ي GERD done by adila - PowerPoint Presentation

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ي

GERD

done

by

adila

abulhamail

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Defination

Epidemiology

ClassificationMechanism that protect from GERDPresentaionCausesD.DInvestigation

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Treatment

Conservative

Medical Surgical : open or laproscopic ( indication , contraindication, technique)Complication of operationsummary

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Definition

the pathologic consequences of involuntary passage of gastric contents into the esophagus

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Epidemiology

the most common gastroenterological disorder that leads to referral to

pediatric gastroenterologist during infancy.Approximately 85% of infants vomit during the first week of life, and 60-70% manifest clinical gastroesophageal

reflux at age 3-4 months..

. Resolution of symptoms occurs in approximately

90%

of infants by age 8-10 months.

Symptoms that persist after age 18 months suggest a higher likelihood of chronic

gastroesophageal

reflux .

Age:

most commonly seen in infancy, with a peak at age 1-4 months. However, it can be seen in children of all ages, even healthy teenagers

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Classification of GERD

Primary:

physiological: These patients have no underlying predisposing factors. Growth and development are normal, and pharmacologic treatment is typically not necessary. Pathologic :

Patients frequently experience complications, requiring careful evaluation and treatment.

Secondary :

This refers to a case in which an underlying condition may predispose to

gastroesophageal

reflux. Examples include

asthma

and gastric outlet obstruction.

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LA CLASSIFICATION

Grade A: one or more mucosal breaks no longer than 5 mm, no extends between the tops of the mucosal fold

Grade B: one or more mucosal breaks more than 5 mm long, noextends between the tops of two mucosal foldsGrade C: mucosal breaks that extend between the tops of two or more mucosal folds, but are not circumferentialGrade D: one or more circumferential mucosal breaks .

Below Grade A, we added a Grade M (minimal change), defined as prominent

erythema

without clear demarcation or whitish cloudiness of the lower esophageal mucosa obscuring the longitudinal blood vessels

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Mechanism that protect from GERD

Clear Esophageal

SalivaEsophageal peristalsisGravity

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Prevent Gastric Reflux

Lower esophageal sphincter

Angle of HisElevated intraabdominal pressure

 

                                

 

The angle of His is formed between the esophagus (the tube arriving at the top of

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Limit Esophageal Injury

Amount of gastric acid

PepsinTrypsinBile acids

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causes

multifactorial

.Anatomic factors that: The angle of His (made by the esophagus and the axis of the stomach) is obtuse in newborns but decreases as infants develop. The presence of a hiatal hernia may displace the lower esophageal sphincter (LES) into the thoracic cavityResistance to gastric outflow raises intragastric pressure and leads to reflux and vomiting. Examples include gastric outlet obstruction, and pyloric

stenosis

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Other causes

Other factors that predispose individuals to

gastroesophageal reflux include the following: Medications (eg, diazepam, theophylline)SmokingAlcoholPoor dietary habits (eg, overeating, eating late at night, assuming a supine position shortly after eating)

Food allergies

Certain foods (

eg

, greasy, highly acidic)

Motility disorders

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presentation

Signs and symptoms of

gastroesophageal reflux in infants and young children Typical or atypical crying and/or irritabilityApneaPoor appetiteVomitingWheezingAbdominal and/or chest painStridor

Weight loss or poor growth

Recurrent

pneumonitis

Sore throat

Chronic cough

Hoarseness and/or laryngitis

Signs and symptoms in older children - All of the above, plus heartburn and history of vomiting, regurgitation, unhealthy teeth, and halitosis

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D.D

Duodenal

AtresiaEsophageal Motility DisordersEsophagitisFood Allergies

Gastric Ulcers

Gastritis, Acute

Gastritis, Chronic

Helicobacter Pylori Infection

Hiatal

Hernia

Intestinal

Malrotation

Tracheoesophageal

Fistula

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INVESTIGATION:

Upper Gastrointestinal Contrast Series

Esophageal pH Monitoring:Gastric scintiscanEsophageal MonometryEndoscopy

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Upper Gastrointestinal Contrast Series:

This is used to evaluate the anatomy of the upper GI

tract.provide a detailed road map of the patient's anatomy to role out other causes of vomiting. Problems such as pyloric stenosis, malrotation, partial duodenal outlet obstruction, hital hernia, and esophageal stricture.

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Esophageal pH Monitoring:

Esophageal pH monitoring measures the duration

and frequency of acid refluxdefined as an esophageal pH of less than 4 for a period of 15 to 30 seconds In children, the upper limit of normal is a pH below 4 less than 5.5% of the time. In infants younger than 1 year, the normal value increases to 12%.

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Dual-channel proximal and distal esophageal pH monitoring is used to monitor patients with reflux symptoms off therapy. b: Dual channel

distalesophageal

and gastric pH monitoring is used to monitor patients

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Gastric

scintiscan

This imaging study, using milk or formula that contains a small amount of technetium sulfur colloid, can assess gastric emptying and can reveal reflux

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gold standard for assessment of the body of the esophagus. It is also mandatory before antirefluxoperations.

  Assesment

of the LESEsophageal Monometry 

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Endoscopy 

To detect complications

eg reflux esophagitis, esophageal stricture, Barrett metaplasia, and esophageal adenocarcinoma To detect other gastroesophageal

diseases (peptic ulcer)

Indication for this procedure includes:

All patients prior to

fundoplication

surgery.

Eldery

patient with GERD symptoms.

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Histologic

Findings

Useful for diagnosing cancers or causes of esophageal inflammation other than acid reflux, particularly infections. Only means of diagnosing cellular changes of Barrett¶sesophagus.

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.

 

                                                                                      

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.Barrett metaplasia

c.

 

 

A

 

m

 

b

ulatory/Impedance PH monitoring

i.

 

determines refluxate presence, distribution, clearancetime, liquid, gas or mixed.ii.

 

Shows GER contents as acid, weak acid or non-acid anddetermines bolus transfer of gas, liquid or solids.

iii.

 

done when there¶s lack of response to therapy (todetermine correlation between symptoms and acid andnon-acid reflux episodes) / Recurrence of symptoms afterdiscontinuation of acid-reducing medications

 

iv.

 

as a physiological assessment pre-fundoplication (toconfirm disease for which surgery is offered)

 

v.

 

can be catheter based or Bravo wireless capsule

 

vi.

 

Patients with endoscopically confirmed esophagitis do notneed pH monitoring to establish a diagnosis of

 

gastroesophageal reflux disease (GERD).

 

 

                                                                                      

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COMPLICATION

FTT

EsophagitisAspiration pneumoniaeroded dental enamelEsophageal strictureEsophageal cancer

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Treatment

Conservative

Medical treatmentSurgical

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reassurance is the only treatment needed.

Conservative measures may include upright positioning after feeding, elevating the head of the bed, prone positioning (infants >6 mo), and providing small, frequent feeds thickened with cereal

conservative

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Medical treatment

Histamine H2 Receptor Antagonists:

decrease acid secretion by inhibiting the H2 receptor at the parietal cell of the stomach cimetidine, ranitidine, and famotidine are effective in controlling symptoms and treating esophagitis

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Proton Pump Inhibitors :

PPIs bond and deactivate

Hf,K+-ATPase, or proton pumps, by crossing parietal cell membranes and accumulating in secretory canalicul omeprazole

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Antacids and Surface Agents :

Antacids neutralize gastric acid and are preferred for

the short-term relief of GER symptoms

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Prokinetic

Agents:

Prokinetic agents increase LES pressure, enhance esophageal peristalsis, and accelerate gastric emptying

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Surgical treatment

Indication:

Failure of medical therapy. In children who have continuing symptoms such as persistent pulmonary symptom. Presence of an associated anatomic defect such as a hiatal hernia. Neurologically impaired children who have difficulty feeding and have serious reflux as an associated symptom.

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contraindication

In some children, reflux is caused by gastric or intestinal motility disorders or by gastric outlet obstruction.

esophageal dysmotility disorders. In children with weak or uncoordinated peristalsis of the esophagus

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Surgical Techniques

Open Operative Techniques:

Nissen FundoplicationThal-Ashcraf FundoplicationToupet Fundoplication

Intervention

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Laparoscopic

Nissen

Fundoplication:Pyloroplasty or AntroplastyGastrostomy

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Post op

Some surgeons leave a

nasogastric tube in place or leave the G-tube to gravity until return of bowel function. This is not always done, particularly if a laparoscopic approach is used. The patient should be started on a clear liquid diet initially (either by mouth or feeding tube), then slowly transitioned to formula or soft solids

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Complication after operation:

Early complications

include retching, gas bloat dysphagia, atelectasis, pneumonia, wound infection, small-bowel obstruction due to adhesions, and delayed gastric emptying. Dysphagia may result from postoperative edema and spontaneously resolves.

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Late complications

include bowel obstruction and wrap failure, including wrap disruption, slipped wrap,

herniation of the wrap into the chest, or excessively tight wrap. Patients in whom the wrap fails typically present with dysphagia, retching, or recurrent reflux symptoms. In patients with suspected wrap failure, an upper GI barium study may help to evaluate the integrity and anatomy of the repair, and endoscopy may be used to diagnose recurrent or persistent esophagitis.

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Future

The future of

gastroesophageal reflux (GER) therapy includes several endoscopic therapies that are gaining favor in adult populations and that may replace surgery in some patients. These therapies include radiofrequency ablation (Stretta procedure), the injection of inert substances at the LES, and endoscopic gastroplication. In the Stretta

procedure, a catheter is used to deliver radiofrequency energy, creating thermal lesions deep to the mucosa at the GE

junctionFinally

, robot-assisted laparoscopic

fundoplication

in children has been reported with good results

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SUMMARY

GER is a common disorder in children and often requires surgical correction. GER in infants and children is more complex than adult GER. Failure of medical management and an inability to wean from

antireflux medications are the most common indications for the surgical treatment of reflux. A complete-wrap fundoplication appears to have better outcomes than partial-wrap fundoplication,although this contention is controversial. Postoperative

retching and recurrent GER are the most common and vexing complications of

antireflux

surgery.