Notes in Chapter 28

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Published	11/02/2024	{{c1::Gastroesophageal reflux (GER)}} is commonly encountered in infants but usually resolves by {{c2::2 years}} of age.
Published	11/02/2024	GER is the {{c1::involuntary retrograde passage}} of gastric contents into the esophagus.
Published	11/02/2024	{{c1::Regurgitation}} occurs when refluxate reaches the pharyngeal region.
Published	11/02/2024	Infants ingest {{c1::twice}} the volume of food per kilogram body weight compared to adults.
Published	11/02/2024	Delayed gastric emptying increases postprandial reflux by increasing {{c1::transient relaxations}} of the lower esophageal sphincter.
Published	11/02/2024	Physiologic GER does not require medical treatment but may cause {{c1::parental distress}}.
Published	11/02/2024	GERD occurs when reflux causes symptoms affecting {{c1::quality of life (QOL)}} or complications such as failure to thrive.
Published	11/02/2024	Before the 1990s, GERD treatment relied on {{c1::antacids and histamine antagonists}}.
Published	11/02/2024	{{c1::Transient LES relaxations (TLESR)}} are the primary mechanism for GERD.
Published	11/02/2024	Up to {{c1::40%}} of refluxate in infants is not acidic.
Published	11/02/2024	Nonacid and weakly acidic reflux can account for {{c1::up to 90%}} of refluxate in children.
Published	11/02/2024	Children with GERD may have associated {{c1::neurologic impairment}} that exacerbates symptoms.
Published	11/02/2024	{{c1::Hiatal hernia}} can further predispose children to GERD.
Published	11/02/2024	Congenital anomalies like {{c1::esophageal atresia}} predispose infants to GERD complications.
Published	11/02/2024	GERD in children can lead to {{c1::pulmonary complications}} such as reactive airway disease.
Published	11/02/2024	The {{c1::lower esophageal sphincter (LES)}} is crucial for preventing reflux of gastric contents into the esophagus.
Published	11/02/2024	The LES arises from the {{c1::inner circular muscle layer}} of the esophagus.
Published	11/02/2024	{{c1::Phrenoesophageal membrane}} holds the LES in position partially in the chest and abdomen.
Published	11/02/2024	LES pressure >30 mmHg in adults prevents GER, while pressures 0-5 mmHg correlate with abnormal {{c1::pH studies}}.
Published	11/02/2024	{{c1::Transient LES relaxations}} contribute significantly to GER episodes in children with normal LES pressures.
Published	11/02/2024	{{c1::Short LES length}} and abnormal smooth muscle function can lead to LES failure and GERD.
Published	11/02/2024	An intra-abdominal esophageal length of {{c1::3–4.5 cm}} provides LES competency in adults.
Published	11/02/2024	{{c1::Esophageal peristalsis}} is essential for clearing refluxed contents from the esophagus.
Published	11/02/2024	Primary esophageal contractions initiated with {{c1::swallowing}} clear refluxed material in most cases.
Published	11/02/2024	{{c1::Saliva}} neutralizes refluxed material and aids in esophageal clearance.
Published	11/02/2024	Decreased {{c1::salivary function}} is observed in patients with GERD.
Published	11/02/2024	{{c1::Gravity}} assists in the clearance of esophageal refluxate, influencing GERD treatment outcomes.
Published	11/02/2024	{{c1::PPIs (Proton Pump Inhibitors)}} increase gastric pH and decrease acid volume in GERD treatment.
Published	11/02/2024	{{c1::Alkaline bile reflux}} is implicated in esophageal mucosal injury alongside acid.
Published	11/02/2024	{{c1::Pepsin and trypsin}} are proteolytic enzymes that can injure the esophageal mucosa.
Published	11/02/2024	The {{c1::angle of His}} creates a flap valve at the gastroesophageal junction, contributing to resistance against GER.
Published	11/02/2024	Abnormal development or iatrogenic changes, such as those following {{c1::gastrostomy placement}}, can compromise the angle of His.
Published	11/02/2024	Patients with {{c1::increased abdominal pressure}} due to neurologic conditions or anatomical abnormalities are at higher risk for GERD.
Published	11/02/2024	{{c1::Esophageal motility}} is crucial for clearing refluxed contents and preventing esophageal mucosal injury in GERD.
Published	11/02/2024	Primary esophageal contractions initiated with swallowing clear refluxed material in {{c1::80–90%}} of reflux episodes.
Published	11/02/2024	Secondary esophageal contractions occur when material is refluxed and clearance is required, especially during {{c1::sleep}}.
Published	11/02/2024	{{c1::Tertiary}} esophageal contractions are sporadic and non-propagating.
Published	11/02/2024	Impaired esophageal motility due to abnormal smooth muscle function or obstruction can lead to prolonged exposure to refluxed gastric contents and sub…
Published	11/02/2024	{{c1::Saliva}} not only neutralizes refluxed material but also lubricates the esophagus, aiding in the clearance of retained refluxate.
Published	11/02/2024	{{c1::Bile salts}} increase esophageal mucosal permeability to acid, exacerbating mucosal injury in the presence of acid reflux.
Published	11/02/2024	{{c1::Pepsin and trypsin}} are enzymatic factors that can further injure the esophageal mucosa, particularly in acidic conditions.
Published	11/02/2024	{{c1::Proton Pump Inhibitors (PPIs)}} play a crucial role in controlling GERD by increasing gastric pH and reducing acid volume.
Published	11/02/2024	Although acid reflux is traditionally considered the main contributor to esophageal injury in GERD, {{c1::alkaline bile reflux}} is also implicated.
Published	11/02/2024	The {{c1::LES}} creates a pressure gradient in the distal esophagus that helps prevent {{c2::reflux}} of gastric contents.
Published	11/02/2024	Embryologically, the LES arises from the {{c1::inner circular muscle layer}} of the esophagus, which thickens asymmetrically in the distal esophagus.
Published	11/02/2024	The {{c1::phrenoesophageal membrane}} helps maintain the position of the LES, which spans partially in the chest and abdomen, critical for {{c2::barri…
Published	11/02/2024	{{c1::Esophageal manometry}} identifies the transition from thoracic to abdominal esophagus, known as the {{c2::respiratory inversion point}}.
Published	11/02/2024	In adults, LES pressures >{{c1::30 mmHg}} prevent GER as demonstrated by 24-hour {{c2::pH study}}.
Published	11/02/2024	LES pressures between {{c1::0 and 5 mmHg}} correlate with abnormal pH studies in {{c2::more than 80%}} of patients.
Published	11/02/2024	{{c1::Transient LES relaxations (TLESR)}} are major contributors to GER episodes, particularly in children with normal LES function.
Published	11/02/2024	{{c1::Short LES length}} and abnormal smooth muscle function increase the risk of {{c2::LES failure}} and subsequent GERD development.
Published	11/02/2024	An intra-abdominal esophageal length of {{c1::3–4.5 cm}} provides adequate LES competency in {{c2::most adults}}.
Published	11/02/2024	{{c1::Esophageal peristalsis}} is essential for {{c2::clearing refluxed contents}} and preventing esophageal mucosal injury.
Published	11/02/2024	{{c1::Primary}} esophageal contractions initiated with swallowing are responsible for clearing refluxed material in {{c2::80–90%}} of cases.
Published	11/02/2024	{{c1::Saliva}} neutralizes refluxed material and assists in {{c2::lubricating the esophagus}}, aiding in the clearance of retained refluxate.
Published	11/02/2024	Patients with {{c1::GERD}} may experience impaired salivary function, which contributes to {{c2::esophageal mucosal injury}}.
Published	11/02/2024	{{c1::Proton Pump Inhibitors (PPIs)}} effectively control GERD by {{c2::increasing gastric pH}} and reducing acid volume.
Published	11/02/2024	Besides acid, {{c1::alkaline bile reflux}} is also implicated in {{c2::esophageal mucosal injury}} in patients with GERD.
Published	11/02/2024	{{c1::Pepsin and trypsin}}, enzymatic factors present in gastric contents, can further {{c2::injure the esophageal mucosa}}, especially in acidic cond…
Published	11/02/2024	Persistent {{c1::regurgitation}} is the most common complaint in infants with {{c2::GERD}}.
Published	11/02/2024	Chalasia of infancy, characterized by physiologic {{c1::vomiting}}, resolves spontaneously by {{c2::2 years of age}} without requiring treatment.
Published	11/02/2024	{{c1::Irritability}} due to pain is a common symptom of GERD in infants, often resulting from {{c2::esophagitis}} caused by reflux.
Published	11/02/2024	Chronic GERD in children can lead to {{c1::esophagitis}} and subsequent {{c2::ulcer formation}} with potential for {{c2::stricture}} and dysphagia.
Published	11/02/2024	Barrett esophagitis, a premalignant condition associated with prolonged GERD, involves {{c1::metaplasia}} of esophageal epithelium to {{c2::columnar e…
Published	11/02/2024	Respiratory symptoms in infants and children with GERD include {{c1::chronic cough}}, {{c2::wheezing}}, and {{c2::recurrent bronchitis or pneumonia}} …
Published	11/02/2024	{{c1::Laryngospasm}} and {{c2::bronchospasm}} can occur due to esophageal acidification in GERD, mimicking symptoms of {{c2::asthma}}.
Published	11/02/2024	{{c1::Hemorrhage}} can rarely present as a symptom of GERD, manifesting as {{c2::hematochezia or melena}} from esophagitis, gastritis, or ulcer format…
Published	11/02/2024	Aggressive management and long-term surveillance are essential for patients with Barrett esophagitis due to the increased risk of {{c1::adenocarcinoma…
Published	11/02/2024	In premature infants, GERD can exacerbate respiratory distress syndrome or bronchopulmonary dysplasia, requiring {{c1::intubation}} and subsequent imp…
Published	11/02/2024	{{c1::Esophageal stricture}} in children with long-standing GERD can lead to {{c2::dysphagia}} and obstructive symptoms.
Published	11/02/2024	{{c1::Chronic inflammation}} from GERD can lead to {{c2::Barrett esophagitis}}, a condition with increased risk of esophageal adenocarcinoma.
Published	11/02/2024	Children with {{c1::neurological impairment}} are at increased risk of GERD-related complications due to increased {{c2::spasticity}} and {{c2::gastro…
Published	11/02/2024	{{c1::Aspiration}} of gastric refluxate in infants with GERD can lead to {{c2::respiratory complications}} such as apnea and pneumonia.
Published	11/02/2024	Infants with severe GERD may present with {{c1::apparent life-threatening events (ALTEs)}} due to complications such as {{c2::severe respiratory dist…
Published	11/02/2024	Management of Barrett esophagitis includes {{c1::long-term surveillance}} via {{c2::esophagogastroscopy}} to monitor for dysplasia or malignancy.
Published	11/02/2024	{{c1::Gastric acid injury}} is a primary cause of esophageal mucosal injury in GERD, though alkaline reflux also plays a role, particularly in {{c2::B…
Published	11/02/2024	{{c1::Esophageal motility}}, aided by gravity and saliva, helps in clearing refluxate from the esophagus in GERD.
Published	11/02/2024	{{c1::Primary esophageal contraction waves}}, initiated by swallowing, are responsible for clearing refluxed contents in most GERD episodes.
Published	11/02/2024	{{c1::Pepsin and trypsin}}, proteolytic enzymes present in gastric refluxate, contribute to {{c2::esophageal mucosal injury}} in GERD, especially when…
Published	11/02/2024	{{c1::Saliva}} neutralizes refluxed material and aids in lubricating the esophageal mucosa, facilitating the clearance of retained refluxate in GERD.
Published	11/02/2024	{{c1::Failure to thrive}} and {{c2::malnutrition}} can result from GERD in infants due to inadequate caloric intake secondary to feeding difficulties.
Published	11/02/2024	Esophageal complications of GERD in children may include {{c1::stricture formation}} and {{c2::esophageal dysmotility}} from chronic inflammation.
Published	11/02/2024	Surgical intervention may be required in infants with severe GERD who fail to respond to {{c1::medical management}}.
Published	11/02/2024	Nonpharmacologic therapies for GER in infants and children include {{c1::parental reassurance}}, {{c2::dietary modification}}, and {{c3::positional ad…
Published	11/02/2024	{{c1::Thickening formula}} is endorsed by pediatric gastroenterology societies to reduce {{c2::regurgitation}} in infants with GER.
Published	11/02/2024	The {{c1::prone position}} is no longer recommended due to increased risk of {{c2::sudden infant death syndrome (SIDS)}}.
Published	11/02/2024	{{c1::Cisapride}} was withdrawn from the market due to {{c2::cardiac}} side effects despite earlier use for GERD management.
Published	11/02/2024	{{c1::Metoclopramide}} and {{c2::domperidone}} lack efficacy in treating GERD and pose {{c3::significant adverse effects}}.
Published	11/02/2024	{{c1::Proton pump inhibitors (PPIs)}} are considered the preferred pharmacologic option for treating GERD in children due to their {{c2::higher effica…
Published	11/02/2024	PPIs do not reduce the {{c1::incidence of reflux episodes}} but alter reflux pH to {{c2::nonacidic or weakly acidic}} states.
Published	11/02/2024	{{c1::Fundoplication}} is recommended if medical management of GERD is ineffective or complications are {{c2::significant}}.
Published	11/02/2024	Medical history and symptoms are often sufficient for diagnosing GERD, with diagnostics reserved for {{c1::unclear cases}} or those needing {{c2::adva…
Published	11/02/2024	{{c1::Esophageal inflammation}} from GERD can lead to {{c2::chronic}} inflammation, ulcers, and eventually {{c3::Barrett esophagitis}}, a premalignant…
Published	11/02/2024	{{c1::Respiratory symptoms}} like chronic cough, wheezing, and recurrent pneumonia in infants and children can be attributed to {{c2::GER-related aspi…
Published	11/02/2024	{{c1::Hemorrhage}} can occur in a small percentage of infants or children with GERD due to {{c2::esophagitis, gastritis, or ulcer formation}}.
Published	11/02/2024	The {{c1::contrast upper gastrointestinal (GI) study}} is commonly used preoperatively for GERD evaluation but is {{c2::not helpful in determining}} t…
Published	11/02/2024	Upper GI sensitivity for reflux compared to pH monitoring is {{c1::30.8%}}, highlighting its {{c2::low sensitivity}} in {{c3::detecting GERD}}.
Published	11/02/2024	Malrotation was an {{c1::unexpected finding}} in {{c2::4.2%}} of upper GI studies, influencing {{c3::operative planning}} in a small number of cases.
Published	11/02/2024	{{c1::Multichannel intraluminal impedance (MMI)}} combined with pH monitoring is {{c2::now considered}} the {{c3::gold standard}} for evaluating {{c4:…
Published	11/02/2024	MMI detects {{c1::nonacid reflux}} episodes and can distinguish between {{c2::liquid and gas reflux}}, providing {{c3::comprehensive diagnostic inform…
Published	11/02/2024	Endoscopic biopsy is recommended if GERD presents with {{c1::unexplained anemia}} or {{c2::recurrent pneumonia}} despite {{c3::pharmacologic therapy}}…
Published	11/02/2024	{{c1::Pyloroplasty}} with fundoplication was historically used for {{c2::improving gastric emptying}}, but studies show it may not significantly benef…
Published	11/02/2024	{{c1::Technetium-99m-labeled meal}} scans are ideal for assessing {{c2::gastric emptying}} and are particularly useful in {{c3::neurologically impaire…
Published	11/02/2024	Preoperative imaging for fundoplication is now less common, with {{c1::clinical history}} guiding {{c2::management decisions}} in most cases, except w…
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