NR 602 Gastroesophageal Reflux Disease

NR 602 Gastroesophageal Reflux Disease

NR 602 Gastroesophageal Reflux Disease

Gastroesophageal Reflux Disease

Gastroesophageal reflux refers to the passage of gastric contents into the esophagus from the stomach through the LES. It is a normal physiologic process that occurs several times a day in healthy infants, children, and adults. “GERD is present when the reflux causes troublesome symptoms and or complications” (Vandenplas et?al, 2009, p 499). GERD is the most common esophageal disorder in children (Khan and Orenstein, 2011b).

The etiology of GERD is unclear and probably multifactorial. Inappropriate relaxation of the LES with failure to prevent gastric acid reflux into the esophagus, prolonged esophageal clearance of the gastric refluxate, and impaired esophageal mucosal barrier function are the likely causes of most GERD (Loots et?al, 2014). LES function usually is influenced by intraabdominal pressure, hormones, neurologic control, and age. Young infants have increased intraabdominal pressure because of their inability to sit upright. They can also regurgitate when they cough, cry, or strain. In healthy infants, regurgitation is highest in the first month of life (73%) and decreases to 50% by the fifth month of life. During the first 2 months of life, 20% of infants regurgitate more than four times per day. After 1 year old, less than 4% of infants regurgitate daily and nearly all resolve by 2 years old. Weight gain is less in infants who regurgitate more than four times per day and breastfed babies regurgitate less than formula-fed babies (Khan and Orenstein, 2011b).

Alterations in swallowing, pharyngeal coordination, esophageal motility, and delayed gastric emptying are also potential factors related to GERD. Increased muscle tone, chronic supine positioning, and altered GI motility exacerbate GERD. Helicobacter pylori has been associated with GERD. Children with H. pylori are about six times more likely to develop GERD than non–H. pylori-positive children. H. pylori has not been found in infants younger than 1 year old (Polat and Polat, 2012).

NR 602 Gastroesophageal Reflux Disease

The American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) states that 10% of infants younger than 1 year old with regurgitation develop significant complications (GERD) (AAO-HNS, 2011). Risk factors include prematurity, neurologic impairment, obesity, CF, hiatal hernia, and family history of GERD.

Clinical Findings

Common signs and symptoms by age that should lead the clinician to suspect GERD are found in Table 33-4; 845 although, according to the guidelines, there is no symptom or symptom complex that is diagnostic of GERD or predicts response to therapy. In older children and adolescents, history and physical examination may be sufficient to diagnose GERD. The most common symptom is “heartburn.” Recurrent regurgitation with or without vomiting, weight loss or poor weight gain, ruminative behavior, hematemesis, dysphagia, and respiratory disorders such as, wheezing, stridor, cough, apnea, hoarseness, and recurrent pneumonia are also associated with GERD.

Intussusception

Intussusception involves a section of intestine being pulled antegrade into adjacent intestine with the proximal bowel trapped in the distal segment. The invagination of bowel begins proximal to the ileocecal valve and is usually ileocolic, but it can be ileoileal or colocolic. Intussusception is 859thought to be the most frequent reason for intestinal obstruction in children. Intussusception most commonly occurs between 5 and 10 months of age and is also the most common cause of intestinal obstruction in children 3 months to 6 years old; 80% of the cases occur before 2 years of age. In younger infants, intussusception is generally idiopathic and responds to nonoperative approaches. In some children, there is a known medical predisposing factor, such as polyps, Meckel diverticulum, Henoch-Schönlein purpura, constipation, lymphomas, lipomas, parasites, rotavirus, adenovirus, and foreign bodies. Intussusception may also be a complication of CF. Children older than 3 years are more likely to have a lead point caused by polyps, lymphoma, Meckel diverticulum, or Henoch-Schönlein purpura; therefore, a cause must be investigated. The currently approved rotavirus vaccines have not been associated with an increased risk of intussusception (Kennedy and Liacouras, 2011). NR 602 Gastroesophageal Reflux Disease.

Clinical Findings

History

• The classic triad for intussusception, intermittent colicky (crampy) abdominal pain, vomiting, and bloody mucous stools, are present in fewer than 15% of cases (Kennedy and Liacouras, 2011):
• Paroxysmal, episodic abdominal pain with vomiting every 5 to 30 minutes. Vomiting is nonbilious initially. Some children do not have any pain.
• Screaming with drawing up of the legs with periods of calm, sleeping, or lethargy between episodes.
• Stool, possibly diarrhea in nature, with blood (“currant jelly”).
• A history of a URI is common.
• Lethargy is a common presenting symptom.
• Fever may or may not be present; can be a late sign of transmural gangrene and infarction.
• Severe prostration is possible.

Physical Examination

• Observe the baby’s appearance and behavior over a period of time; often the child appears glassy-eyed and groggy between episodes, almost as if sedated.
• A sausage-like mass may be felt in the RUQ of the abdomen with emptiness in the RLQ (Dance sign); observe the infant when quiet between spasms.
• The abdomen is often distended and tender to palpation.
• Grossly bloody or guaiac-positive stools.

Clinical Findings

History

• The classic triad for intussusception, intermittent colicky (crampy) abdominal pain, vomiting, and bloody mucous stools, are present in fewer than 15% of cases (Kennedy and Liacouras, 2011):
• Paroxysmal, episodic abdominal pain with vomiting every 5 to 30 minutes. Vomiting is nonbilious initially. Some children do not have any pain.
• Screaming with drawing up of the legs with periods of calm, sleeping, or lethargy between episodes.
• Stool, possibly diarrhea in nature, with blood (“currant jelly”).
• A history of a URI is common.
• Lethargy is a common presenting symptom.
• Fever may or may not be present; can be a late sign of transmural gangrene and infarction.
• Severe prostration is possible.

Physical Examination

• Observe the baby’s appearance and behavior over a period of time; often the child appears glassy-eyed and groggy between episodes, almost as if sedated.
• A sausage-like mass may be felt in the RUQ of the abdomen with emptiness in the RLQ (Dance sign); observe the infant when quiet between spasms.
• The abdomen is often distended and tender to palpation.
• Grossly bloody or guaiac-positive stools.

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Diagnostic Studies

• An abdominal flat-plate radiograph can appear normal, especially early in the course and reveal intussusceptions in only about 60% of cases (Fig. 33-5). A plain radiograph may show sparse or no intestinal gas or stool in the ascending colon with air-fluid levels and distension in the small bowel only.

Abdominal ultrasound is very accurate in detecting intussusception and is the test of choice (Ross and LeLeiko, 2010). It shows “target sign” and the “pseudo kidney” sign and can also be used to evaluate resolution following air contrast enema.

• An air contrast enema is both diagnostic and a treatment modality.

Differential Diagnosis

The differential diagnosis includes incarcerated hernia, testicular torsion, acute gastroenteritis, appendicitis, colic, and intestinal obstruction.

860 NR 602 Gastroesophageal Reflux Disease

Management

• Emergency management and consultation with a pediatric radiologist and a pediatric surgeon is recommended.
• Rehydration and stabilization of fluid status; gastric decompression.
• Radiologic reduction using a therapeutic air contrast enema under fluoroscopy is the gold standard.
• Surgery is necessary if perforation, peritonitis, or hypovolemic shock is suspected or radiologic reduction fails.
• IV antibiotics are often administered to cover potential intestinal perforation.
• A period of observation following radiologic reduction is recommended (12 to 18 hours); clear discharge instructions to return with any recurrence of symptoms are required, and close phone follow-up for up to 72 hours is prudent.

Complications

Swelling, hemorrhage, incarceration, and necrosis of the bowel requiring bowel resection may occur. Perforation, sepsis, shock, and re-intussusception (reported to typically be less than 10%, usually within 72 hours of radiologic reduction but can occur up to 36 months later) can all occur. Recurrence is associated with the lead points described earlier.