GER : the involuntary passage of gastric

contents into the eshopaghus

Regurgitation : reflux dribbled efffortlessly
into or out of the mouth
Vomiting : forceful expulsion of
gastrointestinal contents into the
esophagus
3 months old infant with regurgitation 4-6
times a day
Sometimes through out from the nose
Weight gain is OK (normal growth)
Parenteral concern
Gastro Esophageal Reflux (GER)
9 months old infant with regurgitation 4-6
times a day since 3 months old
Refuse to feed
Sometimes with hematemesis
Failure to thrive
Gastro Esophageal Relux Disease (GERD)
6 years old child with sinusistis
Not response to standard treatment
Referring for esophageal PH monitoring
Related to gastroesopageal reflux
Good response to prokinetic drug

Spectrum of GERD
GER and GERD
Infant - Older Children - Adult
Frequen
cy
Of
Regurgit
ation
Age
0-3 mo
Age
4-6 mo
Age
&-3 mo
Age
10-12
mo
1-4
x/day
74% 65% 30% 4%
>4x/day 21% 10% 5% 0%
Problem
?
24% 18% 16% 4%
GER is a physiologic phenomena
Postprandial
Regurgitation occur everyday in 70%
infants aged 4 months and 25% of
parents considered as a problem
GER resolve spontaneously in 55% infants
at 10 months of age and 81% by the age
of 18 months
The peak onset of GER is at 1-4 months of
age
10% of GER in infants have complications
Incidence of GER in pemature babies is
higer
81% of premature infants with GER
experiencing episodic apnea
Infants Older child /
adolescent
- Feeding refusal
- Recurrent vomiting
- Poor weight gain
- Iritability Colic
- Apnea or apparent life
threatening event
(ALTE)
- Arching or head-tilting
(pseudo torticollis)
- Recurrent vomiting
- Heartburn
- Esophagitis
- Dysphagia
- Asthma
- Reccurent pneumonia
- Upper airway symptoms
(e.g : chronic cough,
hoarse voice)

Incompetense LES (lower esophageal
sphincter)
Delayed gastric emptying
Anatomic position of LES above the
diaphragma in infancy
Due to regurgitation respiratory symptom
Failure to thrive - recurrent cough, wheezing,
sinusitis - apnea, cyanotic spells
-stridor, hoarness
Due to esophagitis
Irritability Neurobehavioral symptom
Anorexia - abnormal posture and
movemen
Hematemesis - sandifer syndrome
melena
GER GERD
Regurgitation with normal
weight gain
No signs or symptoms of
esophagitis



No significant respiratory
symptom



No neurobehavioral
symptomps
Regurgitation with weight loss
or inadequate weight gain
persistent irritability, pain in
infants, dysphagia, food refusal,
hematemesis, melena, iron,
deficiency anemia
apnea and cyanosis, sleep
disturbance, wheezing or
stridor, aspiation or reccurent
pnemonia, chronic cough,
hoarseness
abnormal posturing, sandifers
syndrome
GER
Odynophagia
Heartburn
Esophagitis
Fundoplication
Diagnostic
procedure
Visceral
Hyperalgesia
Refuse to eat
Anorexia
Early satiety
Diagnosis is uncertain
Failure of conservative treatment
Suspect of complications
- failure to thrive
- esophagitis
- respiratory complication
- neurobehavioral symptom
Parenteral anxiety
Barium meal
Esophageal PH monitoring
Scintigraphy
Endoscopy and biopsy
Manometry
Bioelectric impedance monitoring
Gold standard
Frequency and duration of reflux
episode can be mesured
Correlation between reflux event and
episodic apnea
Chronic respiratory symptom infants can
be cause by freflux, even without
vomiting (silent gastroesophageal reflux)
To detect esophagitis
GER with atypical manifestation sucj as
neurobbehavioral symptom
Conservative treatment
Adequate burp
Thickening of formula
Hypoallergenic formula
positioning
Pharmacologic treatment
Prokinetic : cisapride (0.2 mg/kg/dose 3-
4 doses)
Acid supressor
- cimetidine (20-40 mg/kg/day 3-4 doses)
- ranitidine (4-8 mg/kg/day 2-3 doses)
- omeprazole (1-3 mg/kg/day 1-2 doses)
surgical intervention
fundoplication

Infection Intestinal obstruction
- otitis media - pyloric stenosis
- gastroenteritis - malrotation
- urinary tract infection - intussuception
- meningitis
non obstructive GI
disease
Drug and toxic - gastroesophageal reflux
Metabolic diseases - appendicitis
- gastritis
Hypertrophic pyloric stenosis
- same onset at 4 weeks old
- expulsive vomiting
- peristaltic wave
- abdonimal mass
- abdominal ultrasonography
Intestinal obstruction (anatomic defect)
- antral web, stenosis and malrotation
- barium meal
GER is a common symptom occur in
infants and usually resolve spontaneously
with age
Diagnostic evaluation has to be done in
pathologic GER to confirm the diagnosis
and complications, including barium
meal, esophageal PH monitoring and
endoscopy
Treatment follow stepwise approach,
starting fro conservative advice to
medical treatment
Surgical intervention (fundoplication)
reserve only for for cases failed to
optimal medical treatment