Gastroesophageal Reflux Disease Year 4 Paediatrics Notes

Gastroesophageal Reflux Disease Year 4 · Paediatrics Collection: 4TH YEAR ALL NOTES / PAEDS / PAEDS 4.2 / MUNGE / GIT -- Slide 1 Gastroesophageal Reflux Disease Dr Rose Munge Slide 2 Gastroesophageal reflux disease (GERD) is the most common esophageal disorder in children of all ages.\n Gastroesophageal reflux (GER) signifies the retrograde movement of gastric contents across the lower esophageal sphincter (LES) into the esophagus, which occurs physiologically every day in all infants, older children, and adults.\n Physiologic GER is exemplified by the effortless regurgitation of normal infants. Slide 3 The phenomenon becomes pathologic GERD in infants and children who manifest or report bothersome symptoms because of frequent or persistent GER, producing esophagitis-related symptoms, or extra esophageal presentations, such as respiratory symptoms or nutritional effects. Factors determining the esophageal manifestations of reflux include the duration of esophageal exposure (a product of the frequency and duration of reflux episodes), the causticity of the refluxate, and the susceptibility of the esophagus to damage. Slide 4 Pathophysiology The LES, a high-pressure zone, is supported by the crura of the diaphragm at the gastroesophageal junction, together with valve-like functions of the esophagogastric junction anatomy, form the antireflux barrier.\nThe frequency of reflux episodes is increased by insufficient LES tone, by abnormal frequency of LES relaxations, and by hiatal herniation that prevents the LES pressure from being proportionately augmented by the crura during abdominal straining Slide 5 Normal intraabdominal pressure augmentations may be further exacerbated by straining or respiratory efforts.\nThe duration of reflux episodes is increased by lack of swallowing (e.g., during sleep) and by defective esophageal peristalsis.\nVicious cycles ensue because chronic esophagitis produces esophageal peristaltic dysfunction (low-amplitude waves, propagation disturbances), decreased LES tone, and inflammatory esophageal shortening that induces hiatal herniation, all worsening reflux. Slide 6 Transient LES relaxation (TLESR) is the primary mechanism allowing reflux to occur, and is defined as simultaneous relaxation of both LES and the surrounding crura.\nTLESRs occur independent of swallowing, reduce LES pressure to 0-2 mm Hg (above gastric), and last 10-60 sec; they appear by 26 wk of gestation.\nA vagovagal reflex, composed of afferent mechanoreceptors in the proximal stomach, a brainstem pattern generator, and efferents in the LES, regulates TLESRs.\nGastric distention (postprandially, or from abnormal gastric emptying or air swallowing) is the main stimulus for TLESRs. Slide 7 Straining during a TLESR makes reflux more likely, as do positions that place the gastroesophageal junction below the air–fluid interface in the stomach.\n Other factors influencing gastric pressure–volume dynamics, such as increased movement, straining, obesity, large-volume or hyperosmolar meals, gastroparesis, a large sliding hiatal hernia, and increased respiratory effort (coughing, wheezing) can have the same effect. Slide 8 Epidemiology and Natural History Infant reflux becomes evident in the first few mo of life, peaks at 4 mo, and resolves in up to 88% by 12 mo and in nearly all by 24 mo. \nHappy spitters are infants who have recurrent regurgitation without exhibiting discomfort or refusal to eat and failure to gain weight. \nSymptoms of GERD in older children tend to be chronic, waxing and waning, but completely resolving in no more than half, which resembles adult patterns. Slide 9 Clinical Manifestations Infantile reflux manifests more often with regurgitation (especially postprandially), signs of esophagitis (irritability, arching, choking, gagging, feeding aversion), and resulting failure to thrive; symptoms resolve spontaneously in the majority of infants by 12-24 mo. Older children can have regurgitation during the preschool years; this complaint diminishes somewhat as children age, and complaints of abdominal and chest pain supervene in later childhood and adolescence.\nOccasional children present with food refusal or neck contortions (arching, turning of head) designated Sandifer syndrome. Slide 10 The respiratory presentations are also age dependent: GERD in infants may manifest as obstructive apnea or as stridor or lower airway disease in which reflux complicates primary airway disease such as laryngomalacia or bronchopulmonary dysplasia.\nOtitis media, sinusitis, lymphoid hyperplasia, hoarseness, vocal cord nodules, and laryngeal edema have all been associated with GERD.\nAirway manifestations in older children are more commonly related to asthma or to otolaryngologic disease such as laryngitis or sinusitis. Slide 11 Neurologically challenged children are one group that is recognized to be at an increased risk for GERD.\n It is not well established if the greater risk is due to inadequate defensive mechanisms