Gastroesophageal reflux

Question 1

GOR - background

Answer 1

1. Def = involuntary passage of gastric contents into esophagus
2. Epi = peaks at 4mo of age where 2/3 of healthy term infants have >1 daily episode of regurgitation
3. Caused by inappropriate relaxation of lower esophageal sphincter as a result of functional immaturity
4. Extremely common in infancy. Self-resolving in the majority of cases
5. GORD (disease) = GOR leading to complications

Question 2

GOR - RF for more severe reflux/GORD (3)

Answer 2

1. Cerebral palsy or other neurodevelopmental disorders
2. Preterm infants (esp. if coexistent bronchopulmonary dysplasia)
3. Following surgery for esophageal atresia or diaphragmatic hernia

Question 3

GOR - complications

Answer 3

1. FTT from severe vomiting
2. Esophagitis - haematemesis, discomfort on feeding or heartburn, iron deficiency anaemia
3. Recurrent pulmonary aspiration - recurrent pneumonia, cough/wheeze, apnea in preterm infants
4. Dystonic neck posturing (Sandifer syndrome)
5. Apparent life-threatening events (ALTE)

Question 4

GOR/GORD - ix (3)

Answer 4

Usually dx clinically; no ix required. However, may be indicated if hx atypical, complications present or failure to respond to tx.

1. 24-hour esophageal pH monitoring = quantifying the degree of acid reflux, 24-hr impedance monitoring (use of electric circuit - ?)
2. Endoscopy with esophageal biopsies = identification of esophagitis and exclusion of other causes of vomiting
3. Contrast studies of upper GI tract = may support dx (but not sensitive nor specific), may be required to exclude underlying anatomic abnormalities in the esophagus, stomach and duodenum

Question 5

GOR/GORD - mx

Answer 5

Uncomplicated GOR (excellent prognosis)

1. Parental reassurance
2. Adding inert thickening agents to feeds, positioning in 30 degree head-up prone position after feeds

GORD

3. Acid suppression with H2 receptor antagonists (e.g. ranitidine), or PPIs (e.g. omeprazole). Omeprazole first line (PPIs superior)
4. If child fails to respond, consider other dx (e.g. cow’s milk protein allergy) and perform further ix
5. Surgical mx - reserved for children with complications unresponsive to intensive medical tx or esophageal structure. Nissen fundoplication - fundus of stomach wrapped around intra-abdominal esophagus, laparoscopic or abdominal procedure