Beruflich Dokumente
Kultur Dokumente
04/10/2013
Regurgitation
04/10/2013 2
Vomiting
Forceful expulsion of gastrointestinal contents through the mouth
04/10/2013
Gastroesophageal reflux
the involuntary passage of gastric contents into the esophagus
Regurgitation
reflux dribles effortlessly into or out of the mouth
04/10/2013
04/10/2013
S.motorik somatik
Saraf enterik pl. mienterikus asetil kolin pl. submukosa pleksus mienterikus
motilitas sal.cerna S.motorik somatik
04/10/2013 6
The Stomach
04/10/2013
Impuls
endogen
exogen
Vomiting center
Gastrointestinal tract,
vomiting
Impuls
04/10/2013 8
Vomiting centre
esophagus
04/10/2013
Tonus decrease
Peristaltic decrease
Tonus increase
04/10/2013
10
Vomiting
04/10/2013
11
Approach
Extra-gastrointestinal tract
04/10/2013
12
Etiology
Neonates
Atresia esophagus, pylorus stenosis, spitting up GER, NEC, chalasia, Infection (UTI, OMA, sepsis)
Infants
pylorus stenosis, intususeption, hernia RGE, gastroenteritis, infection, drugs, aerophagia
Children
Intusuception, stricture, gastritis, apendisitis Infection, drugs
04/10/2013 13
04/10/2013
14
Therapy
~ etiology treat acid and base imbalanced Drugs
04/10/2013
15
Gastroesophageal reflux
Just spitting up, or something more serious ?
04/10/2013
16
Regurgitation
RGE
04/10/2013
17
04/10/2013
18
04/10/2013
19
162 infants (1-12 month olds), outpatients clinic for immunization, RSCM
Freq of regurgitation 1-4 time/day 0-3 mo 4-6 mo 7-9 mo 10-12 mo
84%
65%
30%
7%
> 4 time/day
30%
14%
6%
Problem
24%
18%
04/10/2013
16%
4%
20
GER
04/10/2013
21
GER
Physiologic reflux
occurs mainly after meal does not normally cause symptoms short duration of reflux episodes frequent reflux episodes of longer duration reflux episodes occuring during the day/night may produce symptoms & inflamation/mucosal injury
Pathologic reflux
04/10/2013
22
Mechanisms of GER
Deficient or delayed esophageal acid clearance attenuated swallows, dysfunctional peristalsis Length of LES, Maturation of LES TLES relaxation delayed gastric delayed gastric emptying emptying, distention distension
04/10/2013
23
RGE
Acid,Regional blood flow, tissue prostaglandin E2 permeability to acid susceptibility to inflamation inflamation dysfunction vagal nerve
acid/bile
edema
Impairment of LES
fibrosis dysmotility pylorospasm
esophagitis
04/10/2013 24
04/10/2013
26
Usual manifestations
Specific manifestation
regurgitation, nausea, vomiting
Unusual presentations
04/10/2013
29
- Number of reflux episode - Number of reflux episodes longer than 5 min - Longest reflux episodes - Fraction time pH below 4.00
04/10/2013
30
Treatment recommendations
1. a. Parental reassurance b. Milk-thickening agents (?)
2. Prokinetics
04/10/2013
31
Decrease the number of transient LES relaxations Reduced volume cause of distress to infants Restriction volume in clearly overfed babies Decrease the frequency & volume of regurgitation time crying, improves sleep, caloric retention , coughing (after feeding)
Borelli, 1997) (Vandenplas, 1994,
04/10/2013
32
04/10/2013
33
Prokinetics
Gastrokinetic action indirect release of acetylcholine in the myentericus plexus
Reduces regurgitation
The LES pressure and motility Esophageal peristalsis, gastric emptying protect esophagus via salivary component (bicarbonat buffer)
04/10/2013
34
Crying increases abdominal pressure, but also increases LES-P SIDS ? Beyond the age of SIDS ( > 12 months)
04/10/2013
35
04/10/2013
36
GER - ASTHMA
Vagal stimulation leading to bronchospasm
04/10/2013
37
Recent studies report that 45-75% of children with uncontrolled asthma suffer GOR Prokinetic
GER ~ cough episodes at night in 50% children remission of resp. symptoms or less anti-asthma medication
04/10/2013
38
Uncomplicated GER
No investigations
Phase 1 (1-2
weeks)
Phase 2 (1-3
weeks) ?? reconsider diagnosis of GER ??
pH monitoring
Normal
? GOR ?
Abnormal
UGIS ? Endoscopy ?
04/10/2013 39
NO
YES
phase 1 + 2
A-R Formula Cisapride 1-3 mo
phase 1 + 2 + 3 + 4
(+ Positional treatment, H2 / Omeprazole)
control endoscopy
Eso > Grade 3 ?
NO
stop phase 3 continue phase 2
YES
UGIS ?? ? Surgery ?
04/10/2013
40
THANK YOU
04/10/2013
41