Gastro-oesophageal reflux

Key points

Reflux is common in infants - 60-70% up to 6 months of age - physiological - lower oesophageal sphincter relaxes too much, infants have smaller stomach and oesophagus - so it cannot be used as a reservoir

Becomes pathological when there are complications

History

Timing of symptoms with feeds

Passive or active vomiting

Retching

Other conditions

Dystonic neck posturing (Sandifer syndrome)

Apnoeas and acute life-threatening events (ALTE)

Respiratory tract infections and worsening asthma

Examination

Signs of malnutrition

Faltering growth - plot height and weight on chart

Tooth decay

Investigations

pH study - quantifies amount of acid

pH impedance study - directional, quantifies acid-alkali reflux, can link it to symptoms and feeding, can show level of reflux

Impedance is 3x more expensive and takes specialist to analyse, no standardised results in children

Use pH study for unclear diagnosis e.g. secretions vs reflux

Not necessary to do pH study for patients less than 6 months of age

Interpreting pH impedance study

• Ask if on PPI

• Look for pH of reflux episodes

• Number and length of episodes

• What oesophageal level reflux reaches

• Correlate to vomits and feeds

• Compare to expected values set by department

Before undertaking surgical management

Do pH impedance study to confirm reflux

UGI contrast to look for malrotation and hiatus hernia - these will alter surgical management

Oesophageal manometry to exclude achalasia

OGD + biopsy (can be done at same time as pH study) to look for reflux oesophagitis, metaplasia (Barretts) and eosinophilic oesophagitis

Sleep study for ALTE

Management

Management ladder for 4-month-old with reflux

1. PPI and Ranitidine

2. NG tubes, thickened feed

3. NJ tube to protect growth

4. MDT approach if long term jejunal feeding is needed - PEGJ

2010 systematic review - PPIs not shown to reduce symptoms of reflux in infants - unclear causal link

PEGJ vs Fundoplication

PEGJ advantages

• Allows gastric drainage

• Enables secure jejunal feeds overnight

• Smaller procedure compared to fundoplication - complications less severe

• Suitable for patients with CNS driven vomiting/retching

PEGJ disadvantages

• Tube frequently blocks/dislodges

• Commits patient to continuous jejunal feeding (although this can be transitioned to gastric feeds sometimes)

• Does not fully prevent reflux, but improves symptoms - ideally NG/NJ should be trialled first

Fundoplication advantages

• Permits oral and gastric feeding

• No need for logistics of continuous feeding

• Prevents/reduces reflux

Fundoplication disadvantages

• Major procedure, complications difficult to manage

• Not suitable for patients with CNS driven vomiting/retching

• Gas bloat/gastric dilatation is possible, may need gastrostomy to decompress

  
  
  
  

Each patient consultation for reflux should take an individualised approach when deciding which procedure (if any) is appropriate. The parents should be counselled about the above advantages and disadvantages and should take an active role in decision making.

When deciding to do a fundoplication consider:

1. Is gastric feeding feasible?

2. Is it a lower oesophageal sphincter problem that can be corrected by fundoplication

3. If patient has a small stomach that spontaneously contracts, fundoplication is not a good idea as it will shrink stomach and cause a closed system

4. Should a PEG be placed as well to decompress?

Do not do fundoplication for Barratts oesophagus - does not alter outcomes - offer ablation

Do not do fundoplication for eosinophilic oesophagitis

Do not do fundoplication for retching - may make worse

Fundoplication only of benefit for ATLE if symptoms related to reflux

Fundoplication

Laparoscopic approach is standard

Nathanson liver retractor - normal for left lobe to go purple and have raised LFT. Make sure tip of retractor is off liver

Baseball diamond port placement

Incise pars flaccida, expose GOJ, reduce hiatus hernia if present, divide short gastrics with ligasure (sometimes not needed)

Protect spleen

Retro-oesophageal crural apposition suture(s), not too tight

Make sure fundus is mobilised enough - then wrap:

Types of wrap:

Posterior - Nissen 360°, Toupet 270°

Anterior - Watson (Thal is similar) 180°, Dor 180°

After fundoplication - Antireflux medication can be stopped in neurologically normal. May have to be restarted in neurologically impaired

Fundoplication does not affect hospitalisation rate for aspiration pneumonia or symptoms of severe reflux

Generally favourable outcomes reported after fundoplication - but poor quality evidence - difficult to estimate true benefits

Complications

If recurrent vomiting - possible wrap migration into chest (hiatus hernia) - do UGI contrast - if confirmed then needs redo fundoplication

If no hiatus hernia then likely loose wrap, do pH study to confirm - if confirmed then needs redo fundoplication

If dysphagia/regurgitation/food bolus obstruction - likely wrap too tight - do UGI contrast - if confirmed do trial of dilatations, if unsuccessful needs redo fundoplication but not full 360° wrap

Gastroesophageal dissociation is not a commonly practiced procedure - is last resort for complex cases of intractable reflux/vomiting

Cystic fibrosis and reflux

Half of CF patients have reflux

Fundoplication helps slow lung decline

Consider fundoplication if doing lung transplant

Eosinophilic oesophagitis

Vomiting, dysphagia/food bolus obstruction

Endoscopy and oesophageal biopsies to confirm diagnosis

The oesophageal mucosa may appear normal or have the following features:

• 'Corrugated' rings or 'trachealisation'

• Longitudinal furrows

• White plaques

• Stricture

• Friable, bleeding mucosa

Histology diagnostic criterion is >15 eosinophils per high powered field

Manage with topical ingested steroids - fluticasone/budesonide

Page edited by Mrs Charnjit Seehra BSc November 2024

References

Hirschl, Ron, et al., editors. "Gastroesophageal Reflux." Pediatric Surgery NaT, American Pediatric Surgical Association, 2023. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829036/all/Gastroesophageal_Reflux.

Thakker H; Clarke S, ePIPS podcast Gastro-oesophageal reflux https://soundcloud.com/epips

Ng J, Friedmacher F, Pao C, Charlesworth P. Gastroesophageal Reflux Disease and Need for Antireflux Surgery in Children with Cystic Fibrosis: A Systematic Review on Incidence, Surgical Complications, and Postoperative Outcomes. Eur J Pediatr Surg. 2021 Feb;31(1):106-114. doi: 10.1055/s-0040-1718750. Epub 2020 Nov 17. PMID: 33202431; PMCID: PMC7853868.

Roussel JM, Pandit S. Eosinophilic Esophagitis. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459297/