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<TITLE>GASTROESOPHAGEAL REFLUX</TITLE>

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<P ALIGN="CENTER">GASTROESOPHAGEAL REFLUX</B></FONT>


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Gastroesophageal reflux (GER) is the regurgitation of acidic gastric contents into the esophagus. About one-third of the 

roughly 8 million babies born annually in the US will have GER during the first few months of life; the great majority of these infants will resolve their 

reflux by their first birthday. Infants with serious symptoms or children with continuing symptoms of GER should be treated to eliminate both the associated 

symptoms and the complications.</p>

 
<font face="Trebuchet MS" size="3"><strong>Symptoms</strong> 

<font face="Trebuchet MS" size="2">Symptoms of GER in children are numerous but are inconsistent between patients. Crying, refusing food, failure to gain weight, or complaints of chest pain 

in older children might be signs of acid irritation of the esophagus. Halitosis, belching, or effortless regurgitation could indicate the presence of 

gastric contents within the esophagus. Cyanotic episodes, coughing, voice changes, recurrent episodes of pneumonia, or symptoms of reactive airway disease 

may indicate aspiration of refluxed gastric contents onto or through the vocal cords. Chronically poor dentition or frequent episodes of otitis media or 

sinusitis, can indicate regurgitation of gastric contents into the mouth or nasopharynx is occurring during sleep. Chronic GER may result in the development 

of metaplasia of the distal esophageal mucosa, i.e., a change from squamous to columnar epithelium (Barrett’s esophagus). This occurs in about 10% of all 

patients seeking treatment for symptomatic GER. Barrett’s esophagus is a premalignant condition. The risk of developing adenocarcinoma of the esophagus with 

this condition is low—about 0.5%—but this is still 30 to 125 times the usual risk.</p>

 
The presence of a hiatus hernia is a risk factor for developing GER but does not necessarily indicate that GER is occurring. Formula-fed infants are more 

likely to reflux than breast-fed. Infants ‘burped’ frequently when feeding are less likely to reflux. Overfed infants are predisposed to reflux.</p>


<font face="Trebuchet MS" size="3"><strong>Diagnosis</strong>

<font face="Trebuchet MS" size="2">Useful diagnostic studies include upper GI radiography (UGI), reflux sonography (RS), esophageal pH monitoring, esophageal impedance monitoring (IM), and 

esophagogastroscopy (EGD). The UGI and RS can each detect about 80% of cases of GER; but because these tests are not mutually inclusive, about 10% of cases 

will still go undiagnosed. A pH study is the most accurate test for acid reflux, but it must be performed after the child has been off of antacid 

medications for several days, and it usually requires general anesthesia to ensure proper probe placement. IM is not pH-dependent, and a combined pH/IM 

study may become the “gold standard” for diagnosing GER. EGD is not as helpful in the diagnosis of GER as it is in assessing the effects of GER such as 

chronic inflammatory changes, or, in older patients with long-standing disease, Barrett’s esophagus.</p>


<font face="Trebuchet MS" size="3"><strong>Etiology</strong>

<font face="Trebuchet MS" size="2">A complex interaction between the anatomy of the area and muscle activity normally results in a functional ‘one-way valve’ at the gastroesophageal junction. 

The angle between the stomach and the esophagus entering the stomach (the angle of His) is of particular importance in preventing GER; when a cadaver stomach 

with an intact angle of His is filled with water, it will usually rupture before reflux occurs.</p>


<font face="Trebuchet MS" size="3"><strong>Treatment options</strong>

<font face="Trebuchet MS" size="2">The treatment of GER in infants and children includes non-medicinal, pharmaceutical, and surgical methods.</p> 

Non-medicinal methods include thickening of infant formulas with rice cereal or with modified cornstarch (e.g., Thick-It), positioning the child on his 

stomach or left side, and elevating the head of the bed. Although food and even water may be artificially thickened, prepared thickened formulas such as 

Enfamil AR (Added Rice) are also available.</p>


Medications effective in treating GER include proton pump inhibitors (esomeprazole [Nexium], lansoprazole [Prevacid], omeprazole [Prilosec], pantoprazole 

[Protonix], rabeprazole [Aciphex]); antacids (Maalox, Mylanta, Riopan, Rolaids, Tums); H2 receptor blockers (cimetidine [Tagamet], famotidine 

[Pepcid], ranitidine [Zantac]); and prokinetics (metoclopramide [Reglan], cisapride [Propulsid, no longer available in the US], bethanechol). 

Practically speaking, the first three classes of medications are aimed at reducing only the acid-related effects of GER, not the GER itself, while 

prokinetics alone promote prograde esophageal motility and gastric emptying.</p>


The ‘gold standard’ for the surgical treatment of GER in children is the fundoplication, with the Nissen version being the most frequently performed, 

although the Thal and Toupet varieties are preferred by some surgeons.</p>


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In the Nissen fundoplication, the fundus of the stomach is passed behind the distal esophagus (Figure 1), wrapped around the esophagus 360o, and sutured or 

plicated to itself anteriorly (Figure 2). We commonly perform the Nissen fundoplication laparoscopically. While the procedure is highly effective at 

preventing GER, precisely how the procedure works is unclear. Restoring the angle of His, providing gentle pressure on the distal esophagus, placing the 

distal 2 cm of the esophagus within the abdomen, and repairing any hiatal hernia present are all plausible reasons for the approximately 90% success rate of 

the procedure. Complications include making the wrap too tight (may cause future difficulty in swallowing), making the wrap too loose (may allow some mild 

residual GER), or dehiscence of the plication (a 5-10% risk, which causes a return to preoperative GER). About one-third of all children who undergo a 

Nissen fundoplication will experience gagging or retching, but this usually resolves spontaneously within a few months.</p>


In the Thal procedure, the fundus of the stomach is wrapped anteriorly, and only 270º rather than 360º. In the Toupet procedure, the wrap is posterior and 

180º. Both of these latter procedures have a lower risk of dysphagia, but both also carry a higher risk of post-operative GER.</p>


Four procedures have gained approval by the FDA for the endoscopic treatment of GER in adults—the Endocinch, the Stretta procedure, the NDO Surgical 

Plicator, and the Enteryx. The Endocinch places sutures at the GE junction, gathering the tissue into pleats and tightening the junction. In the 

Stretta procedure, a probe is positioned at the GE junction and high-frequency radio waves are emitted. The radio waves induce the development of 

scar tissue which tightens the junction. The Plicator is similar to the Endocinch but has been recalled. The Enteryx procedure involved injection of a 

polymer into the GE junction, but this was removed from the market by the FDA due to complications. The long-term efficacy of each method is undetermined, 

and none are approved yet for use in children.


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