GERD / Gastro-Esophageal Reflux

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Gastro-esophageal (GER) reflux is a condition that is defined as the transfer of gastric contents into the esophagus. Typically, it occurs throughout the day, most frequently after meals and at nights. This condition differs from gastro-esophageal reflux disease, a.k.a. GERD’s. GERD represents symptoms or tissue damage that result from GER. With “physiologic” GER, the condition usually resolves spontaneously by 1 year of age. The causes of GER is multifactorial, however, the primary mechanism likely involves an inappropriate relaxation of the lower esophageal sphincter. Factors that increase abdominal pressure such as coughing, sneezing, scoliosis and overeating, may contribute to GERD. There are certain conditions that may predispose a child to a higher likelihood of developing GERD. Those conditions include neurological impairment, hiatal hernia, obesity, trachea-esophageal and esophageal atresia repair, asthma, cystic fibrosis and cerebral palsy.

Diagnostic Evaluation

A simple history and physical may be sufficient in establishing a diagnosis of GER. However, in many cases, the physician may order an upper GI series. This is a radiological examination of the upper gastro-intestinal tract, which consists of the esophagus, stomach and duodenum (the first section of the small intestine). This test is also useful in determining the presence of anatomical abnormalities which may contribute to GER. Another test, which is considered the gold standard for diagnosing GER, is the pH monitoring study. This test allows direct, physiological measurement of acid in the esophagus. It consists of a probe being placed by a physician to the distal end of the esophagus. The probe is connected to a machine which measures the pH of the esophagus. A continuous measurement of the acidity of that area is recorded for up to 24 hours depending upon the length of time the physician requires. Upon completion of the monitoring process, the physician will download and analyze the data. A reflux episode is defined as esophageal pH drop below a four. Components of the pH study include the following:

  • Percent total time pH < 4
  • Percent Upright time pH < 4
  • Percent Supine (lying on your back) time pH < 4
  • Number of reflux episodes
  • Number of reflux episodes ≥ 5 min
  • Longest reflux episode (minutes)

His findings will determine whether the physician will treat this condition medically (with medication / diet / activity) or whether to treat it surgically, with a procedure known as a fundoplication.

Therapeutic Management

The severity of GER varies from individual to individual. Therefore, its therapeutic management will vary as well. For example, an infant who is not experiencing respiratory complications and who continues to plot favorably on the growth chart, may not need therapeutic management. For others, it may involve the aversion of certain foods with exacerbates the reflux, such as citrus, caffeine, tomatoes, peppermint, alcohol, spicy or fried foods. Therapy may involve lifestyle modifications, such as smaller portions and shorter intervals between feedings, thickened feedings and upright position may prove to be helpful. Continuous, nasogastric tube feedings may be necessary for those with severe reflux and growth failure until surgery can be performed. Elevating the head of the bed 30 degrees or placing the child in an infant seat for 1 hour after feeding may decrease GER.

Pharmacological Therapy Medication used to treat GERD fall into two classifications. The H2-receptor antagonist includes Zantac (Ranitidine), Tagamet (cimetidine) and Pepcid (famotidine). The proton pump inhibitors are Nexium (esomeprazole), Prevacid (lansoprazole), Prilosec (omeprazole), Protonix (pantoprazole) and Aciphex (rabeprazole). Their mechanism of action is by reducing the amount of hydrochloric acid secreted and also may stimulate an increase in lower esophageal sphincter tone.

Surgical Management

The medical community is typically very, conservative when it comes to recommending surgery. Surgery is usually recommended for the child with severe complications, such as recurrent aspiration pneumonia, apnea, severe esophagitis, or growth failure. It also may be recommended for the child who fails to respond to medication and non-pharmacological treatment. The Nissen fundoplication is the most common surgical procedure and there are different variations of fundoplication performed. This procedure is now commonly performed using a laparoscope, which results in less recovery time, less pain, better cosmetic results and fewer complications. This procedure involves passage of the gastric fundus (the upper, left portion of the stomach) behind the esophagus to encircle the distal (lower end of) portion of the esophagus. This results in preventing the reflux by reinforcing the closing function of the lower esophageal sphincter.