Gastroesophageal Reflux (GER)

1. Gastroesophageal Reflux (GER) Elaine Porter, MD Pediatric Resident, PGY-2 Children’s Hospital of the King’s Daughters

2. Definitions: • GER:Passage of gastric contents into the esophagus, a normal physiologic process in healthy infants, children, and adults but may cause distress for caregivers or patients. • Gastroesophageal reflux disease (GERD): Passage of gastric contents into the esophagus that results in troublesome symptoms or complicationsfor the infant, child, or adolescent, and not for the caregiver alone. (PIR 2012;33;243)

3. Definitions: • Regurgitation: Commonly referred to as “spitting up,” is the effortless passage of gastric contents into the pharynx or mouth. • Vomiting: The forceful expulsion of the gastric contents; while rumination is voluntary, habitual, and effortless regurgitation of recently ingested food. (PIR 2012;33;243)

4. Objectives • Understand other diseases and conditions that may mimic GERD. • Understand methods of diagnosing GERD. • Describe therapeutic options for the treatment of GERD (including lifestyle modifications, medical therapies, and surgical therapies).

5. Case 1: • M.G. - 6 week old female infant, ex 34 week premie presents in clinic for f/u of “spitting up with every feed”. • Frequent burps and upright position after feeds. • Exclusively BF until a day ago, started Neosure 22 - “decrease” milk supply. • No BM x 2 days, slightly distended abdomen. • Growth parameters within normal limits. Mom wants to know if she should switch formula and if her baby will get better. • Without further history at this point what information would you convey to mom?

6. Case 1: • BHx - maternal preeclampsia, HELLP, prior HSV lesions, GBS +, adequately treated. Stable on discharge after a relatively benign course in Level 2 nursery. • Diagnosed with NEC after presenting to clinic with bloody stools at 2 weeks of life; admitted, NPO status, triple antibiotic. • D/c in stable condition with f/u in clinic. First f/u a week ago infant with adequate weight gain despite “spitting up with feeds”. • Given further history would you recommend any further testing for infant?

7. Epidemiology • 50% of infants < 3 months of age and 67% of infants at 4 months of age will have at least one episode of regurgitation daily. • By 12 months of age, however, only 5% experience episodes of regurgitation. • Uncomplicated reflux – reassurance by PCP • Referral to a pediatric GI is recommended if symptoms > 12 to 18 months of age

8. Etiology • Transient relaxation of the lower esophageal sphincter (LES). • Gastric distention associated with large volume feeds (100–150 mL/kg per day) causes more frequent transient LES relaxation. • Delayed Gastric emptying. • In neurologically impaired children, decreased basal LES tone.

10. Signs and Symptoms - GI • Infants • Regurgitation or spitting up • “Happy spitters” – benign physiologic GER • Hematemesis • Feeding difficulties • Arching of the back/irritability • Children • Heartburn • Dysphagia • Chest pain • Hematemesis • Feeding difficulties • Regurgitation • Vomiting

11. Signs and Symptoms - Extraintestinal • Infants • Failure to thrive • Wheezing • Stridor • Persistent cough • Apnea/ALTE • Irritability • Sandifer syndrome • Children • Persistent cough • Wheezing • Laryngitis • Stridor • Chronic asthma • Recurrent pneumonia • Dental erosions • Anemia

12. Supraesophageal manifestations of GER http://www.gastroscan.ru

13. Categorization of symptoms

14. Worrisome signs and symptoms • Bilious emesis • GI bleeding • FTT • Forceful or projectile vomiting • Emesis beginning after 6 months of age • Difficulty swallowing • h/o food allergies • Fever • Diarrhea/constipation • Abdominal pain • Hepatosplenomegaly • Lethargy • Bulging fontanelle • Anxiety or disordered eating • Suspicion of genetic or metabolic disease

15. Non – reflux causes of vomiting • Infections – sepsis, meningitis, UTI • Anatomic obstruction - FB, pyloric stenosis, malrotation, intussusception • GI – esophagitis, achalasia, gastroparesis, IBD • Neurologic – ICP, migraine • Respiratory – pneumonia • Renal – obstructive uropathy, renal insufficiency • Cardiac – CHF • Oncology – lymphoma, other solid tumors • Psychologic/Behavioral – overfeeding, rumination

16. Differential Diagnosis

17. Differential Diagnosis

18. A. Normal Esophagus: B. Severe Peptic esophagitis

19. A. Erosive esophagitis: severe erythema and edema with linear ulcerations, associated with chronic GERD. B. Eosinophilic esophagitis: white plaques, linear ridging, and trachealization of the esophagus consistent with eosinophilic esophagitis.

20. Infectious esophagitis C. (Candida): white plaques consistent with candidal esophagitis in a patient with Crohn disease. D. (Herpes simplex Virus): severe ulcerations consistent with herpes simplex virus infection.

21. Barrett’s esophagus

22. Histological progression of untreated reflux Barrett’s epithelium Esophagitis Normal epithelium

23. Diagnostic Studies • Empiric trial of acid suppression • PPI - 4 week trial suggested, 2 weeks insufficient • Barium contrast radiography • Anatomic abnormalities • Mimickers – Webs, strictures, achalasia, hiatal hernia, gastric outlet obstruction (Antral web, pyloric stenosis)

24. Esophageal stricture. Upper GI series demonstrating a tapered circumferential mid and lower esophageal stricture.

25. Achalasia. *Proximal esophageal dilation and **bird’s beak appearance suggestive of achalasia.

26. Radiograph of a Sliding hiatal hernia. The lower esophageal sphincter (arrow) and a pouch of stomach have herniated through the diaphragmatic hiatus (arrowhead)

27. Diagnostic Studies • Esophageal pH monitoring • Trans - nasal catheter with one or more probes • Monitors frequency and duration of acidic esophageal reflux episodes • Associated with pH < 4.0 • Measures total episodes and number of episodes lasting > 5 minutes, duration of longest episodes • Monitors efficacy of acid suppression • Limitations: • Infants who feed q2-4 hours, feedings may buffer gastric acidity

28. Diagnostic Studies • Combined multiple intraluminal impedance and pH monitoring (MII) • Measures air, fluids, and solids in esophagus • Detects acid and non-acid reflux • Distinguishes between antegrade (swallowed) and retrograde (regurgitated) boluses • Benefits: Can be used while patient on acid suppression

29. Diagnostic Studies • Esophageal manometry • Assesses peristalsis and U/LE sphincters • Motility disorders • Limitations: Does not detect reflux (acid or non-acid) • Scintigraphy (GES) • Labels food with 99-technitium • May identify reflux and aspiration (Sensitivity 15% – 59%) (Specificity 83% - 100%) • Not recommended to diagnose or manage reflux in infants and children

30. Diagnostic Studies

31. Reflux patterns by pH probe

32. Reflux patterns by pH probe

33. Prognosis of GER • Most uncomplicated GER will be “out - growned” by 7 – 12 months of age • Children with neurological impairment, obesity, interstitial lung disease, anatomic GI abnormalities, malrotation, hiatal hernia, prematurity – higher risk of GERD and its complications

34. Complications of GER • Esophagitis • Barrett's esophagus (Extremely rare in pediatrics < 0.25%) • Esophageal Strictures (rare ~ 5%) • Adenocarcinoma • Associated frequently with asthma in pediatric population • Aspiration of gastric contents leads to hyper-responsiveness and inflammation • Decreased LES tone from increased intra-thoracic pressure • Hoarseness and chronic cough • Dental caries • ALTEs

35. Treatment of GER • Thicken formula (1 tbsp per 2 oz) • Antiregurgitant formulas have not been proven to decrease regurgitation compared with thickened feeds • Changing the type of formula does not positively affect GER symptoms • Prone positioning decreases the number of regurgitation events, however supine to sleep • Lifestyle changes in children and adolescents • Transpyloric feeding

36. Pharmacological Treatment • Antacids - act within minutes to buffer acids • Administer caution with aluminum containing products (osteopenia, rickets, microcytic anemia, neurotoxicity) • Histamine – 2 receptor antagonist (H2RAs) • Decrease acid production by biding to H2 receptor on parietal cells • Used to heal esophagitis and reduce symptoms of GERD • Proton pump inhibtors • Suppress gastric acid irreversibly by blocking H+/K+ ATPase • Not approved for children < 12 months • Generally safe, 12% - 14% have idiosyncratic reactions – headache, diarrhea, constipation, nausea • Drug induced hypergastremia may occur • Abnormal intestinal bacterial overgrowth (Candida in neonates, higher incidence of NEC)

37. Pharmacological Treatment • Pro-kinetic agents: • Bethanechol, baclofen, domperidone (potential adverse effects) • Metoclopramide • Reactions: dystonic reactions, gynecomastia, permanent tardive dyskinesia • Erythromicin • Prolonged QT interval • Pyloric stenosis • Surface agents: • Sucralfate (Sucrose, sulfate, aluminum)

38. Surgical Treatment • Nissen Fundoplication • Increases LES and increases intra-abdominal length of the esophagus • Up to 10% of children will have complications • Up to 10% will require surgical revision

39. Potential causes of treatment failure

40. medscape

41. Review of Case 1: • M.G. - 6 week old female infant, ex 34 week “spitting up with every feed”. • Exclusively BF until a day ago, started Neosure 22 - “decrease” milk supply. • H/o NEC, no BM x 2 days, slightly distended abdomen. • Growth parameters within normal limits. Mom wants to know if she should switch formula and if her baby will get better.

42. References: Gastroesophageal Reflux • Gastroesophageal Reflux, Pediatrics in Review 2012;33;243, Jillian S. Sullivan and Shikha S. Sundaram • Gastroesophageal Reflux, Pediatrics in Review 1992;13;174, Susan R. Orenstein • Gastroesophageal Reflux, Pediatrics in Review March 2007; 28:101-110; doi:10.1542/pir.28-3-101, Sonia Michail • Focus on Diagnosis : New Technologies for the Diagnosis of Gastroesophageal Reflux Disease, Pediatrics in Review 2008;29;317, Jason E. Dranove,