1. In the name of God Diagnostic approach to GERD Pediatric Gastroenterology and Hepatology department of Shahid Beheshti university of medical sciences, Mofid children hospital, IRAN 2016 1

2. Type of Gastroesophageal reflux 2 Physiologic GER No need treatment Reassurance Change life style Avoid of intensifying foods reflux by mother Pathologic or symptomatic GER Need to treatment. Diagnostic approach may be different.

3. Are there alarm signs? 3 Recurrent vomitingHistory and physicalAre there alarm signs? Alarm signals suggestive of non GERD diagnosis  Bilious or forceful vomiting  Onset of vomiting after 6 months of life  Hematemesis / Hematochezia  Abdominal tenderness / distension  Fever, Lethargy  Hepatolsplenomegaly  Macrocephaly, Microcephaly  seizure NASPGHAN position statement J pediatr Gastroenterol Nutr 2001;32:51

4. The aim of diagnostic Approaches 4 GERD A test may be useful to document the occurrence of GER To detect complications of GER To establish a causal relationship between GER and symptoms To evaluate therapy or To exclude other causes of symptoms

5. History, physical examination and questionnaires form In adults, diagnosis of GERD is based primarily on clinical history. However, even in adults, the sensitivity and specificity of history is questioned. History is useful for predicting acid GERD, but not for diagnosing nonacid GERD, and is inferior to MII-pH. However, in children younger than 8 years of age, or even younger than 12 years of age, history is considered poorly reliable. 5

6. History in GERD diagnosis Orenstein developed the Infant Gastroesophageal Reflux Questionnaire (I-GERQ). Aggarwal and co-workers obtained with the same I-GERQ a sensitivity of only 43% and a specificity of 79%. I-GERQ cut-off score failed to identify 26% of infants with GERD (according to pH-metery results or presence of esophagitis) and was positive in 81% of infants with a normal esophageal histology and normal pH-metery results. Deal et al. developed two different questionnaires, one for infants and one for older children, and showed that the score was higher in symptomatic than in asymptomatic children. 6

7. Conclusion Nonetheless, based upon expert opinion, in most infants with vomiting and most older children with regurgitation and heartburn, a history and physical examination are sufficient to reliably diagnose GER, recognize complications, and initiate management. 7

8. Empiric therapy 8  An empiric test trial of acid suppression is often used as a diagnostic, and is suggested for older children and adolescence with uncomplicated heartburn.  The trial typically consists of a two- to four- week course of acid suppressing medication eg. Proton pump inhibitor.  But this is not a valuable diagnostic test in infants and young children if symptoms of GERD are less specific.  An empiric test trial of acid suppression is often used as a diagnostic, and is suggested for older children and adolescence with uncomplicated heartburn.  The trial typically consists of a two- to four- week course of acid suppressing medication eg. Proton pump inhibitor.  But this is not a valuable diagnostic test in infants and young children if symptoms of GERD are less specific.

9. 9 The upper gastrointestinal (GI) series is useful to detect anatomic abnormalities, such as hiatal hernia, achalasia, Tracheoesophageal fistula, anastomotic strictures, malrotation, duodenal web, hiatal hernia and stenosis. Barium have sensitivity of 31 to 86% and specificity 21 to 83 percent and positive predictive value from 80% to 82%. Barium studies of the esophagus compared with esophageal PH studies are neither sensitive nor specific for the diagnosis of GERD. Thus radiologic contrast studies is not useful to confirm or exclude GERD. There is broad consensus that barium studies are not recommended as first-line investigation for diagnosis of GERD. Barium contrast radiography

10. 10 Achalasia Hypertrophic Pyloric Stenosis Vascular ring Esophageal stenosis Esophageal stricture Malrotation Hiatal hernia

11. Does ultrasound can help diagnose of reflux? 11 The results of esophageal ultrasound are investigator dependent, and a relation between reflux seen on ultrasound and symptoms has not been established. There is no indication for ultrasonography in the diagnostic workup of a patient suspected of GERD Except for rule out other cause including hypertrophic pyloric stenosis, malrotation.

12. Esophageal pH Monitoring 12 Esophageal PH monitoring is the best method and permits the assessment of the frequency and duration of acid exposure and its relationship to symptoms to determine if there is a temporal association between acid reflux and frequently occurring symptoms, and to assess the adequacy of therapy in patients who do not respond to treatment with acid suppression.. But not all reflux that causes symptoms is acidic and not all acid reflux causes symptoms. The results do not correlate consistently with symptoms severity or objective finding on endoscopy Esophageal pH metrics generally include an absolute number of reflux episodes detected during monitoring, the duration of reflux episodes detected, and the reflux index, which is calculated as the percentage of a study period during which esophageal pH is <4.0.

13. Esophageal PH monitoring 13 The severity of pathologic acid reflux does not correlate consistently with symptom severity or complication. Drinking acidic beverages( fruit juice, carbonated beverage ) affect PH monitoring. Useful for evaluating the efficacy of antisecretory therapy. May be useful to correlate symptoms( cough, chest pain, asthma, apnea) with acid reflux episodes. Sensitivity, specificity and clinical utility of PH monitoring for diagnosis and management of extraesophageal complication of GER are not well established

14. Esophageal PH with multichannel intraesophageal impedance monitoring 14 Multichannel intraluminal impedance (MII ) measures electrical potential differences. As a consequence, the detection of reflux with MII is not pH dependent, but in combination with pH-metry MII allows detection of acid (pH 7.0), solids, and air in the esophagus,. Combined pH/MII testing is evolving into the test of choice to detect temporal relationships between specific symptoms and the reflux of both acid and nonacid gastric contents. MII can be used to measure volume, speed, and physical length of both anterograde and retrograde esophageal boluses.

15. Esophagogastroduodenoscopy 15. Endoscopy allows direct visual examination of the esophageal mucosa. Macroscopic lesions associated with GERD include esophagitis, erosions, exudate, ulcers, strictures, ring, stenosis and hiatal hernia. Biopsies of duodenal, gastric, and esophageal mucosa are mandatory to exclude other diseases such as EGID. exclude other disorders, such as Crohn’s disease and eosinophilic or infectious esophagitis.

16. Esophageal manometry 16 Esophageal manometry is of minimal use in the diagnosis of typical GERD. It is main purpose is to diagnose achalasia in patients with suggestive finding on barium contrast radiography. Esophageal manometry is of minimal use in the diagnosis of typical GERD. It is main purpose is to diagnose achalasia in patients with suggestive finding on barium contrast radiography.

17. Esophageal Manometry Indication 17  Primary esophageal motility disorders –Achalasia –Nutcracker esophagus –Diffuse esophageal spasm –Hypertensive LES  Nonspecific Esophageal motility disorders  Secondary esophageal motility disorders –Scleroderma –Diabetes mellitus –Chronic idiopathic intestinal pseudo-obstruction

18. 18 Normal esophageal manometery

19. Bronchoalveolar lavage 19 occasionally used to assess for evidence of recurrent small volume aspiration. In aspiration contain a high percentage of lipid laden macrophages, aspiration thought to be more likely

20. Nuclear scintigraphy 20 A nuclear scintiscan is performed by the oral ingestion or instillation of technetium-labeled formula or food into the stomach. The areas of interest, the stomach, esophagus and lungs, are scanned for evidence of GER and aspiration. Provide information about gastric emptying which may be delayed in some children with GERD. Can demonstrate pulmonary aspiration in children with refractory respiratory symptoms, apnea. Unlike esophageal pH monitoring, the nuclear scan can demonstrate reflux of non-acidic gastric contents

21. Nuclear scintigraphy 21 A negative test does not exclude the possibility of infrequently occurring pulmonary aspiration. The reported sensitivity and specificity of the nuclear scan for the diagnosis of GER are 15% to 59% and 83% to 100%, respectively, when compared to esophageal pH monitoring. However, a lack of standardized techniques and the absence of age-specific normative data limit the value of this test. Not recommended for routine evaluation of suspected to GERD

22. 22 Thanks for your attention باغ ارم شیراز