الفهرس 
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Abstract
This clinical follow up study was conducted on children with GERD to assess esophageal motility in CMA related GERD compared to non CMA GERD and to determine the risk factors for esophageal dys-motility in GERD. The work included 50 patients followed up in gastroenterology unit, Pediatrics Hospital Ain Shams University.
They were 25 males (50%) and 25 females (50%); their ages ranged from 22 – 49 months with a mean age of 34.2 ± 7.81 months.
All patients had medical history taking, with special emphasis on GI symptoms (vomiting, dysphagia, hematemesis, abdominal pain, diarrhea, constipation, abdominal distension and melena), associated extraintestinal symptoms (chocking, cough, recurrent chest infection, allergy and weight loss) and family history of similar conditions and medication history.
Careful clinical examination was done with special emphasis on vital data (heart rate, respiratory rate, and temperature), pallor, weight, skin allergy, abdominal examination (distension, tenderness, rigidity and organomegaly) and anthropometric measures; (weight for age and length for age in terms of Z score value).
All patients had a laboratory assessment of CBC (hemoglobin %, platelet count and TLC), ESR, and serum IgE against whole cow’s milk protein (by RAST), barium meal in Trendleberg position, endoscopic assessment (EGD), 24 hours esophageal pH metry and esophageal manometery.
The present study revealed that vomiting was a constant feature among patients with GERD either CMA or non CMA related.
Hematemesis was reported by 34% of GERD patients and was significantly more frequent among those with CMA (76.5%) compared to those non CMA (23.5%), dysphagia among 44% of GERD patients and was significantly more frequent among those with CMA (68.18%) compared to those non CMA (31.82), abdominal pain among 32% of GERD patients and was significantly more frequent among those with CMA (93.8%) compared to those non CMA (6.2%), abdominal distension among 40% of GERD patients and was significantly more frequent among those with CMA (90%) compared to those without CMA (10%), diarrhea among 32% of GERD patients and was significantly more frequent among those with CMA (93.8%) compared to those non CMA (6.2%), constipation among 18% of GERD patients with no significant difference between those with CMA (66.7%) and non CMA patients (33.3%).
Regarding the extraintestinal manifestations the present study revealed the presence chocking among 46% of GERD patient was significantly more frequent among those with CMA (78.3%) compared to those without CMA (21.7%), chest allergy among 36% of GERD patients and was significantly more frequent among those with CMA (83.3%) compared to those without CMA (16.7%), cough among 26% of GERD patients with no significant difference between those with CMA (69.2%) and those non CMA patients (30.8%), nasal allergy and skin eczema among 32% of GERD patients and were significantly more frequent among those with CMA (87.5% and 93.8% respectively) compared to those without CMA (12.5% and 6.2% respectively).
Regarding anthropometric measures patients of CMA related GERD have significant lower mean Z score of weight for age and length for age compared with patients of non CMA related GERD. Patients of CMA related GERD have significant higher mean Percent of length and weight compared with patients of non CMA related GERD.
The results of EGD showed that patients of CMA related GERD had significant higher frequency of esophageal nodularity (91.7%) and inflammation (91.7%) without ulcers. All patients with non CMA related GERD had variable degree of esophageal inflammation with ulceration.
Laboratory results showed a significant lower mean hemoglobin level among CMA related GERD (9.46±0.66 gm/dl) compared to non CMA related GERD (11.62±1.15 gm/dl) and the presence of anemia among 54%of GERD patients with significantly higher frequency among CMA related GERD (88.8%) compared with non CMA related GERD (13.04%), mean serum level of specific IgE is higher in patients CMA related GERD 3.01±0.67 ku\dl) compared to patients with non CMA related GERD (0.33±0.68 ku\dl).
Patients with CMA related GERD had significantly lower mean number of long episodes (19.17±5.84) and shorter duration of longest reflux episodes (19.67±1.68 minutes) compared to patients with non CMA related GERD (29.88±9.57, 26.11±5.97respectively), But mean % time of acid reflux was significantly higher in CMA related GERD (32.75±6.63) compared to non CMA related GERD (28.81±5.68).
Manometric evaluation of all included patients showed that patients of CMA related GERD had significantly higher mean average LES resting pressure (22.83 ± 2.85), wet swallow 5ml mean amplitude (40±6.9), % simultaneous contractions (5.75±1.96), % retrograde contractions (14.67±3.05) and % of non transmitted contractions (48.9 ± 5.9) compared to patients with non CMA related GERD (16.5 ± 2.8, 49.8 ± 9.4, 3.31±1.26, 5.62±3.23, 38.4±4.6respectively).
The manomertric assessment of esophageal body motility among all patients with GERD showed low mean amplitude of contractions (46.46 ± 7.35 mmHg), high frequency of IEM (84%) and retrograde contractions (18%).
The results of the present study showed that patients with IEM had significantly higher frequencies of dysphagia (51.2%) and chocking (53.5%) compare to those without IEM. Dysphagia is the chief manifestation of esophageal dysmotility in children.
Patients with IEM had significantly longer duration of the disease (33 ± 3.11 months) compared to those without IEM (25.44 ± 7 months).
Patients with IEM had significantly longer duration of acidic reflux (36.88 ± 6.59%) and longest pH reflux episode (29.57 ± 6.16 minutes) compared to those without IEM (29.57 ± 5.47% and 21.95 ± 4.63 minutes, respectively).
Patients with IEM had significantly higher frequency of endoscopic lower end esophagitis (75%) compared to those without esophagitis (50%).
The presence of CMA related GERD was significantly associated with IEM (96%) compared to non CMA related GERD (72%). Patients with IEM had significantly higher frequency of CMA (58.8%) compared to those without IEM (12.5%).
Multivariate regression analysis for the predictors of the presence of IEM among patients with GERD showed that longer duration of the disease, presence of dysphagia, chocking, longer time of acidic reflux, presence of endoscopic inflammation and diagnosis of CMA had independent effects on the presence of IEM.