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Toronto Notes 2019 Gastroenterology Gastroesophageal Reflux
Epidemiology
• extremelycommonininfancy(upto50%)butrarelycausesGERD
Clinical Presentation
• vomitingtypicallysoonafterfeeding,non-bilious,rarelycontainsblood,smallvolume(<30mL)
■ when to suspect GERD, defined as when gastroesophageal reflux causes troublesome symptoms/
complications
◆ infant: poor weight gain, irritability, sleep disturbance, respiratory symptoms (coughing,
choking, wheezing)
◆ older child/adolescent: abdominal pain/heart burn, dysphagia, asthma, recurrent pneumonia/
upper respiratory infections, recurrent otitis media, upper airway symptoms (chronic cough, hoarseness), dental erosions
Investigations
• thrivingbabyrequiresnoinvestigation
• GERDcanbeaclinicaldiagnosisbutdiagnosticinvestigationsmayinclude
■ upper GI tract radiography – assesses anatomy and motility disorder
■ esophageal pH – quantify GER
■ upper endoscopy and esophageal biopsy – rule out other conditions that mimic GERD symptoms,
assess GERD-related esophageal injury
■ warning signs of associated disorders requiring further investigations: bilious vomiting, GI tract
bleeding, consistently forceful vomiting, fever, lethargy, hepatosplenomegaly, buging fontanelle, micro/macrocephaly, seizures, abdominal tenderness/distension, suspected genetic, metabolic syndrome or chronic disease
Management
• conservative(infant):thickenedfeeds,frequentandsmallerfeeds,elevationofhead,changingformula to hydrolyzed protein or amino acid based formula
■ breastfeeding infants – mothers exclude milk and egg in diet
■ older children/adolescent – same as adult management
• medical
■ short-term parenteral feeding to enhance weight gain
■ ranitidine, PPI: decreases gastric acidity, decreases esophageal irritation
■ domperidone, metoclopramide: improves gastric emptying and GI motility; safety concerns and
limited efficacy, should be reserved for children with gastroparesis contributing to GERD
• surgical:indicatedforfailureofmedicaltherapy(Nissenfundoplication)
Complications
• esophagitis,strictures,Barrett’sesophagus,FTT,aspiration,oralfeedingaversion
Tracheoesophageal Fistula
• seeGeneralSurgery,GS64 Pyloric Stenosis
• seeGeneralSurgery,GS62 Duodenal Atresia
• seeGeneralSurgery,GS63
Malrotation of the Intestine
• seeGeneralSurgery,GS63 Diarrhea
• definition of diarrhea varies with diet and age (stool normalcy difficult to define in children)
• infants→increaseinstoolfrequencytotwiceasoftenperday;olderchildren→3+looseorwatery
stools/d
• duration:acute:<2wk;chronic:>2wk
Pathophysiology
• osmotic:duetonon-absorbablesolutesinGItract(e.g.lactoseintolerance)
• secretory: increased secretion of Cl– ions and water in intestinal lumen (e.g. bacterial toxin)
• malabsorption:lesstimeforabsorptionduetoincreasedmotilityorlessvillitoabsorb(e.g.shortbowel
Pediatrics P35
Diarrhea is defined as an increase in frequency and/or decreased consistency of stools compared to normal
Normal stool volume Infants: 5-10 g/kg/d Children: 200 g/d
Diarrhea Red Flags
Bloody stool, fever, petechiae or purpura, signs of severe dehydration, weight loss/FTT
syndrome)