GERD

1. ي GERD done by adilaabulhamail

2. Defination Epidemiology Classification Mechanism that protect from GERD Presentaion Causes D.D Investigation

3. Treatment Conservative Medical Surgical : open or laproscopic ( indication , contraindication, technique) Complication of operation summary

4. Definition the pathologic consequences of involuntary passage of gastric contents into the esophagus

5. Epidemiology the most common gastroenterological disorder that leads to referral to pediatric gastroenterologist during infancy. Approximately 85% of infants vomit during the first week of life, and 60-70% manifest clinical gastroesophageal reflux at age 3-4 months.. . Resolution of symptoms occurs in approximately 90% of infants by age 8-10 months. Symptoms that persist after age 18 months suggest a higher likelihood of chronic gastroesophageal reflux . Age: most commonly seen in infancy, with a peak at age 1-4 months. However, it can be seen in children of all ages, even healthy teenagers

6. Classification of GERD Primary: physiological: These patients have no underlying predisposing factors. Growth and development are normal, and pharmacologic treatment is typically not necessary. Pathologic : Patients frequently experience complications, requiring careful evaluation and treatment. Secondary : This refers to a case in which an underlying condition may predispose to gastroesophageal reflux. Examples include asthma and gastric outlet obstruction.

7. LA CLASSIFICATION Grade A: one or more mucosal breaks no longer than 5 mm, no extends between the tops of the mucosal fold Grade B: one or more mucosal breaks more than 5 mm long, noextends between the tops of two mucosal folds Grade C: mucosal breaks that extend between the tops of two or more mucosal folds, but are not circumferential Grade D: one or more circumferential mucosal breaks . Below Grade A, we added a Grade M (minimal change), defined as prominent erythema without clear demarcation or whitish cloudiness of the lower esophageal mucosa obscuring the longitudinal blood vessels

10. Mechanism that protect from GERD Clear Esophageal Saliva Esophageal peristalsis Gravity

11. The angle of His is formed between the esophagus (the tube arriving at the top of Prevent Gastric Reflux Lower esophageal sphincter Angle of His Elevated intraabdominal pressure

12. Limit Esophageal Injury Amount of gastric acid Pepsin Trypsin Bile acids

13. causes multifactorial. Anatomic factors that: The angle of His (made by the esophagus and the axis of the stomach) is obtuse in newborns but decreases as infants develop. The presence of a hiatal hernia may displace the lower esophageal sphincter (LES) into the thoracic cavity Resistance to gastric outflow raises intragastric pressure and leads to reflux and vomiting. Examples include gastric outlet obstruction, and pyloric stenosis

14. Other causes Other factors that predispose individuals to gastroesophageal reflux include the following: Medications (eg, diazepam, theophylline) Smoking Alcohol Poor dietary habits (eg, overeating, eating late at night, assuming a supine position shortly after eating) Food allergies Certain foods (eg, greasy, highly acidic) Motility disorders

15. presentation Signs and symptoms of gastroesophageal reflux in infants and young children Typical or atypical crying and/or irritability Apnea Poor appetite Vomiting Wheezing Abdominal and/or chest pain Stridor Weight loss or poor growth Recurrent pneumonitis Sore throat Chronic cough Hoarseness and/or laryngitis Signs and symptoms in older children - All of the above, plus heartburn and history of vomiting, regurgitation, unhealthy teeth, and halitosis

16. D.D Duodenal Atresia Esophageal Motility Disorders Esophagitis Food Allergies Gastric Ulcers Gastritis, Acute Gastritis, Chronic Helicobacter Pylori Infection Hiatal Hernia Intestinal Malrotation Tracheoesophageal Fistula

18. INVESTIGATION: Upper Gastrointestinal Contrast Series Esophageal pH Monitoring: Gastric scintiscan Esophageal Monometry Endoscopy

19. Upper Gastrointestinal Contrast Series: This is used to evaluate the anatomy of the upper GI tract.provide a detailed road map of the patient's anatomy to role out other causes of vomiting. Problems such as pyloric stenosis, malrotation, partial duodenal outlet obstruction, hital hernia, and esophageal stricture.

20. Esophageal pH Monitoring: Esophageal pH monitoring measures the duration and frequency of acid reflux defined as an esophageal pH of less than 4 for a period of 15 to 30 seconds In children, the upper limit of normal is a pH below 4 less than 5.5% of the time. In infants younger than 1 year, the normal value increases to 12%.

21. Dual-channel proximal and distal esophageal pH monitoring is used to monitor patients with reflux symptoms off therapy. b: Dual channel distalesophageal and gastric pH monitoring is used to monitor patients

22. Gastric scintiscan This imaging study, using milk or formula that contains a small amount of technetium sulfur colloid, can assess gastric emptying and can reveal reflux

23. Esophageal Monometry gold standard for assessment of the body of the esophagus. It is also mandatory before antirefluxoperations. Assesment of the LES

24. Endoscopy  To detect complications eg reflux esophagitis, esophageal stricture, Barrett metaplasia, and esophageal adenocarcinoma  To detect other gastroesophageal diseases (peptic ulcer) Indication for this procedure includes: All patients prior to fundoplication surgery. Eldery patient with GERD symptoms.

25. Histologic Findings Useful for diagnosing cancers or causes of esophageal inflammation other than acid reflux, particularly infections.  Only means of diagnosing cellular changes of Barrett¶sesophagus.

26. .

27. .Barrett metaplasia c. A m b ulatory/Impedance PH monitoring i. determines refluxate presence, distribution, clearancetime, liquid, gas or mixed.ii. Shows GER contents as acid, weak acid or non-acid anddetermines bolus transfer of gas, liquid or solids. iii. done when there¶s lack of response to therapy (todetermine correlation between symptoms and acid andnon-acid reflux episodes) / Recurrence of symptoms afterdiscontinuation of acid-reducing medications iv. as a physiological assessment pre-fundoplication (toconfirm disease for which surgery is offered)v. can be catheter based or Bravo wireless capsule vi. Patients with endoscopically confirmed esophagitis do notneed pH monitoring to establish a diagnosis ofgastroesophageal reflux disease (GERD).

28. COMPLICATION FTT Esophagitis Aspiration pneumonia eroded dental enamel Esophageal stricture Esophageal cancer

29. Treatment Conservative Medical treatment Surgical

30. conservative reassurance is the only treatment needed. Conservative measures may include upright positioning after feeding, elevating the head of the bed, prone positioning (infants >6 mo), and providing small, frequent feeds thickened with cereal

31. Medical treatment Histamine H2 Receptor Antagonists: decrease acid secretion by inhibiting the H2 receptor at the parietal cell of the stomach cimetidine, ranitidine, and famotidine are effective in controlling symptoms and treating esophagitis

32. Proton Pump Inhibitors : PPIs bond and deactivate Hf,K+-ATPase, or proton pumps, by crossing parietal cell membranes and accumulating in secretorycanalicul omeprazole

33. Antacids and Surface Agents : Antacids neutralize gastric acid and are preferred for the short-term relief of GER symptoms

34. Prokinetic Agents: Prokinetic agents increase LES pressure, enhance esophageal peristalsis, and accelerate gastric emptying

35. Surgical treatment Indication: Failure of medical therapy. In children who have continuing symptoms such as persistent pulmonary symptom. Presence of an associated anatomic defect such as a hiatal hernia. Neurologically impaired children who have difficulty feeding and have serious reflux as an associated symptom.

36. contraindication In some children, reflux is caused by gastric or intestinal motility disorders or by gastric outlet obstruction. esophageal dysmotility disorders. In children with weak or uncoordinated peristalsis of the esophagus

37. Surgical Techniques Open Operative Techniques: NissenFundoplication Thal-AshcrafFundoplication ToupetFundoplication

38. Laparoscopic NissenFundoplication: Pyloroplasty or Antroplasty Gastrostomy

42. Post op Some surgeons leave a nasogastric tube in place or leave the G-tube to gravity until return of bowel function. This is not always done, particularly if a laparoscopic approach is used. The patient should be started on a clear liquid diet initially (either by mouth or feeding tube), then slowly transitioned to formula or soft solids

43. Complication after operation: Early complications include retching, gas bloat dysphagia, atelectasis, pneumonia, wound infection, small-bowel obstruction due to adhesions, and delayed gastric emptying. Dysphagia may result from postoperative edema and spontaneously resolves.

44. Late complications include bowel obstruction and wrap failure, including wrap disruption, slipped wrap, herniation of the wrap into the chest, or excessively tight wrap. Patients in whom the wrap fails typically present with dysphagia, retching, or recurrent reflux symptoms. In patients with suspected wrap failure, an upper GI barium study may help to evaluate the integrity and anatomy of the repair, and endoscopy may be used to diagnose recurrent or persistent esophagitis.

45. Future The future of gastroesophageal reflux (GER) therapy includes several endoscopic therapies that are gaining favor in adult populations and that may replace surgery in some patients. These therapies include radiofrequency ablation (Stretta procedure), the injection of inert substances at the LES, and endoscopic gastroplication. In the Stretta procedure, a catheter is used to deliver radiofrequency energy, creating thermal lesions deep to the mucosa at the GE junctionFinally, robot-assisted laparoscopic fundoplication in children has been reported with good results

46. SUMMARY GER is a common disorder in children and often requires surgical correction. GER in infants and children is more complex than adult GER. Failure of medical management and an inability to wean from antireflux medications are the most common indications for the surgical treatment of reflux. A complete-wrap fundoplication appears to have better outcomes than partial-wrap fundoplication,although this contention is controversial. Postoperative retching and recurrent GER are the most common and vexing complications of antireflux surgery.