Gastro-oesophageal reflux
Key points
Reflux is common in infants - physiological - lower oesophageal sphincter relaxes too much, infants have smaller stomach and oesophagus - so it cannot be used as a reservoir
Gastro oesophageal reflux becomes pathological when there are complications
Reflux/Vomiting/Chalasia of infancy is very common and children - 60-70% up to 6 months of age
It does not interfere with normal growth and development and not clinically significant
There are no identifiable causes
Spontaneous resolution by 2 years of age irrespective of any treatment.
Reasons for resolution are:
Improved Lower oesophageal sphincter tone
Upright posture
Less use of abdominal accessory muscles of respiration
Progression to general diet
Factors preventing reflux
Anatomical Factors
Lower Oesophageal Sphincter (position, length, pressure)
Intra-abdominal Oesophagus
The Angle of His
Lower oesophageal mucosal rosette
Diaphragmatic crural slings
Physiological Factors
Permanent tone of the LOS
Contraction of crural slings
Normal gastric emptying
Oesophageal peristalsis
Secretions
Mucosal regeneration
Conditions predisposing to GORD
Medical Conditions
Neurodevelopmental disorders: Lower tone of LOS
Poor motility of oesophagus and stomach (Gastroparesis)
Aerophagia
Abdominal wall spasm
Supine positions
Medication side effects
Surgical Conditions
Oesophageal atresia
Congenital Diaphragmatic hernia
Anterior abdominal wall defects
Hiatal Hernia
Gastrostomy
Malrotation
Organs and systems affected by GORD
Oesophagus
Oesophagitis (Pain)
Ulcers (Bleeding)
Strictures (Dysphagia)
Barrett’s oesophagus
Dental Caries
Halitosis
Chronic sinusitis
Chronic Otitis Media
Respiratory system (direct and indirect effects)
Indirect effects on the respiratory system
Oesophageal stimulation via acidification of the oesophageal mucosa causes vagally mediated laryngospasm and bronchospasm which clinically presents as apnoea, choking or mistakenly as asthma
Direct effects are due to reflux and aspiration into the respiratory tract
Chronic cough
Wheezing
Choking
Apnoea
Near sudden infant death syndrome
Recurrent bronchitis
Apparent Life-Threatening Events (ALTE): an episode that is frightening to the observer and that is characterised by some combination of apnoea (central or occasionally obstructive), colour change (usually cyanotic or pallid), marked change in muscle tone, choking or gagging. A single episode calls for discussion for surgical intervention.
Aspiration Pneumonia - chemical or bacterial
Longer hospitalisation
Higher rates of morbidity
Higher rates of mortality
Higher rates of PICU admissions
Higher readmission rates compared to other pneumonias
Sandifer Syndrome
Rare complications of GORD
To improve peristalsis and improve oesophageal emptying.
Misdiagnosed with various neuropsychiatric diagnoses
Unnecessary testing
Ineffective medications
Significant side effects
Early diagnosis is the key
Abnormal movement/position of head, neck, upper limb and trunk
Seizure like episodes
Ocular symptoms
Irritability
EEG may rule out neurological causes
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
Medical Therapy
Histamine H2 receptor antagonists
Proton pump inhibitors
Alginate formulas (Gaviscon)
Probiotics
Baclofen (GABA B Agonist)
Dual delayed release PPI (Dexlansoprazole)
Gastric Electrical Stimulation
Surgical Therapy
Gastrojejunostomy
Tube Jejunostomy
Surgical jejunostomy
Fundoplication (Nissan, Thal, Toupet)
Total Oesophagogastric dissociation
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 Prof. Ashok Daya Ram MBBS, FRCS, FRCPS, FEBPS, FRCS (Paed Surgery), Consultant Paediatric and Neonatal Surgeon, Norfolk and Norwich University Hospital, Norwich, UK. June 2025
Page edited by Mrs Charnjit Seehra BSc. June 2025
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/