Gastroesophageal Reflux in Children

(Australia—Australian Family Physician, June 1998, p. 465.) Gastroesophageal reflux is common in infants and children and should be regarded as pathologic only when it results in symptoms or tissue damage. Prolonged exposure to gastric acid damages the esophagus through increased epithelial cell turnover, impaired barrier function and infiltration of inflammatory cells. This damage may present clinically as irritability, heartburn, dysphagia (especially for solid foods), hematemesis or anemia. Prolonged irritability and feeding problems may cause secondary disruption of parental bonding and family function. The assessment of infants with suspected reflux should include a careful history and physical examination, as well as targeted laboratory investigations to rule out other explanations for symptoms. Monitoring of esophageal pH, esophageal manometry and barium studies may be useful. Chest radiography is indicated if aspiration is suspected. Isotopic studies of reflux and gastric emptying and endoscopy may be necessary in selected cases. Postural therapy and thickening of foods is first-line treatment for the majority of cases, although some children require treatment with acid-neutralizing agents, prokinetic drugs, histamine H₂-receptor antagonists or proton pump inhibitors.

Nausea and Vomiting During Pregnancy

(Canada—Canadian Family Physician, July 1998, p. 1455.) Up to 80 percent of pregnant women report nausea, and 50 percent experience vomiting. Symptoms resolve in most cases by the end of the first trimester but, in 9 percent of mothers, symptoms continue until at least 20 weeks of gestation. Most antiemetic drugs are not recommended for use during pregnancy because of concerns about safety, and clinical trials are nearly impossible because of ethical and other concerns. A combination of doxylamine and pyridoxine has been studied in large numbers of patients and has been shown to be effective without increased risk of teratogenicity. Reported side effects include drowsiness and anticholinergic signs and symptoms. Similar results have been reported with other histamine H₁ antagonists, but these have not been studied in large numbers of patients. Data based on small numbers of pregnant patients indicate a low potential for teratogenicity with other antiemetic agents such as cisapride, metoclopramide and ondansetron. If conservative measures are unsuccessful, the initial therapy recommended by the authors is a doxylamine and pyridoxine combination taken as two tablets before bedtime, one tablet in the morning and one in the afternoon. All patients with severe or persistent symptoms should be screened for rare but more sinister causes of nausea and vomiting during pregnancy.

Causes of Horner's Syndrome

(Canada—Canadian Family Physician, July 1998, pp. 1453, 1462.) Classic Horner's syndrome consists of ipsilateral ptosis (drooping eyelid), miosis (constricted pupil) and anhidrosis (inability to sweat). The syndrome may be caused by any disruption of the sympathetic innervation of the eye and so may result from a variety of benign or serious conditions. First-order sympathetic fibers arise from the posterolateral hypothalamus and synapse at the C8 to T2 level (Budge's center). Lesions at this level are usually serious, with causes including stroke or tumor. Second-order neurons leave the spinal cord at T1 and cross the apex of the lung to synapse at the superior cervical ganglion, so they may be vulnerable to chest, neck and thyroid conditions, especially tumors. Third-order neurons travel with the internal carotid artery through the cavernous sinus to the orbit with the third cranial nerve. Several conditions can disrupt third-order neurons, including otitis media and headache syndromes such as cluster and migraine. One review of 450 cases of Horner's syndrome reported that 8 percent were attributable to neoplasm.

Characteristics and Management of Gout

(Great Britain—The Practitioner, July 1998, p. 546.) Gouty arthritis occurs most commonly in men after the fourth decade of life. Small joints are the usual site of gout symptoms, with the first metatarsophalangeal joint most commonly affected. Classically, the joint becomes hot, painful, swollen and red. Recurrent gouty inflammation may result in damage to the joint and the formation of tophi. Most attacks of gout resolve spontaneously. Treatment with nonsteroidal anti-inflammatory drugs is usually effective. An alternative therapy is colchicine, which may be prescribed as a low-dose (0.5 mg twice daily) regimen or a more aggressive regimen (1 mg followed by 0.5 mg every two to three hours until symptoms abate). Gastrointestinal upset may limit the higher dose regimen. Allopurinol (300 mg daily) may be used to prevent gout but may precipitate an acute attack when it is first used.