Gastroesophageal Reflux

Question 1

Mechanism of GER?

Answer 1

Transient lower eso sphincter relaxation (TLESR) –> accounts for 90%

1.Not associated with swallowing or eso peristalisis
2. Increase with gastric distension
3. LES relaxation mediated vagally via brainstem

Note: N pressure btw 10-30mmHg and NOT LOW most GERD patients

Question 2

age of peak GER and resolution

Answer 2

peak: 4-6 mo

<20% have GER 12-15 mo

> 2 years–> unlikely to resolve

Question 3

Extra-esophageal association of GERD

Answer 3

1. sinusitis
2. laryngitis
3. chronic cough
4. pneumonia/bronchiectasis
5. dental erosions
6. irritability

NOT associated with ALTE

Question 4

Pediatric population at risk of chronic GERD?

Answer 4

1. neurological disorders
2. obesity
3. EA/TEF post repair
4. Hiatal hernia
5. achalasia
6. obesity
7. CF
8. Post lung transplantation

Question 5

Testing for reflux, what would you order?

Answer 5

1. UGI contrast study–> r/o anatomic abnormalities
2. pH meter
3. Multichannel intra-luminal impedance (pH-MII)
4. Manometry –> assess for achalasia vs rumination
5. EGD + Biopsy
6. nuclear scintigraphy –> not recommended, but may detect GERD mimickers

Question 6

Role of pH-MII?

Answer 6

-Check if sx related to acid reflux
-Better than pH meter in patients with continuous feeds and max meds
-No normative peds data
-Add PSG to check if GERD causing apneas/ALTE

Question 7

Role of pH meter?

Answer 7

-assess efficacy of anti-acids
-differentiates btw eosinophilic vs erosive esophagitis

Question 8

Life style modifications in infants?

Answer 8

1. Trial of extensively hydrolyzed formula (2-4) wk
2. Thicken feeds (dec regurg but not reflux)
3. prone position (dec reflux but inc SIDS)
4. Lt sided superior to Rt side position

Question 9

Life style modifications in adolescents?

Answer 9

1. NO evidence for food elimination
2. WT loss in obesity
3. Avoid late night meals
4. Lt sided superior to Rt side position

Question 10

Risks of PPI?

Answer 10

• inc resp and GI infections
• hip/spine fractures
• IDA
• hypomagnesemia

Question 11

Indications for fundoplication?

Answer 11

-Severe GERD unresponsive to PPI
-Failure, dependancy, non-adherance on medical therapy
- recurrent aspiration
- recurrent GIB

Question 12

side effects of fundoplication?

Answer 12

1. gas bloating syndrome
2. dysphagia
3. pooling of secretions –> aspiration/retching
4. failure and need for redo

Question 13

what is Barrett’s esophagus?

Answer 13

Change for normal squamous cell epithelium with metaplasic columnar epithelium

Increase risk of adenocarcinoma
Adults: risk from high grade dysplasia to CA 6%

Question 14

Adult screening for barrett’s ?

Answer 14

No dysplasia –> e 3-5 yr
Low grade dysplasia –> e 6- 12 mo
High grade dysplasia –> e 3 mo

Evaluation: light endoscopy + 4 quadrants biopsy every 2cm and e 1c with dysplasia