Pediatric Gastroesophageal Reflux

Introduction
• In pediatric gastroesophageal reflux disease
(GERD), immaturity of lower esophageal
sphincter function is manifested by frequent
transient lower esophageal relaxations, which
result in retrograde flow of gastric contents
into the esophagus.
 Signs and symptoms

•  most often directly related to:

• 1- the consequences of emesis (eg, poor
weight gain)
• 2-the result from exposure of the esophageal
epithelium to the gastric contents.
• - The typical adult symptoms (eg, heartburn,
vomiting, regurgitation) cannot be readily
assessed in infants and children.
 Signs and symptoms

• Pediatric patients with gastroesophageal

reflux disease typically cry and show sleep
disturbance and decreased appetite.
 Other s and s
• Typical or atypical crying and/or irritability
• Apnea and/or bradycardia
• Poor appetite; weight loss or poor growth (failure to thrive)
• Apparent life-threatening event
• Vomiting
• Wheezing, stridor
• Abdominal and/or chest pain
• Recurrent pneumonitis
• Sore throat, hoarseness and/or laryngitis
• Chronic cough
• Water brash
• Sandifer syndrome (ie, posturing with opisthotonus or torticollis)
 Diagnosis

• Most cases of pediatric gastroesophageal

reflux are diagnosed based on the clinical
presentation.
• Conservative measures can be started
empirically.

• if the presentation is atypical or if therapeutic

response is minimal, further evaluation via
imaging is warranted.
 Diagnostic Considerations

• GERD should not be considered if :

1.Bilious or forceful vomiting
2.Hematemesis or hematochezia
3.Vomiting with diarrhea
4.Abdominal tenderness or distention
5.Onset of vomiting after 6 months of life
6.Fever, lethargy, hepatosplenomegaly
7.Macrocephaly, microcephaly, seizures
 DDx
• Antral web
• Intestinal motility disorders
• Irritable bowel syndrome
• Peptic ulcer disease
• Sudden infant death syndrome
• Tracheoesophageal fistula
 DDx
• Acute Gastritis
• Chronic Gastritis
• Eosinophilic Esophagitis
• Eosophageal motility disorders
• Food allergies
• Helicobacter P infection
• Intestinal malrotation
• PUD
 Work up
• Manometry
• This is becoming a more accessible tool for
use in infants and children. It is used to assess
esophageal motility and lower esophageal
sphincter (LES) function.
• Esophagogastroduodenoscopy
• This modality is useful in patients who are
unresponsive to medical therapy. It allows for
visualization of the mucosa for diagnosis of
peptic ulcer disease, Helicobacter pylori
infection, strictures, and peptic esophagitis. It
also provides access to obtain biopsies for
histopathologic examination.
• Histologic findings
• Histologic signs of peptic esophagitis include
basal cell hyperplasia, extended papillae, and
mucosal eosinophils.
• The number of mucosal eosinophils may be
important because finding more than 20 per
high-powered field (hpf) has been associated
with eosinophilic (allergic) esophagitis rather
than with peptic esophagitis.
 Imaging Studies

• Upper GI imaging series/contrast

• to evaluate the anatomy of the upper
gastrointestinal (GI) tract
• neither sensitive nor specific for
gastroesophageal reflux.
• useful in the evaluation of gastric emptying
time, which may be delayed in
gastroesophageal reflux.
 Gastric scintiscan

• A gastric scintiscan study, using milk or

formula that contains a small amount of
technetium sulfur colloid, can assess gastric
emptying and reveal reflux (although not the
degree or severity of it).
• major diagnostic role is in the assessment of
pulmonary aspiration.
 Esophagography

• . Esophagography, conducted under fluoroscopic

control, may reveal the integrity of esophageal
peristalsis
• it should not be used to assess the degree and severity
of gastroesophageal reflux.
• Strictures can also be demonstrated by
esophagography.
• Chronic esophageal mucosal injury secondary to
gastroesophageal reflux involves a
mucosal/submucosal inflammatory cell infiltrate, as
well as basal cell hyperplasia=> may appear as a
ragged mucosal outline on radiography.
 Intraesophageal pH Probe Monitoring

• Although pH monitoring has become a widely overused modality, it

remains the criterion standard for quantifying gastroesophageal
reflux.
• sensitive monitoring modality,
• Recently :dual pH probe monitoring has come into use to assess
distal and proximal esophageal reflux in an attempt to correlate
gastroesophageal reflux with laryngeal and pulmonary symptoms.
• Advantages in using pH monitoring include the quantification of
reflux and the ability to establish a temporal relationship with
atypical symptoms (eg, obstructive apnea) and reflux events.
• Esophageal pH monitoring is not indicated in cases of obvious
gastroesophageal reflux but is useful in demonstrating an
association between reflux and symptoms in atypical presentations
and in grading the risk of esophagitis.
 Intraluminal Esophageal Electrical
Impedance
• Intraluminal esophageal electrical impedance
(EEI) is useful for detecting both acid reflux
and nonacid reflux by measuring retrograde
flow in the esophagus.
• Gastroesophageal reflux episodes as brief as
15 seconds may be measured.
• EEI has not been thoroughly validated, and
normal values have not been determined in
the pediatric age group.
Treatment
 Conservative and pharmacologic
therapy

• upright positioning after feeding

• elevating the head of the bed
• prone positioning (infants >6mo)
• small, frequent feeds thickened with cereal. [
• Older children benefit from a diet that avoids
tomato and citrus products, fruit juices,
peppermint, chocolate, and caffeine-containing
beverages.
• Smaller, more frequent feeds are recommended,
as is a relatively lower fat diet (because lipid
retards gastric emptying).
• Proper eating habits are encouraged and weight
loss and avoidance of alcohol and tobacco are
recommended when applicable.
•  In more severe cases, in addition to dietary
management, pharmacologic intervention
directed at reducing gastric acid secretion can
be employed.
 GER vs GERD
• About two thirds of otherwise healthy infants
spit up because of their physiology ("happy
spitters");
• these infants have simple gastroesophageal
reflux (GER) rather than true
gastroesophageal reflux disease (GERD),
• GERD : troublesome symptoms or
complications (eg, irritability, weight loss,
refusing to eat, coughing, or wheezing)
Algorithm for evaluation and "step-up" management of gastroesophageal reflux (GER
 Medications
• A therapeutic response to treatment for
gastroesophageal reflux may take up to 2 weeks.
• If treatment is successful, weight increases and
vomiting episodes decrease.
• Recurrent aspiration pneumonia or apnea is cause for
decreased length of medical therapy.
• No currently available prokinetic drug (eg,
metoclopramide) has been demonstrated to exert a
significant influence on the number or frequency of
reflux episodes.
•
 Antacids

• These agents are used as diagnostic tools to

provide symptomatic relief in infants.
• Associated benefits include symptomatic
alleviation of constipation (aluminium
antacids) or loose stools (magnesium
antacids).
• (Aluminum hydroxide,Magnesium hydroxide)
 Histamine H2 Antagonists

• They do not reduce the frequency of reflux

but do decrease the amount of acid in the
refluxate by inhibiting acid production.
• They are most effective in patients with
nonerosive esophagitis.
• (ranitidine ,famotidine,cimetidine)
 Proton Pump Inhibitors

• indicated in patients who require complete

acid suppression;
• infants with chronic respiratory disease or
neurologic disabilities.
• Administered with the first meal of the day.
• (omeprazole,Lansoprazole,Esomeprazole)
 Indications for Fundoplication and
Gastrostomy
• 1-Infants and children who have failed step-up
therapy for gastroesophageal reflux (typically
over 12 wk) and those who cannot be weaned off
of acid-reducing medications should be
considered for surgical treatment
• 2- atypical presentation (respiratory)
symptoms are clearly associated with
gastroesophageal reflux (eg, obstructive apnea
temporally associated with reflux during pH
monitoring) following a period of medical
therapy (including acid blockade)
 Indications for Fundoplication and
Gastrostomy
• 3-Patients with complications of gastroesophageal
reflux, such as aspiration, stricture of the esophagus,
or Barrett esophagus, should be considered for surgical
treatment
• 4-Patients with neurologic impairment that requires
feeding gastrostomy who are found to have pathologic
reflux and who remain medication dependent should
be considered for surgery
• 5-Patients with chronic reflux and recurrence of
anastomotic stricture after repair of esophageal atresia
should be considered for surgical treatment
 Fundoplication

• The goal of surgery for patients with GERD is

to reestablish the antireflux barrier without
creating obstruction to the food bolus.
• Nissen fundoplication :a complete 360° wrap,
controls the symptoms of gastroesophageal
reflux. 
• May lead to more episodes of dysphagia
(swallowing difficulty and discomfort) and gas
bloat than would a partial wrap.
Illustration of the Nissen fundoplication. Note how the stomach is wrapped around the
esophagus (360-degree wrap)