Professional Documents
Culture Documents
Vomiting in Children
Vomiting in Children
Badriul Hegar
Pediatric Gastroenterology Univ of Indonesia
08/05/2013
Regurgitation
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Vomiting
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Gastroesophageal reflux
the
Regurgitation
reflux
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S.motorik somatik
Saraf enterik pl. mienterikus asetil kolin pl. submukosa pleksus mienterikus S.motorik somatik
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motilitas sal.cerna
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Impuls
endogen
exogen
Vomiting center
Gastrointestinal tract,
vomiting
Impuls
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Vomiting centre
esophagus
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Tonus decrease
Peristaltic decrease
Tonus increase
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Vomiting
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Approach
Age: neonates, infant, child
Gastrointestinal
obstruction
non
tract
obstruction
Extra-gastrointestinal
tract
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Etiology
Neonates
Atresia esophagus, pylorus stenosis, spitting up GER, NEC, chalasia, Infection (UTI, OMA, sepsis)
Infants
Children
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Scanning
gambar HPS
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Therapy
Domperidone Metoclopramide
Cisapride
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Gastroesophageal reflux
Just spitting up, or something more serious ?
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Regurgitation
40% of children consulting a pediatrician 70% of all 4 months old infants regurgitate at leats 1 x/day 25% is considered by the parents as a problem
RGE
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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%
16%
4%
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GER
saliva, ingested food, drinks, gastric/pancreatic/ biliary secretions normal phenomenon, +/- accompanying symptoms physiologic or pathologic reflux
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GER
Physiologic
reflux
occurs mainly after meal does not normally cause symptoms short duration of reflux episodes
Pathologic
reflux
frequent reflux episodes of longer duration reflux episodes occuring during the day/night may produce symptoms & inflamation/mucosal injury
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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
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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
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manifestations
manifestation related to complications
Specific
Possibly
~ anaemia (iron defiency anaemia) haematemesis & melena dysphagia, weight loss, irritable infants ect ~ adult
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Unusual presentations
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- Number of reflux episode - Number of reflux episodes longer than 5 min - Longest reflux episodes - Fraction time pH below 4.00
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Treatment recommendations
1. a. Parental reassurance b. Milk-thickening agents (?)
2. Prokinetics 3. Positional adjuvant therapy 4. a. H2 receptor antagonist b. Proton pump inhibitors 5. Surgery
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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)
(Vandenplas, 1994, Borelli, 1997)
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Prokinetics
Gastrokinetic action indirect release of acetylcholine in the myentericus plexus
Reduces regurgitation
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GER - ASTHMA
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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
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Uncomplicated GER
No investigations
Phase 1 (1-2
weeks)
Phase 2 (1-3
weeks) ?? reconsider diagnosis of GER ??
pH monitoring
Normal
? GOR ?
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Abnormal
UGIS ? Endoscopy ?
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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 ?
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THANK YOU
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