Gastro Oesophageal Reflux

Question 1

What is gastro oesophageal reflux and how common is it?

Answer 1

Bringing up a small amount if milk after feeding without any other symptoms. It is very common roughly 50% of babies will have it.

Question 2

What is the underlying pathophysiology of reflux?

Answer 2

It is likely due to a combination of the following:

• Inappropriate relaxation of the lower oesophageal sphincter.
• A predominantly fluid diet
• Mainly horizontal posture
• A short intra-abdominal length of oesophagus.

These allow fluid to pass up into to the oesophagus and become regurgitated.

Reflux goes away at 12 months of age due to maturation of the oesophageal sphincter, a more solid diet and less horizontal posturing.

Question 3

What investigations should be done in child with reflux?

Answer 3

No investigations are usually needed.

They are only indicated if hx is atypical, there are complications there is failure of treatment.

Ix:
• 24h oesophageal pH monitoring

• 24h impedance monitoring (measures flow of liquid from the stomach into the oesophagus using a catheter)
• Endoscopy with biopsies
• Contrast studies

Question 4

What are the complications of reflux?

Answer 4

• Failure to thrive from severe vomiting
• Oesophagitis (due to acid reflux) – haematemesis, discomfort on feeding, heartburn and iron deficiency anaemia
• Recurrent pulmonary aspiration – pneumonia, cough, wheeze, apnoea in preterm infants
• Dystonic neck posturing
• Barrett’s oesophagus (very rare in children) It is where the lower oesophagus is repeatedly damaged by acid and this leads to the cells changing from squamous to columnar and is a ore cancerous state.

Question 5

How should you manage reflux?

Answer 5

Simple reflux: easily managed by adding inert thickening agents to feeds and positioning in a 30 degree head-up prone position after feeds.

More severe reflux:
Managed with acid suppression:
- H2 receptor antagonist (e.g. ranitidine)
OR
- Proton pump inhibitor (e.g. omeprazole).

Surgical treatment for:

• Complications unresponsive to intensive medical treatment.
• Oesophageal strictures.
• A Nissen fundoplication (this is where there fundus of the stomach is wrapped around the intra-abdominal oesophagus)