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Transfer of gastric contents into the esophagus.

This is physiologic, occurring throughout the

day. 50% of infants < 2 months old are reported to

have GER

This resolves spontaneously by 1 yr of age.

GER becomes a disease when complications

occur.

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Gastroesophageal reflux disease (GERD):

is a term used to collectively describe the

problems and symptoms that occur whenacid from the stomach washes up into the

esophagus.

This can lead to inflammation and

irritation of the lining of the esophagus as

well as causing the typical symptoms that

are generally associated with GERD or acid

r fl x

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Neurologic impairment

Physiological immaturity

Hiatal hernia

Repaired esophageal atresia

Morbid obesity Cerebral defects

Increased abdominal pressure

Obesity

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Supine position

Coughing

Wheezing

Bronchopulmonary dysplasia

Asthma

Indwelling orogastric or nasogastric tube Medications like theophilline

Mechanical ventilations.

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A complex interaction of many problems can

cause reflux:

Esophageal Dysmotilityweak or uncoordinated esophageal contraction,

Inadequate saliva production

Seen during sleep.

Saliva normally buffers anyacid which is found in the esophagus.

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Impaired resistance of esophageal LiningDefective protection of the esophagus against acid

by the cells which make up the lining of the

esophagus LES dysfunctionPoorly functioning sphincter muscle (gate between

stomach and esophagus) allowing acid to wash upinto the esophagus

Delayed emptying of the stomachPoor motor function of the stomach (not draining

into the intestine) allowing acid to pool in thestomach.

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Hiatal hernia

Allows acid to wash up into the esophagus due to

pressure differences between the abdomen and

chest.

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Classic GERD

Extraesophageal/Atypical GERD

Complicated GERD

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Dysphagia

Difficulty swallowing: food sticks or hangs up

Odynophagia Retrosternal pain with swallowing

Bleeding

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Symptoms in infant Sitting up Regurgitation Vomiting (may be forcefull) Excessive cry Irritability Arching of the back Stiffening Weight loss FTT

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Respiratory problems

Cough

Wheeze

Stridor

Gagging

Chocking with feeding Hematemesis

Apnoea

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Symptoms in children Heart burn

Abdominal pain Noncardiac chest pain Chronic cough Dysphagia

Nocturnal asthma Reccurrent pneumonoa Abnormal Neck posturing (Sandifer

syndrome) often confused with seizures

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Esophagitis

Esophageal stricture

Laryngitis Reccurrent pneumonia

Anemia

Barretts esophagus

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Classic GERD

Extraesophageal/Atypical GERD

Complicated GERD

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Diagnosis of GERD

History collection & Physical examination

Feeding behavior

Presenting signs and symptoms

Frequency and characteristics of emesis

Behavior and respiratory symptoms

Time at which they occur and any associated events Assessment of growth and nutritional status.

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To detect anatomic abnormalities

To observe for reflux following swallowing.

The upper GI series is important to excludeother anatomic obstructions, such as esophageal,

gastric or duodenal web, pyloric mass, or

malrotation.

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A probe is placed through the nose down to the distal esophagus

and connected to a pH monitoring device.

A 24-hour pH probe study provides information regarding

Frequency of acid reflux

the amount of time there is acid in the distal esophagus

the time it takes for the acid to be cleared from the esophagus.

The effects of feeding, positioning, sleep and other events on

GER can be determined.

A pH probe study can be done simultaneous with a

cardiorespiratoy recording monitor to address the relationship

of GER and respiratory symptoms such as apnea.

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Endoscopy may be performed when GFR is

suspected to assess whether esophagitis is

present. The esophagus is examined visually for evidence

of inflammation or ulceration.

Mucosal biopsies are obtained

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Positioning:-It helps to reduce the amount of

reflux.

Infants younger than 6 months should be placed

on right lateral position during sleep. Head ofthe crib should be raised at least 6 inches.

The infant may also be held upright.

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Older children should be placed in head

raised to 30r-45r angle position.

Avoid recumbent position after meal for atleast 3 hours.

Upright of semi upright position during

awaking is helpful.

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Feeding:- Infants to be given thickened feed in small amount

frequently followed by appropriate positioning,

and frequent burping are generally accepted toprevent the reflux.

Feeding is thickened with 1 table spoon of ricecereal per 6 ounces of formula may be

recommended as an initial measure to manageGER.

Older children should be allowed nothing permouth 2 hours before bed time.

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AVOID Fat rich diet Spicy and acidic foods(onion, citrus products,

apple juice, tomato) Esophageal irritants (chocolate, peppermint,

passive smoke) Carbonated beverages. Obesity Tight or constricting clothing at nightChewing gum can be allowed to stimulate parotid

secretions which increase esophageal clearance.

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Antacids or H2 receptor antagonists :

H2 receptor antagonists are used to reduce the

amount of acid present in gastric contents and it

prevent esophagitis. Eg:- Ranitidine, cimetidine

Side effects include rash, dizziness, nausea,

vomiting.

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2.Proton pump inhibitors

Prevent the acid secretion by blocking the proton pump

in the parietal cells of the gastric mucosa.

The drug binds to the hydrogen-potassium ATPaseenzyme. This enzyme also known as the proton pump is

necessary for the last step in the gastric acid secretion

process.

If the enzyme is bound by omeprazole, new enzymemust be synthesized before acid secretion can occur.

This takes approximately 72 hours.

Eg:-Omeprasole

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Best if given hour prior to breakfast, hour

before evening meal

Side effects of omeprazole include- GIT: (Diarrhea, vomiting, constipation and

abdominal pain.)

CNS: (Headache and dizziness)

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Metachlorpramide is used to increase resting LES

pressure and the rate of gastric emptying.

No effect on transient relaxations.

Most useful in treatment of children with GER

accompanied by delayed gastric emptying.

Side effects includes:

Restlessness,drowsiness, and extrapyramidal reactions,

Cisapride is used to increase the LES pressure, promotes

gastric emptying, and has fewer central nervous system

side effects than metachlorpamide.

Side effects includes cardiac arrhythmias.

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Bethanechol has also been shown to greatly

increase LES pressure, but it has not been

proved to decrease the reflux by pH probestudies.

Side effects include respiratory symptoms

such as wheezing.

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Nissen fundoplication

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It restore competence to the LES. In a fundoplication the gastric fundus of the

stomach is wrapped around the lower end of the

esophagus and stitched in place, reinforcing theclosing function of the LES. Whenever stomach contracts it also closes of the

esophagus instead of squeezing stomach acidsinto it.

The fundal wrap also decreases the diameter ofthe distal esophagus and increases the openingpressure necessary to initiate reflux.

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Gas bloat syndrome

Dysphagia

Dumping syndrome (this is a condition wherethe ingested food bypass the stomach too

rapidly mostly undigested.)

Excessive scarring

Achalasia

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Gastrostomy is usually performed at the same

time for decompression of the stomach

postoperatively. Fundoplication combined with

pyeloroplasty may be performed in children

with GER who also have delayed gasric

emptying.

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Endoscopic procedurefor the treatment ofGERD.

A catheter is used todeliver radio frequencyenergy to the lower

esophagal spinctermuscle and gastriccardia.

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Also callled Bards procedure.

Uses a tiny device at the end of the

enodoscope which works like a mini sewingmachiene.

It sutures stitches near the lower esophagal

spincter, which tighten the valve and prevent

reflux.

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(1) identifying children with symptoms

suggestive of GER:

(2) educating parents regarding home care;including feeding, positioning and

medications when indicated: and

(3) if appropriate, caring for the child

undergoing surgical intervention.

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1. Imbalanced nutrition less than body requirementsrelated to less intake of food secondary toregurgitation of gastric contents.

2. fluid volume deficit related to vomiting secondary toGERD.

3. Parental anxiety related to childs condition/ chronichospitalisation.

4. Parental Knowledge deficit regarding care of thechild with GERD.

5. pain related to surgical procedure. 6. ineffective family process related to child with a

physical defect, hospitalisation. Risk for infection related to surgical procedure.

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