GERD Flashcards
What is Gastro-oesophageal reflux disease (GERD)?
GERD occurs when the usual mechanisms to protect the oesophagus and oropharynx from gastric acid (and possibly bile) are overwhelmed, causing damage to the mucosa.
What are some common presenting symptoms of GERD in children?
Symptoms of GERD may include:
• Regurgitation/Vomiting: Recurrent spitting up of feeds, either immediately or some time after feeding.
• Respiratory symptoms: Including life-threatening apnoea spells, recurrent lower respiratory tract infections, chronic lung disease, and recurrent tonsillitis/pharyngitis.
What does bilious vomiting suggest in the context of vomiting in children?
Bilious vomiting suggests a distal cause of bowel obstruction and requires further investigation to rule out conditions like intestinal obstruction.
How can respiratory symptoms manifest in silent GERD?
In silent GERD, respiratory symptoms might be the only presenting signs, including:
• Life-threatening apnoea spells
• Chronic cough
• Recurrent lower respiratory tract infections
• Tonsillitis/Pharyngitis
• Chronic lung disease
How is GERD diagnosed in children?
Diagnostic tools include:
• 24-hour pH manometric studies or impedance monitoring
• Nuclear scintigraphy (also called “milk-scan” using radioisotope-labeled milk)
What are the potential long-term respiratory effects of untreated GERD in children?
Chronic untreated GERD can lead to chronic lung disease, recurrent respiratory infections, and night-time asthma due to recurrent aspiration of gastric contents into the airways.
What is oesophagitis and its potential complication in children with GERD?
Oesophagitis is inflammation of the oesophagus that may lead to scarring and oesophageal stricture over weeks to months, potentially requiring repeated stricture dilation and aggressive anti-reflux treatment, including surgery.
What symptoms might indicate pain from oesophagitis in children?
Pain from oesophagitis may cause:
• Poor feeding and failure to thrive
• Abnormal posturing and facial twisting (Sandifer’s syndrome)
• Projectile vomiting after feeds (Rovo-Rialto syndrome)
What is Sandifer’s syndrome, and how is it related to oesophagitis?
Sandifer’s syndrome is characterized by abnormal posturing and facial twisting, which may resemble seizures, and it occurs due to pain from oesophagitis.
What is Rovo-Rialto syndrome, and how does it present?
Rovo-Rialto syndrome involves pyloric spasm with projectile vomiting after feeds, associated with oesophagitis in children.
What is the primary goal of treating oesophageal strictures resulting from oesophagitis?
The primary goal is to achieve and maintain an acceptable oesophageal calibre through repeated stricture dilation and aggressive anti-reflux treatment, including surgery if necessary.
What is a potential consequence of GERD that can lead to poor growth and development?
Failure to thrive due to excessive reflux of feeds and inadequate nutrient intake.
What anatomical causes should be considered in a child with GERD and failure to thrive?
• Hypertrophic pyloric stenosis (HPS)
• Partial/intermittent midgut volvulus (due to malrotation)
• Oesophageal or intestinal stricture/web
What investigations are recommended when an anatomical cause of GERD is suspected?
A contrast meal and follow-through study to evaluate for anatomical obstructions.
What neurological factors increase the risk of GERD?
• Immature development (e.g., prematurity)
• Central neurological impairment (e.g., after traumatic or ischemic brain injury)
• Degenerative neurological diseases
What anatomical gastrointestinal tract anomalies increase the risk of GERD?
• Hypertrophic pyloric stenosis (HPS)
• Midgut volvulus (especially with associated metabolic alkalosis)
• Hiatal hernia
• Gastric volvulus
• Oesophageal atresia with distorted O-G junction
• Abdominal wall defects (e.g., gastroschisis, omphalocoele, diaphragmatic hernia)
What should be ruled out in cases of gross symptomatic reflux?
An underlying anatomical cause should be ruled out.
What imaging study is recommended to investigate anatomical causes of GERD?
Contrast oesophagogram and meal with gastric outlet imaging.
When is an upper gastrointestinal endoscopy indicated in GERD?
When a stricture is suspected on radiographic imaging or to perform biopsies to establish the cause of the stricture.
What conditions can biopsies help differentiate when evaluating GERD strictures?
• Reflux-related oesophagitis
• Candida or CMV oesophagitis
• Previous caustic injury
• Pre-pyloric peptic ulceration
• Congenital web or duodenal web
What is the gold standard investigation for diagnosing silent reflux?
pH-manometry with impedance over 24 hours.
What are the challenges associated with pH-manometry in infants?
It is labour-intensive, difficult to perform, and can be challenging to interpret in small infants.
What additional test may be useful for assessing aspiration pneumonia in GERD?
A contrast swallow to assess for aspiration due to incoordinate swallowing mechanism.
What is the purpose of a nuclear medicine scintigraphy (“milk scan”) in GERD?
To assess gastric emptying, detect reflux, and identify aspiration.
What anatomical anomalies can a contrast oesophagogram and meal detect in GERD evaluation?
• Oesophageal stricture (congenital or post-reflux oesophagitis)
• Hiatal hernia
• Gastric outlet obstruction
What can histology from tonsillar or oesophageal biopsies indicate in GERD?
Inflammation consistent with GERD.
What can bronchoscopic alveolar lavage reveal in cases of suspected GERD-related aspiration?
Presence of food particles, pepsin, or bile.
How can a therapeutic feeding trial help in GERD diagnosis?
Keeping the child nil by mouth with continuous nasogastric or nasojejunal feeding may demonstrate improvement in respiratory symptoms and reduction in vomiting.
What does a contrast meal study showing a dilated distal oesophagus with gross gastro-oesophageal reflux to the oropharynx suggest?
It suggests a sliding hiatal hernia
What is the significance of an abnormal angle of His seen on a contrast meal study in GERD?
An abnormal angle of His (creating an “elephant trunk” appearance of the oesophagogastric junction) indicates a less acute angle, which increases the incidence of reflux
What positional modification is recommended for GERD management?
Elevate the head of the bed to 30 degrees and keep the patient in a head-elevated position for 30-60 minutes intra- and post-prandially.
What dietary modification can help manage GERD?
Use smaller volume, more frequent feeds and thicken milk feeds with corn-starch or other cereal starch after 4 months of age.
What type of feeding may be required in severe cases of GERD?
Continuous nasogastric feeding or post-pyloric feeding via a naso-jejunal tube. This may be converted to a gastrostomy or gastrojejunostomy feeding tube.
What is the mainstay of medical treatment for GERD?
Proton-pump inhibitor (PPI) therapy for several months.
Which prokinetic agents are commonly used to improve delayed gastric emptying in GERD?
Metoclopramide and erythromycin.
What should be optimized before surgical intervention for GERD complications?
Nutritional and respiratory status should be optimized, including nasogastric/nasojejunal feeding and weaning off oxygen support.
How are oesophageal strictures managed in GERD?
Repeated dilations may be needed, and sometimes resection and anastomosis. In acute obstruction due to impacted food bolus, emergency endoscopic removal is required.
What therapies are used to reduce secondary scarring after oesophageal dilations?
Proton pump therapy, sucralfate barrier therapy, and topical mycostatin to prevent fungal infection.
What novel treatment is under development for reducing secondary scarring after dilation?
The use of temporary stents and other therapies aimed at reducing secondary scarring.
What are the indications for surgical intervention in GERD?
- Inability to tolerate bolus oral or nasogastric feeds with failure to thrive
- Apnoea spells
- Recurrent lower respiratory tract infections
- Oesophageal stricture
What is the most commonly performed surgical procedure for GERD?
The 360-degree fundal plication (Nissen fundoplication), usually performed laparoscopically.
Why is laparoscopic Nissen fundoplication preferred over open surgery?
It allows for faster post-operative recovery with less pain than an open incision.
What type of fundoplication wrap is preferred in neurologically intact patients?
A loose wrap (“floppy Nissen”).
What type of wrap may be indicated in patients with severe neurological impairment?
A tight wrap, often performed concurrently with a feeding gastrostomy.
What are the primary goals of the anti-reflux procedure?
- Repair any hiatal hernia
- Increase intra-abdominal oesophageal length
- Improve the acuteness of the “angle of His”
- Create a high-pressure zone at the oesophagogastric junction (2-3 cm)
What is the reported failure rate of fundoplication after 2 years?
The failure rate ranges from 10 to 50%, particularly in patients with severe neurological impairment.
What factors may contribute to the failure of fundoplication?
- Surgical technique issues
- Patient-related factors (e.g., worsening kyphoscoliosis)
How is a suspected “slipped Nissen” investigated?
Through careful history-taking and a contrast study to evaluate the competence and position of the fundoplication wrap.
What is a potential treatment option if redo fundoplication fails in severe cases?
A gastro-oesophageal dislocation with Roux-en-Y limb for oesophageal drainage and gastrostomy feeding into the stomach.
What complication related to vagal nerve disruption can occur after fundoplication?
Impaired gastric emptying and “dumping syndrome” (diarrhoea and sweating after meals), usually improving over time.
Why should patients who have had a fundoplication avoid fizzy drinks?
They are unable to burp effectively, leading to acute gastric distension.
