Gastroesophageal Reflux

Disease
Pediatric Surgery

Background
Esophagus: conveys food from
pharynx to stomach.
Gastroesophageal reflux: Describes
the (usually) undetected backflow of
gastric contents into the esophagus.
Physiologic phenomenon and occurs in
otherwise normal people several times
daily; especially postprandial with foods
such as soup, tea, coffee, milk, etc.

Background
Mechanisms to ward off negative
effects of reflux:
Rapid clearance of refluxed material by
propulsive peristalsis
Buffering of refluxate by swallowed
saliva
Resistance of esophageal squamous
layer to refluxed contents

GERD
Is a pathologic reflux reflux which causes
major symptoms or complications:
Failure to thrive
Disturbance of sleep
Recurrent aspiration in young infants
Epigastric or retrosternal pain
Heartburn
Esophagitis
Stenosis

20% of western world is affected

Esophagogastric Junction
Separates higher pressure abdominal
compartment from lower pressure
thoracic compartment.
Consists of:
Crura of diaphragmatic hiatus
Angle of His
LES (Lower esophageal sphincter)

LES structures
Crural Diaphgram - forms an oblique slit
encircling the esophagus which constitutes
an external pinchcock mechanism.
Angle of His: Acute angle created between
cardia at entrance of stomach and
esophagus.
Forms valve preventing reflux; angle created by
the collar sling fibres and circular muscles around
GE junction
Underdeveloped in infancy; esophagus makes a
vertical junction with stomach so reflux more
likely.

LES
Lies within diaphgragmatic hiatus, which forms
a firm tunnel in which esophagus is secured by
phren-esophageal membrane.
Maintains basic tonus, but relaxes with
ongoing propulsive peristaltic wave of swallow.
Transient lower esophageal sphincter
relaxations (TLESRs) of 5-30 seconds occur
even in absence of any other esophageal
peristalsis.
Remain unrecognized in health individuals refluxed
material only reaches lower esophagus.

TLESR
TLESR is primary pathophysiologic mechanism
in all individuals with GERD.
Relaxation triggered by gastric mechanoreceptors
that signal distension to hindbrain generates
motor signals to LES/esophagus via vagus n.

Babies with pathologic reflux experience more

prolonged TLESR
Indigested fluid triggers TLESR by gastric
distension; so largely liquid food (milk) given to
infants is another factor that may cause more
frequent TLESR.

TLESR
Delayed gastric emptying with pathologic
TLESR is observed in children with
neurologic disorders may increase the
incidence of reflux episodes.
Pathologic reflux may be regarded as sign
of delayed maturation or disturbed
coordination of control centers in the
hindbrain, disrupting function of esophageal
peristalsis, LES, and gastric motility.

Symptoms
Mild regurg or occasional vomiting as
a sign of GER may be seen in all
newborns/young infants fed milk.
Symptoms less frequent after 4-6 mo
of life.
Pathologic reflux frequent regurg
episodes, restless sleep with sudden
unexplained wake-up and excessive
crying episodes and even
malnutrition and failure to thrive.

Symptoms
Beyond infancy, recurrent
regurgitation of acid gastric juice,
nighttime symptoms during sleep;
can develop recurrent respiratory
tract disease due to micro-aspiration
of reflux.
Chronic inflammation of mucosa may
lead to microscopic bleeding and
chronic anemia; may eventually
cause stenosis due to scarring

Symptoms
Micro-aspiration may lead to
laryngitis, laryngeal pseudopolyps
and wheezing, chronic cough,
pneumonia, severe symptoms of
asthma

Diagnostic Investigations
UGI Series: eval of peristaltic fxn of esophagus,
visualize GE jxn, demonstrate sliding or fixed hiatal
hernia, assess angle of His, eval of epithelium for
signs of inflammation.
24hr pH Monitoring: Probes in stomach, lower and
upper esophagus to evaluate pH.
# of acidic refluxes that reach upper esophagus can be
determined.
Reflux Index: Percentage of time when pH < 4 in 24 hrs.

Combined multiple intraluminal impedance and

pH monitoring: Allow ability to record neutral and
alkaline reflux; microaspiration of nonacid reflux
plays important role in recurrent respiratory tract
infxn.

Diagnostic Investigations
Manometric
Investigations
demonstrate
motor fxn and
peristalsis of
esophagus.
Manometric sign
of a TLESR is the
CPP (common
cavity
phenomenon).

Diagnostic Investigations
Endoscopy & Histology: Invasive but essential
part of dx workup of GERD.
Reddening, ulceration or pseudopolyps on the
vocal cords are typical signs of laryngeal reflux.
Bx specimen from duodenum and antrum of
stomach are tested for H. Pylori.
Essential to take several bx specimens proximal
to Z-line; hyperplasia of basal cell layer and
elongation of papillae are signs of increased
turnover due to reflux associated acid exposure.

Conservative Therapy
In infants, GERD resolves spontaneously in
90%; so conservative therapy is tx of choice.
Supine position with elevation of head of the bed
or left sided position during sleep are preferred.
Frequent small-volume meals and thickening of
food with rice gruel.

Older children, no evidence of any specific

change in food to reduce reflux.
Obesity, large-volume meals, and late eating have
been associated with symptoms of GERD.

Medical Therapy
H2 receptor antagonists have been used
since 70s to provide symptomatic relief.
Today PPIs are tx of choice.
Children on long-term PPI for GERD have
higher risk of acute gastroenteritis and
community acquired pneumonia.

New promising therapy option inhibition

of TLESR by GABAB agonists (ex:
baclofen).
Has shown significant reduction in TLESR and
reflux in both adults and children.

Surgical Therapy
Lap fundoplication is tx of choice.
Most commonly used procedure is
Nissen technique with 360degree
wrap.
Essential element is to mobilize GE jxn
to achieve 2-5cm long intra-abdominal
esophagus and creation of partial or
total fundus wrap around esophagus;
should be loose in order to avoid
complications (inability to belch, vomit,
etc.).

Laparoscopic Nissen

Results of surgery
1) TLESR reduced to 50% of
preoperative state
2) Rate of TLESR accompanied by
reflux reduced from 47% to 17%
3) Mean residual pressure at GE jxn
during swallowing-induced relaxation
increased from 0.7 mm Hg to 6 mm
Hg while basal LES Pressure not
affected.

Results
Fundoplication with a floppy wrap is a powerful
means of controlling reflux in appropriately
selected children in whom medical treatment fails,
or in symptomatic refluxers with specific
comorbidities.
Lap vs open: RCTs in adult patients have shown
significantly lower operative morbidity, shorter
postop stay, and less prolonged sick leave following
laparoscopic approach.
Randomized multicenter trial with 5 year follow up
showed that antireflux surgery was more effective
than omeprazole with respect to failure rates.

Complications
Most common: wrap herniation
(1.3%).
Reoperation rate 2.7%
Mortality rate 0.08%
Persistent dysphagia is related to
tightness of wrap.
In childhood, recurrent GERD is most
common problem after
fundoplication.