Fundoplication for GERD in children

Gastro-esophageal reflux disease (GERD) is not commonly seen in the Indian populations as is seen in the western world. Most commonly children with GERD will present with recurrent vomiting.

Other common signs and symptoms in infants and young children include the following:

  • 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)

Cause of GERD: 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.

Diagnosis

Most cases of pediatric gastroesophageal reflux are diagnosed based on the clinical presentation. Conservative measures can be started empirically. However, if the presentation is atypical or if therapeutic response is minimal, further evaluation via imaging is warranted.

Investigations

The following procedures are used to visually assess the esophagus and stomach:

  • Esophageal manometry
  • Esophagogastroduodenoscopy

Biopsies may also be performed during esophagogastroduodenoscopy for histopathologic evaluation.

Radiologic studies used to evaluate pediatric gastroesophageal reflux include the following:

  • Upper gastrointestinal imaging series
  • Gastric scintiscan study
  • Esophagography

Physiologic and electrophysiologic studies

The following studies are used to detect gastroesophageal reflux:

  • Intraesophageal pH probe monitoring: Criterion standard for quantifying gastroesophageal reflux
  • Intraluminal esophageal electrical impedance: For detecting acid and nonacid reflux by measuring retrograde flow in the esophagus; normal values have not been determined in the pediatric age group.

Management

The goals of medical therapy in gastroesophageal reflux are to decrease acid secretion and, in many cases, to reduce gastric emptying time.

Nonpharmacotherapy

Conservative measures in treating children with gastroesophageal reflux include the following [1]:

  • Providing small, frequent feeds thickened with cereal
  • Upright positioning after feeding
  • Elevating the head of the bed
  • Prone positioning (infants >6 months)

Older children with gastroesophageal reflux may benefit from the following:

  • Smaller, more frequent feeds
  • Relatively lower fat diet (lipids retards gastric emptying)
  • Proper eating habits
  • Weight loss

For patients who fail medical therapy, continuous intragastric administration of feeds alone (via nasogastric tube) may be used as an alternative to surgery[2].

Pharmacotherapy

The following medications are used in pediatric patients with gastroesophageal reflux disease:

  • Antacids (eg, aluminum hydroxide, magnesium hydroxide)
  • Histamine H2 antagonists (eg, nizatidine, cimetidine, ranitidine, famotidine)
  • Proton pump inhibitors (eg, lansoprazole, omeprazole, esomeprazole,[3] dexlansoprazole, rabeprazole sodium, pantoprazole)

No currently available prokinetic drug (eg, metoclopramide) has been demonstrated to exert a significant influence on the number or frequency of reflux episodes.

 

Surgical option

Surgical intervention such as gastrostomy or fundoplication (see the video below) is required in only a very small minority of patients with gastroesophageal reflux (eg, when rigorous medical step-up therapy has failed or when the complications of gastroesophageal reflux pose a short- or long-term survival risk). The goal of surgical antireflux procedures is to “tighten” the region of the lower esophageal junction and, if possible, to reduce hiatal herniation of the stomach (occasionally seen in patients with gastroesophageal reflux disease). The surgery is know as Fundoplication which may or may not be added with a feeding gastrostomy as the condition warrants. Below is a vdeo of a 6 month old baby who underwent Nissens’s fundoplication with feeding gastrostomy as he had massive reflux flooding the lungs and leading to near death syndrome.

 

 

REFERENCES:

  1. Chao HC, Vandenplas Y. Effect of cereal-thickened formula and upright positioning on regurgitation, gastric emptying, and weight gain in infants with regurgitation. Nutrition. 2007. 23:23-28.
  2. Orenstein SR. Management of supraesophageal complications of gastroesophageal reflux disease in infants and children. Am J Med. 2000. 108 (4A):139S-143S.
  3. Tolia V, Gilger MA, Barker PN, Illueca M. Healing of Erosive Esophagitis and Improvement of Symptoms of Gastroesophageal Reflux Disease After Esomeprazole Treatment in Children 12 to 36 Months Old. J Pediatr Gastroenterol Nutr. 2015 Jul. 60 Suppl 1:S31-6.

 

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