Gastroesophageal

Reflux Disease
(GERD)

National Pediatric Hospital

Head of Surgical Department
CHOEU HOR.MD.MSc.PhD
 I. Introduction
• Vomiting and regurgitation are common occurrences
in childhood.
• Seventy percent (70%) of 4-month-old infants
regurgitate daily but only 25% of their parents
consider it a problem.
• The challenge for physicians is to differentiate the
symptoms that are physiologic and will resolve
spontaneously from those that need medical or
surgical intervention.

2
 I. Introduction
• Gastroesophageal reflux disease (GERD) is defined as
the pathologic consequences of the involuntary passage
of gastric contents into the esophagus.
• Gastroesophageal reflux disease (GERD) is the most
common esophageal disorder in children of all ages.
• Gastroesophageal reflux (GER) signifies the retrograde
movement of gastric contents across the lower
esophageal sphincter (LES) into the esophagus, which
occurs physiologically every day in all infants, older
children, and adults.
3
 I. Introduction
• Physiologic GER is exemplified by the effortless
regurgitation of normal infants.
• The phenomenon becomes pathologic GERD in
infants and children who manifest or report
bothersome symptoms because of frequent or
persistent GER, producing esophagitis-related
symptoms, or extraesophageal
presentations, such as respiratory
symptoms or nutritional effects.

4
I. Introduction

5
 II. Etiology
• The precise mechanisms that predispose infants and children
to gastroesophageal reflux are unknown.
• A high pressure zone in the lower portion of the esophagus
plays an important role in the prevention of gastroesophageal
reflux.
• A critical length of intra abdominal esophagus is necessary to
prevent GERD.
• Anatomical defects that affect the high pressure zone of the
gastroesophageal junction and interfere with rapid clearing of
physiologic gastroesophageal reflux are associated with
significant reflux pathology.
6
II. Etiology

7
 III. Pathophysiology
• The competence of the cardia is due to the tone of the LES(1),
the length(2) of the abdominal esophagus, the diaphragmatic
hiatus(3), the angle(4) of His, the esophageal mucosa(5), the level
of intra-abdominal pressure(6), and the ability of the stomach
to empty(7).
• Reflux occurs when intra-gastric pressure exceeds the ability of
the above factors to resist it and the gastric fluid then flows down
a pressure gradient.
• The nature of the refluxate may injure the esophageal mucosa
due to acid and biliary secretions; defensive mechanisms include
esophageal clearing, and salivary and mucous secretions of the
esophageal mucosa.
8
III. Pathophysiology

9
 III. Pathophysiology
• Factors determining the esophageal manifestations of
reflux include the duration of esophageal exposure (a
product of the frequency and duration of reflux
episodes), the causticity of the refluxate, and the
susceptibility of the esophagus to damage.
• The LES, defined as a high pressure zone by
manometry, is supported by the crura of the
diaphragm at the gastroesophageal junction, together
with valve-like functions of the esophagogastric
junction anatomy, form the anti reflux barrier.
10
 III. Pathophysiology
• Transient LES relaxation (TLESR) is the primary mechanism
allowing reflux to occur, and is defined as simultaneous
relaxation of both LES and the surrounding crura.
• Gastric distention is the main stimulus for TLESRs.
• Factors influencing gastric pressure–volume dynamics, such as
increased movement, straining, obesity, large-volume or
hyperosmolar meals, gastroparesis, a large sliding hiatal
hernia, and increased respiratory effort
(coughing, wheezing) can have the same
effect.

11
 IV. Clinical Presentations
• The presentation of GERD in Infants and Children is variable and
depends on the patient’s age and overall medical condition.
• Most of the common clinical manifestations of esophageal disease can
signify the presence of GERD and are generally thought to be mediated
by the pathogenesis involving acid GER.
• Infantile reflux manifests more often with regurgitation, signs of
esophagitis (irritability, arching and resulting failure to thrive; symptoms
resolve spontaneously in the majority of infants by 12-24 mo.
• Older children can have regurgitation during the preschool years; this
complaint diminishes somewhat as children age, and complaints of
abdominal and chest pain supervene in later childhood and
adolescence.
12
13
 Symptoms According to Age
MANIFESTATIONS INFANTS CHILDREN ADOLESCENTS
AND ADULTS

Impaired quality of life +++ +++ +++

Regurgitation ++++ + +
Excessive crying/irritability +++ + -
Vomiting ++ ++ +
Food refusal/feeding disturbances/anorexia ++ + +
Persisting hiccups ++ + +
Failure to thrive ++ + -
Esophagitis + ++ +++
Persistent cough/aspiration pneumonia + ++ +
Wheezing/laryngitis/ear problems + ++ +
Laryngomalacia/stridor/croup + ++ -

14
 Symptoms According to Age
MANIFESTATIONS INFANTS CHILDREN ADOLESCENTS
AND ADULTS
Sleeping disturbances + + +
Anemia/melena/hematemesis + + +
Heartburn/pyrosis ? ++ +++
Epigastric pain ? + ++
Chest pain ? + ++
Dysphagia ? + ++
Dental erosions/water brush ? + +
Chronic asthma/sinusitis - ++ +
Stenosis - +/- +
Barrett/esophageal adenocarcinoma - +/- +

15
 Symptoms and Signs That May Be
Associated with Gastroesophageal Reflux
• Symptoms • Signs
– Recurrent regurgitation with or – Esophagitis
without vomiting – Esophageal stricture
– Weight loss or poor weight gain – Barrett esophagus
– Irritability in infants – Laryngeal/pharyngeal inflammation
– Ruminative behavior – Recurrent pneumonia
– Heartburn or chest pain – Anemia
– Hematemesis – Dental erosion
– Dysphagia, odynophagia – Feeding refusal
– Wheezing – Dystonic neck posturing (Sandifer
– Stridor syndrome)
– Cough – Apnea spells
– Hoarseness – Apparent life-threatening events

16
 V. Diagnosis
• The history and physical examination are the most
important components of the evaluation of an infant or
child with GERD.
• The history is an invaluable asset when evaluating for the
presence of GERD and for the determining the need for
antireflux therapy.
• Reflux-related symptoms such as failure to thrive, recurrent
coughing, reactive airways disease, stridor, apnea, recurrent
aspiration pneumonia, irritability, heartburn, abdominal pain,
and dysphagia are all seen in patients with symptomatic
GERD.
17
 V. Diagnosis
• In general, infants and children are high volume
refluxers.
• Recurrent vomiting is a common clinical event
reported in these children.
• There are several diagnostic tests to determine a
pathological reflux.
• It depends on the underlying problem whether or
not an extensive diagnosis is needed.

18
 V. Diagnosis
1. Contrast radiographic study of the esophagus and
upper gastrointestinal tract is performed in children
with vomiting and dysphagia to evaluate for
achalasia, esophageal strictures and stenosis, hiatal
hernia, and gastric outlet or intestinal obstruction.
- Upper gastrointestinal radiography is the most
frequent initial study employed.
- Evidence for reflux is sometimes seen on
examination.

19
 V. Diagnosis
• The contrast study is most useful for delineating the
anatomy of the esophagus and esophagogastric
junction.
• It also evaluates esophageal clearance and assesses
esophageal and gastric motility.
• The contrast study can identify the presence of
esophageal strictures, webs, or distal obstruction as
the cause of the reflux symptoms.

20
 V. Diagnosis
• It has poor sensitivity and specificity in the
diagnosis of GERD as a result of its limited
duration and the inability to differentiate
physiologic GER from GERD.

21
ACHALASIA

22
 V. Diagnosis
2. Esophageal pH monitoring measures the duration
and frequency of acid reflux episodes.
• 24h pH monitoring is the gold standard for
establishing the diagnosis of GER, especially in
infants and children whose history is unclear.
• The study is performed by placing an electrode 2 to 3
cm proximal to the gastroesophageal junction and
measearing the pH in the distal of esophagus.

23
24
25
 V. Diagnosis
• Normal values of distal esophageal acid exposure (pH
< 4) are generally established as <5-8% of the total
monitored time, but these quantitative normals are
insufficient to establish or disprove a diagnosis of
pathologic GERD.
• A reflux episode is defined as an esophageal pH of
less than 4 for a period of 15–15 s.
• Ideally, the examination should occur over an
uninterrupted 24-hour period.

26
 V. Diagnosis
3. Endoscopy:
• Endoscopy allows diagnosis of erosive esophagitis
and complications such as strictures or Barrett
esophagus; esophageal biopsies can diagnose
histologic reflux esophagitis in the absence of
erosions while simultaneously eliminating allergic
and infectious causes.
• Endoscopy is also used therapeutically to dilate
reflux-induced strictures.

27
28
 V. Diagnosis
4. Scintigraphy:
• Nuclear scintigraphy scanning is commonly used to detect
delayed gastric emptying in children with GER.
• Many children with GER show delayed gastric emptying.

29
 V. Diagnosis
5. Manometry
• Manometric investigations of esophageal function were
introduced as a diagnostic procedure in the late 1960s,
primarily to measure pressure in the LES.
• It was presumed at the time that low pressures are
responsible for the reflux.
• Manometry is an excellent method to demonstrate the
motor function and peristalsis of the esophagus.
• It shows that reflux of the contents of the stomach occurs
during spontaneous transient relaxations of the LES.
30
31
 VI. Differential Diagnosis
• An upper GI study can often help differentiate the
presence of achalasia or duodenal stenosis from GER.
• Esophageal biopsies can detect eosinophilic esophagitis.
• A good history will usually define cyclical vomiting as
opposed to GER.

Age,
History,
Past History,
Symptoms

32
 VII. Treatment
A. Medical management
• Position and Feeding
– Most infants and children who have symptoms of
gastroesophageal reflux can benefit from changes in life
style.
– Smaller, frequent feeding is encouraged in babies instead
of larger feedings at infrequent intervals.
– Infants and children with poor weight gain can be fed
diets with higher caloric density.
– Hypoallergenic feedings can also be given to infants who
may be vomiting due to a reaction to a particular formula.
33
 VII.Treatment
A. Medical management

• Prone positioning is acceptable if the

baby is awake, in the postprandial period.
• In older children, conservative treatment includes
weight loss if the patient is overweight, and
avoidance of large meals, caffeine, chocolate, and
spicy foods.
• The addition of proton pump inhibitors (PPIs) or
histamine-2 receptor antagonists (H2RA) have been
shown by randomized studies to be helpful in treating
GERD in children.
34
 VII. Treatment
A. Medical management
• Pharmacologic Therapy
– If symptoms persist despite a well-monitored program
of postural therapy and dietary modifications,
pharmacologic measures should be added.
– Medical therapy includes the administration of one or
more drugs that increase esophageal peristalsis,
increase LES pressure, increase gastric emptying, or
lessen gastric acid production.
– Antacids are the most commonly used antireflux
therapy and are readily available over the counter.
35
 VII. Treatment
A. Medical management
• Prokinetic Agents
– Historically, prokinetic agents have been utilized in an
attempt to increase LES pressure, enhance esophageal
peristalsis, and accelerate gastric emptying.
– The use of cisapride and, more recently, metoclopramide,
has been questioned with regard to their safety.
• Cisapride: 0,15-0,3mg/kg/dose *3 times (Max: 10mg/day)
• Metoclopramide: 0.5mg/kg/day * 4 times (before meal 15mn)
• Domperidone: 1mg/kg/day *3 times before meal 15mn

36
 VII. Treatment
A. Medical management
• Acid Alteration
– Measures to reduce gastric acidity should be given to
patients with complicated reflux, especially with esophagitis.
– Histamine-2 (H2)-receptor antagonists, or by PPIs.
– PPIs inhibit the final step of gastric acid secretion by blocking
proton production by bonding and deactivating H+,K+-
ATPase (or proton pump) by traversing the parietal cell
membrane and accumulating in the secretory canaliculi.
• Ranitidine: 4-10 mg/kg/day 2 or 3 × a day
• Omeprazole: 1 - 3,3mg/kg/day (am before 30mn) <20kg
10mg/day, >20kg: 20kg

37
 B. SURGICAL THERAPY
• Surgery of reflux is not indicated in most of the newborns and
infants due to the spontaneous maturation of the esophageal
function within the first year of life.
• Operative management usually follows failed medical
management for growth failure (failure to thrive or gain
weight appropriately), most respiratory symptoms, and other
symptoms such as pain and esophagitis.
• The strategic principles of reflux surgery consist of creating an
intra-abdominal portion of the esophagus and a complete
(Nissen) or partial plication (dorsal Toupet, ventral Thal) of the
gastric fundus around the esophagus.
38
 B. Surgical Management
• Surgical management is indicated for children in
the following circumstances:
1. Failure of medical therapy,
2. Presence of an associated anatomical defect such as
a hiatal hernia, malrotation, or diaphragmatic hernia,
3. Esophageal stricture secondary to GERD,
4. Postesophageal atresia repair with a recurrent
stricture that does not respond to medical treatment,
5. Neurologically impaired children who have difficulty
feeding and have serious reflux-associated symptoms.
39
40
 VIII. Complication
• Medical:
– Malnutrition
– Developmental delay
– Esophageal: Esophagitis, Sequelae (Stricture, Barrett) and
Adenocarcinoma…
• Surgical:
– Complications may be classified according to their occurrence
—early or late after surgery. Early complications include
dysphagia, which usually resolves within a few weeks.
– The most common complication is recurrent reflux, which has
been observed with all three surgical methods.

41