gerd-
TRANSCRIPT
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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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