Gerd

GOOD MORNING
T
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GASTRO ESOPHAGEAL
REFLUX DISEASE (GERD)
Gastro esophageal reflux (GER)
 Transfer of gastric contents into the esophagus.

 This is physiologic, occurring throughout the
day.
 50% of infants < 2 months old are reported to
have GER
 This resolves spontaneously by 1 yr of age.
 GER becomes a disease when complications
occur.
GERD (reflux, acid reflux, reflux esophagitis,
acid regurgitation, and heartburn.)
What is GERD?
• Gastroesophageal reflux disease (GERD):
is a term used to collectively describe the
problems and symptoms that occur when
acid from the stomach washes up into the
esophagus.
•This can lead to inflammation and
irritation of the lining of the esophagus as
well as causing the typical symptoms that
are generally associated with GERD or acid
Predisposing factors
Neurologic impairment
Physiological immaturity
Hiatal hernia
Repaired esophageal atresia
Morbid obesity
Cerebral defects
Increased abdominal pressure
Obesity
Associated conditions causes GERD:
 Supine position
 Coughing
 Wheezing
 Bronchopulmonary dysplasia
 Asthma
 Indwelling orogastric or nasogastric
tube
 Medications like theophilline
 Mechanical ventilations.
Etiopathology
 A complex interaction of many problems can

cause reflux:
 Esophageal Dysmotility
weak or uncoordinated esophageal contraction,
 Inadequate saliva production
Seen during sleep. Saliva normally “buffers” any
acid which is found in the esophagus.
 Impaired resistance of esophageal Lining
Defective protection of the esophagus against acid by
the cells which make up the lining of the esophagus
 LES dysfunction
Poorly functioning sphincter muscle (gate between
stomach and esophagus) allowing acid to wash up
into the esophagus
 Delayed emptying of the stomach
Poor motor function of the stomach (not draining into
the intestine) allowing acid to “pool” in the stomach.
 Hiatal hernia
Allows acid to wash up into the esophagus due to
pressure differences between the abdomen and
chest.
CLINICAL PRESENTATIONS OF GERD
 Classic GERD
 Extraesophageal/Atypical GERD
 Complicated GERD
Extra esophageal GERD
Symptoms of Complicated GERD
 Dysphagia
 Difficulty swallowing: food sticks or hangs up
 Odynophagia
 Retrosternal pain with swallowing
 Bleeding
Clinical manifestations
 Symptoms in infant
 Sitting up
 Regurgitation
 Vomiting (may be forcefull)
 Excessive cry
 Irritability
 Arching of the back
 Stiffening
 Weight loss
 FTT
 Respiratory problems
 Cough
 Wheeze
 Stridor
 Gagging
 Chocking with feeding
 Hematemesis
 Apnoea
 Symptoms in children
 Heart burn
 Abdominal pain
 Noncardiac chest pain
 Chronic cough
 Dysphagia
 Nocturnal asthma
 Reccurrent pneumonoa
 Abnormal Neck posturing (Sandifer syndrome)
often confused with seizures
Complications
 Esophagitis
 Esophageal stricture
 Laryngitis
 Reccurrent pneumonia
 Anemia
 Barrett’s esophagus
Barrett’s esophagus
Clinical Presentations of GERD
 Classic GERD
 Extraesophageal/Atypical GERD
 Complicated GERD
 Diagnosis of GERD
 History collection & Physical examination
 Feeding behavior
 Presenting signs and symptoms
 Frequency and characteristics of emesis
 Behavior and respiratory symptoms
 Time at which they occur and any associated
events
 Assessment of growth and nutritional status.
Barium swallow
 To detect anatomic abnormalities
 To observe for reflux following swallowing.
 The upper GI series is important to exclude
other anatomic obstructions, such as
esophageal, gastric or duodenal web, pyloric
mass, or malrotation.
Esophageal pH monitoring
 A probe is placed through the nose down to the distal
esophagus and connected to a pH monitoring device.
 A 24-hour pH probe study provides information regarding
 Frequency of acid reflux
 the amount of time there is acid in the distal esophagus
 the time it takes for the acid to be cleared from the
esophagus.
 The effects of feeding, positioning, sleep and other events on
GER can be determined.
 A pH probe study can be done simultaneous with a
cardiorespiratoy recording monitor to address the
relationship of GER and respiratory symptoms such as apnea.
Endoscopy
 Endoscopy may be performed when GFR is
suspected to assess whether esophagitis is
present.
 The esophagus is examined visually for evidence
of inflammation or ulceration.
 Mucosal biopsies are obtained
Scintigraphic study
 During Scintigraphic studies a

radionuclide (Technetium) is added to
the infant’s formula, and a gamma
counter detects the presence of formula
refluxed to the esophagus of lungs by
scanning for 1 hour and 24 hours later.
 It is a useful tool for assessing delayed
gastric emptying, which may contribute
to GER.
Therapeutic management
 Positioning:-It helps to reduce the amount of
reflux.
 Infants younger than 6 months should be placed
on right lateral position during sleep. Head of the
crib should be raised at least 6 inches.
 The infant may also be held upright.
 Older children should be placed in head
raised to 30-45 angle position.
 Avoid recumbent position after meal for at
least 3 hours.
 Upright of semi upright position during
awaking is helpful.
 Feeding:-
 Infantsto be given thickened feed in small amount
frequently followed by appropriate positioning,
and frequent burping are generally accepted to
prevent the reflux.
 Feeding is thickened with 1 table spoon of rice
cereal per 6 ounces of formula may be
recommended as an initial measure to manage
GER.
 Older children should be allowed nothing per
mouth 2 hours before bed time.
AVOID
 Fat rich diet
 Spicy and acidic foods(onion, citrus products, apple
juice, tomato)
 Esophageal irritants (chocolate, peppermint, passive
smoke)
 Carbonated beverages.
 Obesity
 Tight or constricting clothing at night
Chewing gum can be allowed to stimulate parotid
secretions which increase esophageal clearance.
Medications:-
 Antacids or H2 receptor antagonists :
 H2 receptor antagonists are used to reduce the
amount of acid present in gastric contents and
it prevent esophagitis.
 Eg:- Ranitidine, cimetidine
 Side effects include rash, dizziness, nausea,
vomiting.
Proton pump inhibitors
2.Proton pump inhibitors
 Prevent the acid secretion by blocking the proton
pump in the parietal cells of the gastric mucosa.
 The drug binds to the hydrogen-potassium ATPase
enzyme. This enzyme also known as the proton pump
is necessary for the last step in the gastric acid
secretion process.
 If the enzyme is bound by omeprazole, new enzyme
must be synthesized before acid secretion can occur.
This takes approximately 72 hours.
 Eg:-Omeprasole
 Best if given ½ hour prior to breakfast, ½
hour before evening meal
 Side effects of omeprazole include-
 GIT: (Diarrhea, vomiting, constipation and
abdominal pain.)
 CNS: (Headache and dizziness)
Prokinetic Therapy
Metachlorpramide is used to increase resting LES

pressure and the rate of gastric emptying.
 No effect on transient relaxations.
 Most useful in treatment of children with GER
accompanied by delayed gastric emptying.
 Side effects includes:
 Restlessness,drowsiness, and extrapyramidal reactions,
Cisapride is used to increase the LES pressure, promotes
gastric emptying, and has fewer central nervous system
side effects than metachlorpamide.
 Side effects includes cardiac arrhythmias.
Bethanechol has also been shown to greatly
increase LES pressure, but it has not been
proved to decrease the reflux by pH probe
studies.
 Side effects include respiratory symptoms
such as wheezing.
Surgical management: nissen fundoplication
 Nissen fundoplication
 It restore competence to the LES.
 In a fundoplication the gastric fundus of the stomach
is wrapped around the lower end of the esophagus
and stitched in place, reinforcing the closing
function of the LES.
 Whenever stomach contracts it also closes of the
esophagus instead of squeezing stomach acids into it.
 The fundal wrap also decreases the diameter of the
distal esophagus and increases the opening pressure
necessary to initiate reflux.
Complications of nissen fundoplication
 Gas bloat syndrome

 Dysphagia
 Dumping syndrome (this is a condition where
the ingested food bypass the stomach too
rapidly mostly undigested.)
 Excessive scarring
 Achalasia
 Gastrostomy is usually performed at the same
time for decompression of the stomach
postoperatively.
 Fundoplication combined with
pyeloroplasty may be performed in children
with GER who also have delayed gasric
emptying.
Stretta procedure
 Endoscopic procedure
for the treatment of
GERD.
 A catheter is used to
deliver radio frequency
energy to the lower
esophagal spincter
muscle and gastric
cardia.
Transoral flexible Endoscopic suturing
 Also callled Bard’s procedure.
 Uses a tiny device at the end of the
enodoscope which works like a mini sewing
machiene.
 It sutures stitches near the lower esophagal
spincter, which tighten the valve and prevent
reflux.
Nursing management
 (1) identifying children with symptoms

suggestive of GER:
 (2) educating parents regarding home care;
including feeding, positioning and
medications when indicated: and
 (3) if appropriate, caring for the child
undergoing surgical intervention.
POSSIBLE NURSING DIAGNOSIS FOR
GERD
 1. Imbalanced nutrition less than body requirements related
to less intake of food secondary to regurgitation of gastric
contents.
 2. fluid volume deficit related to vomiting secondary to GERD.
 3. Parental anxiety related to child’s condition/ chronic
hospitalisation.
 4. Parental Knowledge deficit regarding care of the child with
GERD.
 5. pain related to surgical procedure.
 6. ineffective family process related to child with a physical
defect, hospitalisation.
 Risk for infection related to surgical procedure.
THANK
YOU

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GOOD MORNING

 Transfer of gastric contents into the esophagus.

 A complex interaction of many problems can

 During Scintigraphic studies a

Metachlorpramide is used to increase resting LES

 Gas bloat syndrome

 (1) identifying children with symptoms

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