Seoul National University Children’s Hospital Pediatric Gastroenterology, Hepatology and

NutritionFellow. Sang Hee, Cho

Gastroesophageal Reflux Disease

Gastroesophageal reflux (GER) : passage of gastric contents into the esophagusGER disease (GERD) : symptoms or complications of GER

Infancy GER- 50% of infants in the first three months of life- 67% of four month old infants- 5% of 10~12 month old infants : resolves spontaneously in nearly all of these infants: small minority of infants develop GERD with symptoms - anorexia, irritability, hematemesis,- dysphagia (difficulty swallowing), - odynophagia (painful swallowing), - arching of the back during feedings, - anemia, failure to thrive

Colin D. Rudolph et al. Pediatric GE Reflux Clinical Practice Guidelines. JPGN, 2001;32:S1-S31

History and Physical Examination

Barium Contrast Radiography

Esophageal pH Monitoring

Multichannel Intraluminal Impedance

Endoscopy and Biopsy

Scintigraphy

Empiric Therapy

Diagnostic Approaches

History and Physical Examination

Barium Contrast RadiographyUpper gastrointestinal series : useful to detect anatomic abnormalities : pyloric stenosis, malrotation, hiatal hernia,

esophageal stricture : sensitivity (31-86%), specificity (21-83%), positive predictive value (80-82%) : brief duration of the upper GI series false negative results

: frequent occurrence of non-pathhological reflux false positive results

Diagnostic Approaches

Reflux index : percentage of the total time - esophageal pH is <4- the most valid measure of reflux - reflects the cumulative exposure of the esophagus to

acidSensitivity : 87-93.3%, Specificity : 92.9-97%Mean upper limit of normal of the reflux index

: 11.7% in infants 0 to 11 months: 5.4% in children 0 to 9 years old: approximately 6% in 432 normal adults

upper limit of normal of the reflux index : up to 12% in the first year of life and up to 6% there-

after

Esophageal pH Monitoring

Esophageal pH Monitoring

Multichannel Intraluminal Im-pedance

Michiel P. et al. Role of the MCII Technique in Infants and Children. JPGN, 2009;48(1):2-12

New diagnostic tool for GERD Combination with manometry : determination of the relation

between esophageal pressures and esophageal bolus flow Symptom Index (SI) = No. of reflux-related symptom/total No. of symptom (positive when above 50%)Symptom Sensitivity Index (SSI) = No. of reflux-related symptom/total No. of reflux (abnormal when higher than 10%)Symptom association probability score (SAP) : statistical means of calculating the probability that the

symptoms and GER episodes found are unrelated : calculated as (1.0-P) * 100%

Multichannel Intraluminal Im-pedance

Michiel P. et al. Role of the MCII Technique in Infants and Children. JPGN, 2009;48(1):2-12

Impedance(electrical resis-tance)

: resistance to electrical current flow between two electrodes

: impedance being inversely proportional to ionic concen-trations of luminal contents

: bolus with relatively low ionic contents (eg, air) : higher im-pedance measurements com-pared with a bolus with rela-tively high ionic contents (eg, saline, refluxate)

Multichannel Intraluminal Im-pedance

Multichannel Intraluminal Im-pedance

Michiel P. et al. Role of the MCII Technique in Infants and Children. JPGN, 2009;48(1):2-12

Multichannel Intraluminal Im-pedance

Limitation : Poor reproducibility, no normal range, costly and time-consuming technique

Multichannel Intraluminal Im-pedance

Endoscopy and Biopsypresence and severity of esophagitis, stric-

tures and Barrett's esophagus,exclude other disorders, such as Crohn's

disease, webs and eosinophilic or infectious esophagitis

Diagnostic Approaches

Lundell. et al. Endoscopic assessment of oesophagitis. Gut. 1998;45;172

Lifestyle Changes-Feeding Changes in Infants-Positioning Therapy for Infants

Pharmacological TherapiesAcid Suppressants

-Histamine-2 receptor antagonists (H2RAs) -Proton Pump Inhibitors-Antacids

Prokinetic TherapySurface Agents

Surgical Treatment

Treatment Options

Pharmacological Thera-pies

Rome III crite-ria

Paul E. et al. Childhood Functional Gastrointestinal Disorders. Gastroenterol-ogy. 2006;130:1519-26

Must include all of the following in otherwiseHealthy infants 3 weeks to 12 months of age:1. Regurgitation 2 or more times

per day for 3 or more weeks2. No retching, hematemesis,

aspiratioin, apnea, failure to thrive, feeding or swallowing difficulties, or abnormal pos-turing

Bilious vomitingGI bleeding : he-

matemesis, hema-tochezia

Forceful vomitingOnset of vomiting after

6 months of lifeFailure to thriveDiarrheaConstipationFeverLethargy

Hep-atosplenomegaly

Bulging fontanelleMacro/microcephalySeizuresAbdominal tender-

ness, distentionGenetic disorder

(eg:Trisomy21)Other chronic disor-

ders(eg:HIV)

Warning Signals in the vomiting infant

Colin D. Rudolph et al. Pediatric GE Reflux Clinical Practice Guidelines. JPGN, 2001;32:S1-S31

Management of an infant with uncomplicated GER(the “happy spit-ter”)

Algorithm

Colin D. Rudolph et al. Pediatric GE Reflux Clinical Practice Guidelines. JPGN, 2001;32:S1-S31

Algorithm

Management of an infant with vomiting and poor weight gain

THANK YOU!!!

Consisted of 14 items – maximum possible score of 31Characteristics of regurgitation : frequency, volumeFeeding refusalWeight gainIrritabilityCrying : daily frequency and correlation with mealHiccupsArching backRespiratory symptomsPosture

Score 7 : value usually indicated as the threshold limit over which the presence of GERD is a possible risk

Infant Gastroesophageal Reflux Question-naire