Download functional and organic diseases of oesophagus in children

FUNCTIONAL AND ORGANIC
DISEASES OF THE OESOPHAGUS AND
STOMACH IN CHILDREN PART I
LABARAN KAMAL UMAR (MED)
INTRODUCTION
The esophagus is the hollow tube that
leads from the throat (pharynx) to the
stomach. The walls of the esophagus
propel food to the stomach not by
gravity but by rhythmic waves of
muscular contractions called
peristalsis.
FUNCTIONS OF THE OESOPHAGUS
As a person swallows, food moves from the mouth to the
throat, also called the pharynx (1). The upper esophageal
sphincter opens (2) so that food can enter the esophagus,
where waves of muscular contractions, called peristalsis,
propel the food downward (3). The food then passes
through the lower esophageal sphincter (4) and moves
into the stomach (5).
Just below the junction of the throat and
the esophagus is a band of muscle called
the upper esophageal sphincter. Slightly
above the junction of the esophagus and
the stomach is another band of muscle
called the lower esophageal sphincter.
When the esophagus is not in use, these
sphincters contract so that food and
stomach acid do not flow back up the
esophagus from the stomach to the mouth.
During swallowing, the sphincters relax so
food can pass to the stomach.
GASTROESOPHAGEAL REFLUX DISEASE- GERD
Gastroesophageal reflux is the backward movement of food
and acid from the stomach into the esophagus and sometimes
into the mouth .
Reflux may be caused by the infant’s position during feeding;
overfeeding; exposure to caffeine, nicotine, and cigarette smoke;
a food intolerance or allergy; or an abnormality of the digestive
tract.
Infants may vomit, spit up excessively, have feeding or breathing
problems, and also appear irritable.
Tests that help doctors diagnose the disorder include a barium
study, an esophageal pH probe, a gastric emptying scan, and
endoscopy.
Treatment options include thickened or hypoallergenic formula
for feedings, special positioning, frequent burping, histamine-2
blockers, proton pump inhibitors, and, in certain
cases, metoclopramide and surgery.
Nearly all infants have episodes of
gastroesophageal reflux, which are
characterized by wet burps, burping up, or
spitting up. Wet burps typically occur
shortly after eating and are considered
normal. Gastroesophageal reflux becomes
known as gastroesophageal reflux disease
(GERD) when it
Interferes with feeding and growth
Damages the esophagus (esophagitis)
Leads to breathing difficulties (such as
coughing, wheezing, or stopping breathing)
Continues beyond infancy into childhood
CAUSES
Healthy infants have reflux for many reasons. The circular
band of muscle at the junction of the esophagus and
stomach (the lower esophageal sphincter) normally keeps
stomach contents from entering the esophagus. In infants,
this muscle may be underdeveloped, or it may relax at
inappropriate times, allowing stomach contents to move
backward (reflux) into the esophagus. Being held flat
during feeding or lying down after feeding promotes reflux
because gravity is no longer able to help keep material in
the stomach from flowing back up the esophagus.
Overfeeding and drinking carbonated beverages
predispose to reflux by increasing pressure in the
stomach. Cigarette smoke (as secondhand smoke) and
caffeine (in beverages or breast milk) relax the lower
esophageal sphincter, allowing reflux to occur more
readily.
Caffeine and nicotine (in breast milk) also stimulate acid
production so any reflux that does occur is more acidic. A food
allergy or intolerance also can contribute to reflux, but this is a
less common cause.
Anatomic abnormalities, such as narrowing of the esophagus,
partial blocking of the stomach (pyloric stenosis), or abnormal
positioning of the intestines (malrotation), can initially mimic
reflux. However, these abnormalities are more serious and can
progress to vomiting and other symptoms of obstruction, such
as abdominal pain, listlessness, and dehydration.
SYMPTOMS
The most obvious symptoms of gastroesophageal reflux in
infants are vomiting and excessive spitting up. Reflux
typically worsens in the first several months of life, peaks
around 6 to 7 months of age, and then gradually lessens.
Nearly all infants with reflux outgrow it by about 18
months of age.
In some infants, reflux causes complications and becomes
known as GERD. Such complications include irritability
due to stomach discomfort, feeding problems that can
result in poor growth, and “spells” of twisting and
posturing that may be confused with seizures. Less
commonly, small amounts of acid from the stomach may
enter the windpipe (aspiration).
Acid in the windpipe and breathing passages may result in
coughing, wheezing, stopping breathing (apnea), or
pneumonia. Many children with asthma also have reflux.
Ear pain, hoarseness, hiccups, and sinusitis also can occur
as a result of GERD. If the esophagus is significantly
irritated (esophagitis), there may be some bleeding,
resulting in iron deficiency anemia. In others, esophagitis
can cause scar tissue, which can narrow the esophagus
(stricture). Heartburn, a common symptom among
adolescents and adults with GERD, is more commonly
expressed as chest pain or abdominal pain among young
children.
DIAGNOSIS
Tests are often not needed to diagnose
gastroesophageal reflux in infants who simply have
mild symptoms such as frequent spit-ups. However,
if symptoms are more complicated, various tests
can be performed.
A barium test is the most common test. The child
swallows barium, a liquid that outlines the digestive
tract when x-rays are taken. Although this test can
help the doctor diagnose gastroesophageal reflux, it
more importantly helps the doctor identify some of
the possible causes of the reflux.
An esophageal pH probe is a thin flexible tube with a sensor at the tip that
measures the degree of acidity (pH). Doctors pass the tube through the
child’s nose, down the throat, and into the end of the esophagus. The tube is
usually left in place for 24 hours. Normally, children do not have acid in their
esophagus, so if the sensor detects acid, it is a sign of reflux. Doctors
sometimes use this test to see whether children with symptoms such as
coughing or breathing difficulties have reflux.
In a gastric emptying scan (milk scan), the child drinks a beverage that
contains a small amount of mildly radioactive material. This material is
harmless to the child. A special camera or scanner that is highly sensitive to
radiation can detect where the material is in the child’s body. The camera can
see how rapidly the material leaves the stomach and whether there is reflux,
aspiration, or both.
In upper endoscopy the child is sedated, and a small flexible tube with a
camera on the end (endoscope) is passed through the mouth into the
esophagus and stomach. Doctors may perform upper endoscopy if they need
to see whether the reflux has caused an ulcer or irritation or if they need to
obtain a sample for a biopsy. Endoscopy can also help make sure the
symptoms of reflux are not due to something else such as an allergy, infection,
or celiac disease.
Bronchoscopy is a similar test in which doctors use an endoscope to examine
the voice box (larynx) and airways. Bronchoscopy can help doctors decide
whether reflux is a likely cause of lung or breathing problems.
Treatment
Treatment of reflux depends on the child’s age and symptoms.
For infants who just have wet burps, doctors may recommend no
treatment or may suggest measures such as thickening formula for
feedings, special positioning, and frequent burping. Formula can be
thickened by adding 1 to 3 teaspoons of rice cereal per ounce of
formula. The nipple may have to be cross-cut to allow the formula to
flow. Infants with reflux should be fed in an upright or semi-upright
position and then maintained in an upright position for 30 minutes after
eating.
Infants with a food intolerance or allergy may benefit from a
hypoallergenic formula.
The head of the bed can be raised 6 inches (about 15¼ centimeters) to
help reduce nighttime reflux. Infants should be secured in a sling fitted
over the mattress or wedge to keep them from rolling or sliding down
to a horizontal position on the lower end of the crib. Older children
also should avoid eating 2 to 3 hours before bedtime, drinking
carbonated beverages or those that contain caffeine, taking certain
drugs (such as those with anticholinergic effects), eating certain foods
(such as chocolate), and overeating. All children should be kept away
from tobacco smoke.
DRUGS
If changes in feeding and positioning do not control symptoms, doctors may
prescribe drugs. Several types of drugs are available for reflux:
Those that neutralize acid
Those that suppress acid production
Those that improve the movement of the digestive tract
Antacids are drugs that neutralize gastric acid. These drugs work quickly to relieve
symptoms such as heartburn.
For children with more severe disease, acid-suppressing drugs are required. By
reducing stomach acid, these drugs lessen symptoms and allow the esophagus to
heal. There are two types of acid-suppressing drugs, histamine-2 (H2) blockers and
proton pump inhibitors (PPIs). H2 blockers do not suppress acid production quite
as much as PPIs.
Promotility drugs stimulate the movement of contents through the esophagus,
stomach, and intestines. These drugs (such as metoclopramide) may help increase
the strength of the lower esophageal sphincter and increase the speed at which
the stomach empties. Improved gastric emptying should decrease gastric pressure,
making reflux less likely to occur. Doctors used to prescribe these drugs
frequently for reflux but now think they are helpful only for certain children.
Surgery
Rarely, reflux does not respond to nonsurgical treatment
and is so severe that doctors recommend surgery. The
most common surgical procedure is a fundoplication. In
fundoplication, the surgeon wraps the top of the stomach
around the lower end of the esophagus to make that
junction tighter and decrease reflux
DIAPHRAGMATIC HERNIA
Hernia is a protrusion of a piece of the intestine through
an abnormal opening. Some infants are born with a
diaphragmatic hernia . A diaphragmatic hernia is a hole or
weakening in the diaphragm (the muscle that separates
the chest from the abdomen and that helps in breathing).
This opening allows some of the small intestine to push
through the opening, creating a bulge. Sometimes the
intestine becomes trapped (incarcerated) in the opening.
Sometimes incarceration cuts off the blood supply to the
trapped intestine (strangulation), which can lead to a tear
(perforation) and peritonitis (inflammation and usually
infection of the abdominal cavity and its lining), creating a
surgical emergency. A large diaphragmatic hernia can
decrease lung volume and create breathing problems.
Doctors do a surgical procedure to correct this type of
hernia. A diaphragmatic hernia that bulges through the
opening that the esophagus normally passes through (the
hiatus) is called a hiatus hernia
What are he different types of congenital
diaphragmatic hernia?
There are two kinds of CDH:
A Bochdalek hernia is a hole in the back of the
diaphragm. Ninety percent of CDHs are this type.
A Morgagni hernia involves a hole in the front
of the diaphragm.
SYMPTOMS
•Respiratory
distress
•Scaphoid abdomen
•Bowel sounds heard over the hemithorax( gurgle- like noises)
•Absence of breath sounds
•Difficulty breathing
•Fast breathing
•Fast heart rate
•Cyanosis (blue color of the skin)
•Abnormal chest development, with one side being larger than
the other
DIAGNOSIS/TREATMENT
X-ray: Chest protruding into the chest
Ultrasound, prenatally
Treatment is by surgery
You are called to a delivery room after the birth of a full- term
infant who has developed respiratory distress. The mother has
been in excellent health and the pregnancy was uncomplicated.
An ultra-sound at 16 weeks was unremarkable. Physical
examination reveals a near total absence of breath sounds
bilaterally. No fluid is obtained by suctioning. You immediately
intubate the infant and obtain a chest radiograph, which reveals
a cystic mass in the right chest that looks similar to bowel
loops. Which of the following conditions is the most likely
diagnose?
A. Tracheosophageal fistula
B. Respiratory distress syndrome
C.Meconium aspiration
D. Tetralogy of Fallot
E. Diaphragmatic hernia
END OF PART I