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1、Gastroesophageal reflux in children,浙江大学医学院附属儿童医院 江米足,Definition of GER or GERD,GER: means involuntary passage of gastric contents into the esophagus and is often physiological. GERD: means symptoms or complications associated with pathological GER.,Hassall E. Arch Dis Child 2005,Prevalence,USA: 3-9
2、 y:566 cases, 1.8% 10-17 y:615 cases, 3.5% Adults (18 y):22% The prevalence of GERD slowly increases with age during childhood and becomes quite frequent among young adults.,Nelson SP, et al. Arch Pediatr Adolesc Med 2000,Prevalence,Australia:863 infants 3-4m(41%) 13-14m(5%),India:602 infants 1-6m(5
3、5%) 7-12m(15%) 12-24m(10%) Italy:2642 infants 0-12m (12%),Martin AJ, et al. Pediatrics 2002 Campanozzi A et al. Pediatrics 2009 De S, et al. Trop Gastroenterol 2001,Prevalence,GER is frequently seen in early infancy and it almost disappears by one year of age. Persistence or appearance of regurgitat
4、ion beyond 18 months of age is suggestive of pathological condition. The prevalence of GERD in infancy is 5%-9% of all infants with regurgitation.,Poddar U. Indian Pediatr 2013,Risk factors of GER,Poor function of LES (pressure and length) Esophageal dysmotility resulting in reduced clearance Abnorm
5、al anatomy-including congenital malformation (short intra-abdominal esophagus) or acquired disease (esophageal atresia repair) Higher intra-gastric pressure and delayed gastric emptying,Liu XL, et al. Hong Kong Med J 2012,Mechanisms,Closing mechanisms The diaphragm creates a pinch cork action and fu
6、nctions to increase the pressure The intra-abdominal portion of the esophagus The angle of His between the stomach and the esophagus Opening mechanisms Increased intra-abdominal pressure (from abdominal tumours, coughing, and constipation) increases intra-gastric pressure,Liu XL, et al. Hong Kong Me
7、d J 2012,TLESR,Omari TI, et al. Gut 2002,TLESR is the predominant mechanism of GER triggering, accounting for 50-100% (median 91.5%) of all GER episodes.,Clinical symptoms of GER,Clinical features of GER vary in children of different ages. Typical symptoms Regurgitation Vomiting Heartburn Chest pain
8、 Atypical symptoms Feeding difficulties/anorexia Failure to thrive Postural defect Stridor Chronic cough Laryngitis, otitis Asthma sinusitis,Martigne L, et al. Eur J Pediatr 2012,Yuksel ES, et al. Eur J Med Sci 2010,Presenting symptoms,Regurgitation or vomiting Healthy: no failure to thrive or other
9、 associated symptoms Infants with GERD Growth failure or indirect symptoms of pain due to esophagitis like irritability, feeding difficulty, sleeping difficulties, crying episodes, anemia Rarely apnea or ALTE Chronic respiratory diseases and upper airway problems like sinusitis, otitis media, laryng
10、itis, dental erosion In children and adolescents, symptoms and complications of GERD are heartburn or substernal pain,Diagnostic test,Esophageal pH monitoring Multichannel intraluminal impedance (MII) measurement High resolution manometry (HRM) Endoscopy Confocal laser endomicroscopy Barium UGI seri
11、es Nuclear scintigraphy GER questionnaire Rome III criteria,Esophageal pH monitoring,To establish the presence of acidic reflux (pH4) To quantify reflux in patients with mainly extra-esophageal symptoms To assess the efficacy of medical therapy To measure GER in patients not responding to antireflux
12、 treatment and in research,24 hr ambularoty pH-metry,Parameters of pH monitoring,Percent total time with a pH4.0 (reflux index, RI) Percent upright time with a pH4.0 Percent supine time with a pH7% as abnormal, 11.99 Demeester score 14.72,Van der Pol RJ, et al. J Pediatrics 2012 Vandenplas Y, et al.
13、 J Pediatr Gastroenterol Nutr 2009 Mattioli G, et al. Dig Dis Sci 2006 Aggarwal S, et al.Trop Gastroenterol 2004 Wenzl TG. J Pediatr Gastroenterol Nutr 2011,Esophageal pH monitoring,Advantages Be done in any age Be relatively non-invasive Disadvantage Does not measure non-acid or weakly acidic reflu
14、x,Multichannel intraluminal-impedance (MII) measurement,To detect the change in electrical resistance (or impedance) when substances pass through the esophagus using a series of impedance sensors lying 1 cm apart on a probe Impedance is inversely proportional to electrical conductivity Since the con
15、ductivity of liquid (high) and air (low) is different, MII can easily differentiate liquid from gas reflux,Wenzl TG, et al. J Pediatr Gastroenterol Nutr 2012,Wenzl TG, et al. J Pediatr Gastroenterol Nutr 2012,Advantages of MII-pH monitoring,Be superior to pH-study alone for evaluation of GER-related symptom association Picking up acid, non-acid or weakly acid reflux, the direction of reflux To distinguish between liquid, solid and gas reflux in all age groups,Limitations of MII-pH study,
