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GERD-pedi-slides-050223 - GERD and Aspiration in the GERD...

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Unformatted text preview: GERD and Aspiration in the GERD Child and Infant Child Diagnosis and Treatment Jacques Peltier, MD Francis B Quinn, MD UTMB Dept of Otolaryngology February 2005 Anatomy and Physiology Anatomy Swallowing reflex begins at 16 weeks gestation Can suckle by 2nd to 3rd trimester 34 weeks, infant can suckle and feed normally Pharyngeal phase earlier developed Oral preparatory phase maldeveloped in premature infants Anatomy and Physiology Anatomy Infant larynx at C2­C3 Adult larynx at C5­C7 At 4 months, enlargement of oropharynx, descent of larynx causes dysphagia Chewing begins at 6 months 40% efficacy of chewing at 6 years Anatomy and Physiology Anatomy Swallow divided into 4 phases Oral preparatory phase Oral transport phase Pharyngeal phase Esophageal phase Anatomy and Physiology Anatomy Oral preparatory phase Suckle in infant, mastication in child and adult Soft palate meets base of tongue and epiglottis allowing breathing during suckle Oral transport phase Anterior tongue propels bolus back to oropharynx Anatomy and Physiology Anatomy Pharyngeal phase Vocal folds close Arytenoid cartilages tilt up and forward Base of tongue moves posteriorly Epiglottis moves posteriorly Soft palate closes off nasopharynx Larynx elevates, cricopharyngeal muscle relaxes Anatomy and Physiology Anatomy Esophageal phase Peristalsis moves food to stomach Lower esophageal sphincter relaxes Upper esophageal sphincter, Lower esophageal sphincter constrict preventing reflux Anatomy and Physiology Anatomy Cough reflex Present in 25% of children less than 5 days old Tactile receptors present at highest concentrations at larynx and bifurcations of airway C­fiber receptors respond to chemical stimuli Stretch receptors present in bronchioles Gastroesophageal Reflux Disease Gastroesophageal Gastroesophageal Reflux Disease Gastroesophageal Gastroesophageal Reflux (GER) Reflux of gastric contents into esophagus Normal physiologic process 50% of infants 0­3 months of age 25% of infants 3­6 months of age 5% of infants 10­12 months of age 20% of pH probe reflux episodes are visible reflux Result of Transient LES relaxations Gastroesophageal Reflux Disease Gastroesophageal Symptoms Weight loss or poor weight gain Irritability Frequent regurgitation Heartburn or Chest pain Hematemesis Dysphagia Gastroesophageal Reflux Disease Gastroesophageal Symptoms Feeding refusal Apnea Wheezing or stridor Hoarseness Cough Abnormal Neck posturing (Sandifer syndrome) often confused with seizures Gastroesophageal Reflux Disease Gastroesophageal Findings Esophagitis Esophageal stricture Barrett’s esophagus Laryngitis Hypoproteinemia Anemia Gastroesophageal Reflux Disease Gastroesophageal Associations Reactive airway disease Recurrent stridor Chronic cough Recurrent pneumonia ALTE SIDS Gastroesophageal Reflux Disease Gastroesophageal Diagnosis History and physical No studies comparing H&P to diagnostic tests. Two pediatric studies – no relationship between symptoms and the presence of esophagitis Still recognized by all as the first line in diagnosis Gastroesophageal Reflux Disease Gastroesophageal Barium Swallow Useful to detect anatomic abnormalities Not sensitive (31­86%), not specific (21­83%) when compared to pH probe monitoring Not physiologic Snapshot of time (High false positive, false negative) Gastroesophageal Reflux Disease Gastroesophageal Scintigraphy Technetium­labeled formula or food Stomach, esophagus, lungs scanned Good for gastric emptying, aspiration Scan for 1 hour, then 24 hours later Sensitivity 15% to 59%, specificity 83% to 100% when compared to pH probe monitoring Role in diagnosis of GERD is unclear Gastroesophageal Reflux Disease Gastroesophageal Endoscopy and biopsy Can identify esophagitis, stricture, Barrett’s esophagus, Crohn’s disease, webs, infectious esophagitis 40% of normal appearing biopsy sites show signs of esophagitis Eosinophils and neutrophils not present in esophageal epithelium of children, and their presence suggests inflammation. Gastroesophageal Reflux Disease Gastroesophageal Esophageal pH Monitoring Transnasal placement of electrode into distal esophagus, +/­ proximal esophagus, +/­ above the UES Acid reflux episode pH <4 for 15­30 seconds 12­24 hour studies recommended Gastroesophageal Reflux Disease Gastroesophageal Esophageal pH Monitoring Normal reflux in 0­11 month old children 31 reflux episode +/­ 21, 73 upper limit Reflux greater than 5 minutes 9.7 infants, 6.8 children, 3.2 in adults Reflux index (% time spent below pH of 4) 11.7% in infants, 5.4% in children, 6% in adults Symptom index > 0.5 abnormal (Number of symptoms with reflux/number of reflux episodes) Gastroesophageal Reflux Disease Gastroesophageal Esophageal pH Monitoring 60% of patients with poorly controlled asthma have abnormal pH probe studies Correlate well with esophageal biopsies Considered gold standard Unclear whether proximal and distal probes more effective than one distal probe Gastroesophageal Reflux Disease Gastroesophageal Treatment Goals Relieve patient’s symptoms Promote normal weight gain and growth Heal inflammation Prevent respiratory symptoms Prevent complications Gastroesophageal Reflux Disease Gastroesophageal Lifestyle changes Children with milk allergy benefit from hypoallergenic formula (1­2 week trial) Thickening does not change number of reflux episodes, does decrease vomiting Studies show decreased numbers of reflux episodes in prone position at night 8%­24% Conflicting evidence regarding reflux in children placed prone 30 degrees vs. prone flat Gastroesophageal Reflux Disease Gastroesophageal Prone vs. Supine Several studies have shown increased incidence of SIDS with prone position (Relative risk 13.9, 4.4/1000 vs. 0.1/1000) Prone positioning postprandial period while awake Prone positioning when child with life threatening complications of GERD Otherwise, supine positioning Gastroesophageal Reflux Disease Gastroesophageal Medical treatment H2 receptor blockers Numerous studies in adults showing superiority over placebo Several studies in children showing superior improvement of pathology over placebo Side effects include rash, dizziness, nausea, vomiting, blood dyscrasias No clear superior agent in class Gastroesophageal Reflux Disease Gastroesophageal Proton pump inhibitors Best if given ½ hour prior to breakfast, ½ hour before evening meal Takes several days for a steady state acid suppression One study showed similar efficacy of omeprazole and high dose ranitidine in children One study showed increased efficacy of omeprazole over ranitidine in severe esophagitis Prevacid FDA approved for 1 ­17 years old Gastroesophageal Reflux Disease Gastroesophageal Antacids Neutralize gastric acid Magnesium hydroxide and aluminum hydroxide as effective as cimetidine in treatment of esophagitis High doses lead to near toxic aluminum levels Not recommended for treatment over 2 weeks Gastroesophageal Reflux Disease Gastroesophageal Prokinetic Therapy Increase LES pressure, no effect on transient relaxations Double blind single drug studies for cisapride, metoclopramide, bethanecol, and domperidone have been done, with cisapride the only agent better than placebo Cisapride off market due to potential cardiac arrhythmias. Available only for severe cases Gastroesophageal Reflux Disease Gastroesophageal Surface agents Sodium alginate ­ forms surface gel that decreases reflux and protects mucosa. Conflicting results from studies, not available in US Sucralfate ­ adheres to peptic lesions. One study available states as effective as cimetidine for treatment of esophagitis. Aluminum compound…toxicity Gastroesophageal Reflux Disease Gastroesophageal Surgical Options Nissen fundoplication +/­ pyloroplasty Success rates from 57%­92% reported Complications from 2.2%­45% Breakdown of wrap, small bowel obstruction, infection, atelectasis, pneumonia, perforation, esophageal obstruction No difference in laproscopic vs. open except in length of stay Gastroesophageal Reflux Disease Gastroesophageal Surgical Consider when maximal medical therapy fails Should be combined with G­tube when aspiration a concern Most effective treatment Highest risk Aspiration Aspiration Penetration of secretions below the level of the true vocal cords Direct aspiration – oral secretions, feeding Indirect aspiration – from refluxed contents Most commonly a result of neurological compromise Aspiration Aspiration Risk factors CNS disease Prematurity Mechanical factors (NG tube, endotracheal tube, tracheostomy tube) Anatomical defects (esophageal atresia, stricture, vascular rings, TE fistula) Intestinal motility disorders Aspiration Aspiration Complications Tracheitis Bronchitis Bronchospasm Reactive airway disease Pneumonia Pulmonary abscess SIDS? Aspiration Aspiration Cerebral palsy, epilepsy, intestinal motility disorders high risk for aspiration pneumonia (41%, 36%, 15%) Nasopharyngeal reflux associated with aspiration 83% of children with ALTE’s had evidence of Nasopharyngeal reflux (Kohda) Aspiration Aspiration Symptoms Cough or choking during feeds Vomiting with choke Nocturnal cough Recurrent stridor Hoarseness Multiple apneas Aspiration Aspiration Signs Dysmorphic features Hoarse or weak cry Wheezing Pooling of secretions in piriforms, valleculae Other Head and neck anomalies Aspiration Aspiration Diagnosis Upper GI series Scintigraphy 24 hour pH probe Dual pH probe measurements Endoscopy (TE fistula, laryngeal cleft, signs of reflux, other anomalies) Aspiration Aspiration Lipid­laden alveolar macrophage BAL obtained during bronchoscopy 100 macrophages stained with oil red to identify intracellular lipid Score greater than 70 diagnostic of aspiration Sensitivity and Specificity of 80 and 85% Aspiration Aspiration Modified barium swallow Identifies anatomic anomalies Identifies NP reflux, laryngeal penetration Speech pathologist can evaluate different food consistencies Expensive equipment Cannot do bedside exams Aspiration Aspiration Functional Endoscopic Evaluation of Swallowing (FEES) Evaluation of swallowing with scope just above larynx Different foods stained Look for penetration, pooling May test different consistencies Good test when visualization of larynx necessary Aspiration Aspiration FEES vs. MBS Similar costs Similar efficacy in children and adults Most studies showed no difference in outcome when either modality chosen Use FEES when upper aerodigestive anomaly suspected Use MBS when esophageal anomaly suspected Use MBS in children 3­8 FEES vs. MBS FEES Aspiration Aspiration Treatment Maximal treatment of GERD 1st line, both medical and surgical Vocal cord paralysis treated with medialization Tracheostomy for pulmonary toilet Pulmonary toilet vs. increased aspiration Aspiration Aspiration Major surgical options Epiglottic flap closure Glottic closure Narrow field laryngectomy (rarely indicated) Tracheoesophageal diversion Laryngotracheal separation Epiglottic Flap Closure Epiglottic Glottic Closure Glottic Tracheoesophageal Diversion and Laryngotracheal Separation Laryngotracheal ...
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