pedi gasro osophogeal reflux presentation
TRANSCRIPT
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Pediatric RefluxPediatric Reflux
Frederick S. Rosen, MD
Norman R. Friedman, MDOctober 25, 2000
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Pediatric RefluxPediatric Reflux
! FunctionalGastroesophagealReflux
!GERD
! SecondaryGastroesophagealReflux
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Lower Esophageal SphincterLower Esophageal Sphincter
! Pinch-Cock Action
! Intraabdominal Esophagus
! Angle of His
!Mucosal Rosette! High Pressure Zone
! Abdominal Pressure
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Reflux events in infantsReflux events in infants
!Maturation of LES at 5-7 weeks of life,regardless of gestational age
! Esophagitis and
TLESRs a viciousCycle
! Acid & Pepsin,
Bile Acids and Trypsin
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Typical presentation of GERDTypical presentation of GERD
! Crying/Irritability
! Poor feeding
! Regurgitation
! Epigastric pain
! FTT/weight loss
! Sore throat
! Waterbrash
! Hematemesis! Anemia
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Atypical presentation of GERDAtypical presentation of GERD
! Apnea/Bradycardia
! ALTEs
!Wheezing/Asthma
! Stridor! Recurrent
pneumonia
! Chronic cough
! Sandiferssyndrome
! Hoarseness/
Laryngitis!Otalgia
! Sinusitis
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GERD UntreatedGERD Untreated
! Resolves by 2years of age in60% of GERD
! Persists until age 4in 30%
! stricture, malnutrition
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GERD in OtolaryngologyGERD in Otolaryngology
!Chronic Sinusitis avoid FESS!Chronic Cough
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Globus Pharyngeus- osteophytes,FB, cricopharyngeus, tonsils, goiter,web, cervical lad, mass
!Dysphagia
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GERD in OtolaryngologyGERD in Otolaryngology
!Otitis Media?
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GERD in OtolaryngologyGERD in Otolaryngology
! Vocal cordgranuloma
! Laryngomalacia
!
Pseudolaryngomalacia
! Subglottic
stenosis! Sandifers Synd.
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Apnea &Apnea & ALTEsALTEs
! 7-15% SIDS
! At least 53% of ALTEs
! Esophagolaryngeal Adductor Reflex
obstructive apnea! Laryngeal Chemoreflex Central Apnea
! Seizure and Reflux?
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AsthmaAsthma
! Vicious Cycle
!Macroaspiration
!Microaspiration
! Esophagitis vagal reflex
!
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Differential diagnosisDifferential diagnosis
!Food allergy (cow milk)
! Infection
! Increased intracranial pressure
(tumor)!Hydronephrosis
!
Intestinal obstruction!Metabolic Disorders (uremia)
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Diagnosing GERDDiagnosing GERD
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Diagnosing GERDDiagnosing GERD
! Upper GI
! Esophageal biopsy
! DL and Bronch
! pH probe! Scintigraphy
!Modified Bernstein
Test!Manometry
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Diagnosing GERDDiagnosing GERD
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Treatment of GERDTreatment of GERD
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Treatment of GERDTreatment of GERD
!Appropriate feeds
!Caffeine, chocolate, and tobacco
!Positioning
!Thickening feeds
!Small, frequent feeds
!Continuous feeding via NGT
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Medical Treatment of GERDMedical Treatment of GERD
!Prokinetics
!Cisapride Prolonged QT interval,Torsades, and heart block
Risk of death 1/250,000Avoid macrolides, azoles, &grapefruit juice; cytochrome P450
!Metoclopramide EPS in 24-48 hr
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Surgical Treatment of GERDSurgical Treatment of GERD
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Surgical Treatment of GERDSurgical Treatment of GERD
! Nissen 2/3
!360 degree wrap
!Gas bloat
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Thal 1/3!180 degree wrap
!Long intraabd,
fixation, restoresangle of His
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Surgical Treatment of GERDSurgical Treatment of GERD
! Indications
!Failure ofmedical tx
!Stricture
!Pulmonary Dz
!Quality of Life
!Esophagealatresia
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Surgical Treatment of GERDSurgical Treatment of GERD
! Indications in children < 2 yo
!Neurologic impairment
!BPD/RDS
!Apneic Episodes
!Congenital anomalies (hiatal
hernia, esophageal atresia)
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Surgical Treatment of GERDSurgical Treatment of GERD
!Outcomes
!More effective in children
!Good outcomes: 94% NN, 85% NI
!Complications: 4.2% NN, 12.8% NI
!Reoperation: 3.6% NN, 11.8% NI
!Mortality: 0.07%!TLESRs and Fundoplication
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ConclusionConclusion
!Similar incidence of GERD in infantsand adults
!Patients < 2 yo: A question of
motility!Reflux and Otolaryngology