1. Baby with vomiting, when to worry

2. Overview What is reflux Primary and secondary reflux
What is normal reflux
Red flags
Treatment of reflux EE

3. What is gastroesophageal reflux ?
PASSIVE movement of stomach contents into the oesophagus
A SYMPTOM

5. Why do we reflux ?
Gastric pressure exceeds
LES pressure

6. What is reflux a symptom of ?
Short intra-abdominal oesophagus
Lax LES
TLESR
pre-term infants
allergy / inflammation
Disabled
 Gastric compliance
Airways obstruction

8. Primary v Secondary Reflux
Short intra-abdominal esophagus
Lax LES
TLESR
pre-term infants
Disabled

9. Primary v Secondary Reflux
Reduced stomach compliance
Food allergy
Inflammation
Mechanical obstruction
Malrotation
TLESR
Sliding Hiatus hernia
Airway obstruction

10. Gastroesophageal Reflux
Associated feeding problems
Pain with or after feeding
Association of pain/discomfort with food
Loss of interest in food

17. Most infantile GER is not pathological
>20% infants “regurgitate excessively”
~7% infants brought to medical retention
80% resolve with little/no Rx and no investigation

18. GER
Normal
Pathological

19. Warning signals Irritability Poor feeding Bile stained vomiting
Retching
Hematemesis
Onset > 6 months of age
Failure to thrive
Recurrent aspiration pneumonitis
ALTEs
Lethargy
Neurological abnormality
Abdominal distension
Dysmorphic syndrome / chromosomal anomaly

22. Conditions Mimicking GER
eosinophillic oesophagitis
Anatomical problems
hypertrophic pyloric stenosis / annular pancreas / duodenal web
achalasia
Upper gut dysmotility
Rumination

23. When to suspect food allergy as a cause of vomiting?
Other atopy FH
Change in feeds
Immune dysregulation

24. Diagnosis of gastroesophageal reflux
IF appropriate:
Ascertain the severity
Define the cause
Delineate complications

25. Investigation order
None
Symptoms guided

26. Gastrooesophageal reflux
What investigations:
Upper gut contrast
For anatomy
24 hours pH vs Impedance
Inflammation
Gastric compliance
Milk scan
Electogastrography
Motor activity
Manometry

33. Ambulatory pH catheter placement.33

34. Ambulatory pH monitoring tracings.34

35. Combined multichannel intraluminal impedance and pH catheter.35

36. Impedance changes produced by liquid, mixed, or gas boluses.36

37. GI Motility online (May 2006) | doi:10.1038/gimo31
Gastroesophageal reflux detected by combined multichannel intraluminal impedance and pH (MII-pH) monitoring.
GI Motility online (May 2006) | doi: /gimo31 37

43. Suggested diagnostic gastroesophageal reflux disease (GERD) algorithm.43

44. Management of GER
Treat the cause !
(If it’s indicated)

45. Management of uncomplicated GER (1)
Simple measures:
Position
Feed frequency / volume
Milk thickening / pre-thickened milks
if unresponsive
Acid suppressants

46. Management of GER (2) If unresponsive to simple measures / PPI
Investigate
Define foregut anatomy (Ba study)
Determine severity – 24 h pH/impedance study
EGD & mucosal biopsy - oesophagus and duodenum
?Prokinetics and acid suppressants
+/- Dietary manipulation

47. Management of GER (3) Transpyloric feeding – NJ / GJ Surgery
Refractory to medical treatments
Complicated GOR
Failure to thrive
Pulmonary aspiration
Refractory esophagitis
ALTEs
Other approaches
Novel pharmacotherapy - Baclofen

48. Nissens fundoplication
gastric volume   compliance
extrinsic denervation   compliance
Retching

49. Eosinophilic Esophagitis
Any age
Vomiting
Upper abdominal pain
Dysphagia
Respiratory symptoms
Seasonal variations

51. Treatment of EE Diet exclusion Montelukast Swallowed inhaled steroids
AA formula
Montelukast
Swallowed inhaled steroids
Budesonide paste
Systemic steroids
Immune modulators
?? Anti IL-5