Vomiting, aspiration and respiratory symptoms like wheezing can result from a variety of GI and non-GI conditions
Most children have oropharyngeal dysphagia and aspiration of food rather than GERD. GERD actually lies very low on the differential.
The first line of investigation is videofluoroscopy
GI causes of are then investigated -food allergy is ruled out, formula is changed and feeds are thickened
The peak age of GERD presentation is 4-6 months of age
Once oropharyngeal dysphagia is ruled out, investigation is begun with a EGD and videolaryngoscopy. pH studies are NOT done and PPIs are NOT started at this point. This age group refluxes milk instead of acid and PPIs are not useful for the typical infant with GERD. For the same reason pH probes don’t pick up this non-acidic reflux.
PPIs also run the risk of c-diff enterocolitis, respiratory infections and necrotizing enterocolitis in this patient population.
Look for eosinophilic esophagitis (EE - most common) and other esophageal inflammatory conditions.
EE is seen in 10% of the patients presenting with GERD like symptoms and is an allergic condition. It can present with cough and failure to thrive in infants and chest pain and food impactions in older children.
EGD before PPIs is ideal as PPIs can also heal some of these non-GERD conditions preventing from arriving at a definitive diagnosis.
Allergic and eosinophilic esophagitis responds to PPIs in some cases. So, response to PPIs is no longer diagnostic for GERD. Allergic esophagitis when diagnosed is managed by eliminating allergens from food (like dairy products) and / or PPIs and / or steroids.
Patients with EE should NOT undergo Nissen fundoplication. Hence, it is crucial for all pediatric patients who present with reflux like symptoms to undergo evaluation by a gastroenterologist.
Normal Endoscopy – What next:
Next steps would be starting a macrolide to help in gastric emptying is other conservative measures like thickening of feeds do not help. Macrolides can also be used in premature infants and development of pyloric stenosis monitored.
PPIs are again not started at this point. pH probes are again useless as the number of reflux episodes are not standardized in pediatric patients and because of predominantly non-acidic reflux.
Patients with certain symptoms can be correlated with reflux episodes – for example a pH study may be more informative in patients with cough rather than those with wheezing.
These conservative measures are to be tried for several months and surgery should not be rushed according to Dr. Rosen.
Upper GI is done not just based on the reflux symptoms but is done to rule out other anatomical problems like malrotation etc. in a child who is vomiting and has failure to thrive. The frequency of such anatomical problems is <4%. UGI by itself is a poor study for reflux (Ref 3).
Management of "suspected GERD”:
Insertion of NG tube is the first step. Patients with oropharyngeal dysphagia will lose the symptoms once the NG tube in placed. Small volume oral feeds are given just to train the pharyngeal musculature.
Patients with suspected GERD who are unable to feed are initially managed with an NG tube for feeds. The patients are then evaluated clinically for reflux symptoms.
The decision for a Nissen + G tube versus juts a G tube is made ideally before discharging the patient.
There is no need to rush to surgery in a patient where reflux is not causing serious respiratory symptoms.
Patients can also be discharged with nasogastric feeds and serially evaluated with swallow studies for improvement of swallowing function. They can be maintained well with good parent education for a few months.
Retching is a symptom that has to be evaluated before surgery. Most of these patients will have retching post op and conservative management is ideal for these patients at least initially.
One usually progresses to nasojejunal feeds if NG feeds are also not tolerated. Nasojejunal feeds can be a predictor of real GERD and GERD symptoms tend to disappear with NJ feeds. However, one needs to be aware that delayed gastric emptying could also have resulted in intolerance to oral and NG feeds and doing a Nissen in these patients could convert the stomach into a closed system creating more problems. Combining the Nissen with a gastric drainage procedure will be good for the latter patients if the delayed gastric emptying is in deed confirmed by a nuclear medicine scan. The disadvantage with nasojejunal feeds is that they dislodge frequently and are really not ideal for home management. Tolerance to nasojejunal feeds and intolerance to NG feeds is one of the good indications for a Nissen.
Patients needing prolonged NJ feeds in the hospital need a Nissen. It is not ideal to send a patient home with NJ feeds. Most surgeons don’t obtain pH testing if NJ tolerance and NG intolerance is documented.
pH impedance testing:
pH impedance studies may be useful when GERD is strongly suspected in a patient needing a gastrotomy (especially in neurologically impaired patients).
Patients with serious respiratory issues like apnea episodes need impedance testing to ensure they are not due to GERD.
pH impedance is more useful in older children and adults: Non erosive esophagitis (NERD) is a condition where the EGD is normal but abnormal acid reflux is detected on pH impedance testing. Reflux hypersensitivity reflux is another condition where the amount of reflux is normal and EGD is normal but these children are hypersensitive to normal amount of reflux. Both these patient categories benefit from PPIs or anti-reflux surgery. Functional heartburn patients also have a normal EGD but the pH test does not correlate with symptoms. These patients need plain pain management. These disease classifications are a part of the ROME IV criteria.
When to do surgery?
PPIs have several side effects and it is important to wean them twice a year. One needs monitor the patients with CBC and electrolytes. Weaning should be tried after they have been on PPIs for 2 months.
Patients who need prolonged PPIs beyond 3-4 yrs are likely to need the same for life.
However, lifelong PPIs versus. Nissen is an issue that is not settled. Dr. Rosen prefers PPIs especially if symptoms are well controlled.
Neurological impairment per se is not an indication for Nissen. It depends on the severity of neurological impairment and its contribution to reflux symptoms.
Internationally, neurological impairment could be much worse requiring a Nissen in such international patients.
Use of blendarized solid food through G tubes prevents reflux and should be done before considering a Nissen.
These are especially useful for patients not tolerating NG feeds but tolerating NJ feeds plus have retching. A gastric emptying study can be obtained to make sure gastric emptying is not fast but most of these children benefit from pyloric botox injections. Botox can help these patients tolerate G tube feeds thus avoiding a Nissen. Botox has not just a motor but also a sensory effect.
Cyprohepatadine can also help with gastric accommodation.
The perfect Fundoplication (Ref 1 and 2):
The part of the outcome of fundoplication depends on how sure one is of the diagnosis. Patients with respiratory symptoms tend to be benefitted less as aspiration could be coming from the oral cavity and a distal esophageal functional obstruction with a Nissen will make the situation worse.
The perfect fundoplication relies on these two surgical principles:
Minimal mobilization of the esophagus. This creates minimal space between the esophagus and the crura.
Tacking the esophagus and the crura with sutures to obliterate this space.
Both the above techniques prevent transmigration of the wrap into the chest which is the commonest cause of failure of Nissen.
Both of these techniques have reduced transmigration rates from 12% to less than 5% in randomized trails. Also, both techniques are equivalent and thus suturing of the esophagus to the crura is not essential.
Minimal mobilization creates the risk of placing the wrap on the stomach instead of the esophagus. This is prevented by ensuring that the wrap is above the level of the Left Gastric artery.
These patients could have delayed gastric emptying or esophageal obstruction due to the Nissen. They thus need a barium study through the G tube and through the esophagus.
If the wrap is too tight, it can be dilated. If there is delayed gastric emptying, these patients need blendarized feeds with/without botox injections with/without cyproheptadine.
The use of a bougie during a Nissen can prevent the wrap from being too tight.
These are especially useful for documented delayed gastric emptying especially with redo fundoplication. Nissen by itself however, improves gastric emptying.
Pyloromyotomy can serve the same purpose but if it cannot be done pyloroplasty can be performed.
This is a part of an ongoing multicenter study but has been anecdotally found to be very effective for post Nissen retching and delayed gastric emptying.
Gastric pacing has both sensory and motor effects. Sensory component could be predominant as several of these patients ha no real improvement in gastric emptying but it does improve symptoms. Also, contraction is better coordinated and it improves receptive relaxation.
Initially temporary pacing is done endoscopically followed by permanent implantation of the gastric electrodes only if there is improvement.
Transoral incisional fundoplication:
It is not suitable for younger children and is costly.
It can be useful for adolescents but experience with this technique is currently limited.
Reintervention is performed only for the presence of symptoms.
A barium swallow is obtained to study the anatomy. Recurrent reflux can be confirmed by pH impedance. Post Nissen patients usually have 10-20 reflux episodes in 24 hrs. Clinical judgement is necessary to identify patients with true recurrent reflux.
Patients with transmigration almost always need a redo-fundoplication. 95% of the failures of Nissen are due to transmigration.
Sometimes, symptomatic reflux is seen without an anatomic problem on diagnostic imaging and these patients may benefit from a reinforcement of the wrap.
This is essentially a gastric bypass.
Not widely performed at this point.
Should NOT be recommended for children with aspiration or respiratory issues.
It is useful for patients with several redo-Nissens and with severe neurological problems. Some do perform this as an up-front procedure for reflux.
Surgery is a wrong option for ruminators. These patients push the stomach contents forcibly into the esophagus and will do it through a Nissen wrap.
They have several episodes of vomiting in a day especially after feeding.
Confirmed by esophageal motility study.
Another reason for these patients to see a gastroenterologist first.
Desai AA, Alemayehu H, Holcomb GW 3rd, St Peter SD. Minimal vs. maximal esophageal dissection and mobilization during laparoscopic fundoplication: long-term follow-up from a prospective, randomized trial. J Pediatr Surg. 2015 Jan;50(1):111-4
St Peter SD, Barnhart DC, Ostlie DJ, Tsao K, Leys CM, Sharp SW, Bartle D, Morgan T, Harmon CM, Georgeson KE, Holcomb GW 3rd. Minimal vs extensive esophageal mobilization during laparoscopic fundoplication: a prospective randomized trial. J Pediatr Surg. 2011 Jan;46(1):163-8.
Valusek PA, St Peter SD, Keckler SJ, Laituri CA, Snyder CL, Ostlie DJ, Holcomb GW 3rd. Does an upper gastrointestinal study change operative management for gastroesophageal reflux? J Pediatr Surg. 2010 Jun;45(6):1169-72
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