) • Irritable after feed • Cries and wakes up several times at night • Mum to restart job after maternity leave • Tried stay down formula Case 1

3. Gastro oesophageal reflux disease

4. Dr Sandip Chakrabarti Gastro oesophageal reflux disease

5. Passage of gastric contents into oesophagus With or without regurgitation or vomiting Physiological process GOR

6. When GOR causes “troublesome” symptoms or complications “troublesome” complications are FTT Food refusal Oesophagitis/ pain, hematemesis Chronic resp disease Anaemia Behavioural problems GoRD

7. In infants and toddlers there is no symptom that is diagnostic of GORD or predicts response to therapy. • In older children and adolescents may be sufficient to diagnose if the symptoms are typical. Diagnosis

8. Recurrent regurgitation with or without vomiting • Weight lost or poor weight gain • Irritability in infants • Ruminative behaviour • Heartburn or chest pain • Hematemesis Symptoms

9. Dysphagia Odynophagia Wheezing Stridor Cough Hoarseness Symptoms

10. DIAGNOSIS AND INVESTIGATIONS

11. NG tube with 1 or more pH electrodes • Distal oesophagus • Acid reflux episode = pH<4.0 • Computer analyzed • Visual inspection for artefacts and clinical correlation oEsophagealpH monitoring

12. Total no reflux episodes • No of episodes lasting >5min • Duration of longest reflux • RI (% of entire record when pH<4.0) Parameters

13. Reflux episode identified by pH monitoring as a rapid drop in pH from above to below 4.0 distally longer than proximal.

14. Normal values: RI < 3 % is normal RI 3 – 7 % is indeterminate RI > 7 % is considered abnormal (severally abnormal in infants is > 10 % ) pH monitoring

15. Ambulatory pH monitoring tracings.

16. Insensitive to weak acid and non acid Does not correlate with symptom severity in infants. The sensitivity and specificity in extra esophageal complications is not established. Limitations

17. Monitoring anti secretory therapy Correlate symtpoms with acid reflux episodes Select children with resp symtoms where reflux may aggravate Uses

18. Oesophageal catheter with electrodes measuring electrical impedance • Liquid impedance with retrograde flow can be analysed • Integrated with pH monitoring, add more value Multiple Intraluminal Impedance

19. Impedance changes produced by liquid, mixed, or gas boluses.

20. Cannot diagnose GORD • Identifies LOS pressure as a causative mechanism • Helps in diagnosing motor disorder/ achalasia Manometry

21. Breaks of distal mucosa are evidence of reflux oesophagitis. • Erythema, pallor and vascular changes are subjective and non specific. Endoscopy and biopsy

22. Useful only for diagnosis of anatomic abnormalities Barium study

23. Not recommended as a routine test for GORD • Useful for diagnosis of pulmonary aspiration in complicated and refractory cases. Nuclear Scintigraphy

24. Not recommended anymore in GORD diagnosis. Ultrasonography

25. Very limited date and not enough evidence. • Studies were done on analysis of presence lactose, pepsin and lipid-laden macrophages in Ear and lung aspirates. Similar studies were done on analysis of presence of bile in oesophagus. Ear, Lung and oEsophagealFluids

26. Valuable only in adolescent and older children. • Not recommended in infants and toddlers. Empiric trial of acid suppression as a diagnostic test

27. Life style changes • Pharmacological therapies • Surgical therapy Management

28. Parental education, guidance and support. 2 – 4 weeks trial of extensive hydrolysed formula Thickened formula decrease visible regurgitation but doesn’t decrease frequency of reflux episodes. Prone position not recommended for risk of SIDS Life style changes in infant

29. No evidence for dietary changes (but avoid anything causing symptoms). • Reduce obesity, big volume meals, late evening meals. • Avoid smoking and alcohol. • Left lateral sleeping position with elevated head. Life style changes in Children and Adolescents

30. Acid suppressant agents are the golden standard. • Antacids for rapid relief in older children and adolescent. • Limited evidence for prokinetics. Pharmacologic therapies

31. Domperidone: very limited evidence of therapeutic effect, use broadly. • Cisaprid contraindicated • Metoclopramide contraindicated • Not enough evidence for Bethanechol and Baclofen. Prokinetic therapy

32. Reserved for chronic and relapsing cases nor responding to pharmacotherapy. • Detail diagnostic studies required before surgery indicated. • Laparoscopy NissensFundoplication Surgical therapy

33. Diagnosis is usually clinical • Parental education: warning signal • Reassurance • Thickening of formula • Referral if not resolved by 18 months Infant with recurrent regurgitation and vomiting (uncomplicated)

35. Evaluate failure to thrive • Trial of hydrolysed formula • Thickened feed • Close monitoring • Consider specialist referral Infant with recurrent vomiting and poor wt gain

37. Rule out other causes: CMPA, neurologic ds, constipation, infection Empiric trial of hydrolysed formula Investigations: pH monitoring, esophagitis Time limited trial of antisecretory therapy Referral Infant with unexplained crying/ distressed

38. Life style changes Trial of PPI for 2 – 4 weeks (may continue up to 3 months). Heartburn in older children and adolescents

39. Chronic regurgitation/ vomiting > 18months

40. PPI for 3 months. • Long term PPI treatment reserved for relapsing and complicated cases. Reflux oEsophagitis

41. GOR is not the cause in most cases. MII/pH study required in recurrent and complicated cases suspected of GORD. Infants with Apnea and apparent Life Threatening event

42. Empiric PPI therapy not recommended. 3 groups may have benefit from long term antireflux medication: 1. With Heartburn 2. Nocturnal asthma symptoms 3. Steroid dependent and difficult to control asthma. Reactive Airway Disease

43. Nuclear scintigraphy can detect aspirated gastric content in lungs. • Aspiration during swallowing is more common. • Trial of medication after full evaluation. • Surgical treatment in sever cases of lung impairment. Recurrent Pneumonia

44. Correlation is well established. • Cooperation required with dental surgeon. • Medication may be indicated after diagnostic studies, evidence is established yet. Dental Erosions

45. Uncommon manifestation of GORD. • Full evaluation required. • May be possibly caused by vagallymediated reflex. • If reflux proven medication is indicated . Dystonic Head posturing (Sandifer syndrome)

46. Bilious vomiting. Gastrointestinal bleeding Consistently forceful vomiting. Onset of vomiting after 6 months. Failure to thrive. Diarrhea. Constipation. Warning signals

47. Fever. • Lethargy. • Hepatosplenomegaly. • Bulging fontanelle. • Macro/Microcephaly. • Seizures. • Abdominal tenderness and distension. • Documented or suspected genetic/metabolic syndrome. Warning signals

48. Distinction between GORD and GOR • Other causes always need to be thought of first • Prokinetics do not have and established role • Trial of hydrolysed formula first in otherwise well children. Take home points

49. Any questions?

50. THANK YOU