GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Gastroesophageal reflux disease (GERD) denotes recurrent regurgitation of gastric contents into esophagus due to any cause, leading to persistent esophagitis by regurgitant acidic gastric content.

Etiopathogenesis: Mild GER is common in first year of life and after meals in older children, with no clinical consequence. Pathological GERD may result from:

1. Incompetence of lower esophageal sphincter due to: (a) abdominal location of esophagus, (b) abnormal angle of its insertion into stomach, (c) hiatus hernia, (d) inappropriate transient relaxation of sphincter during swallowing, crying or after drugs, e.g. theophylline, or (e) nasogastric tube in situ.

2. Increased intra-abdominal pressure, due to chronic cough, constipation and other causes.

Clinical manifestations of GERD begin in early infancy with a triad of: (a) recurrent vomiting/possetting, (b) recurrent chest infections, and (c) failure to thrive. Signs of esophagitis, e.g. dysphagia or sub-sternal pain may not be obvious in infants, while hematemesis is rare.

GERD has been claimed to be associated with acute life-threatening events (ALTE) or sudden infant death syndrome (SIDS), due to sudden choking by aspirated contents.

Diagnosis may be confirmed by:

• Milk scan showing slow gastric emptying and reflux of radiolabel contents, fed before the scan. It is also useful

to identify severity of reflux. However normal milk scan does not exclude GER, which is an intermittent event.

• 24-hour esophageal pH probe monitoring to demonstrate acidic pH at lower end of esophagus is the most reliable indicator of GERD, though rarely indicated in routine cases.

• Esophageal manometry is also useful to identify intermittent relaxation of lower esophageal sphincter.

• Barium swallow or esophagoscopy is indicated in chronic cases to visualize esophagitis, strictures and anatomical abnormalities, e.g.

Management of GERD depends on its severity and includes:

• Positioning: Nursing the baby in semi-upright position, especially after feeds and during sleep, to promote gravity assisted emptying of esophagus.

• Feeding with thickened feeds, given as frequent but small boluses.

• Acid suppressors: Proton pump inhibitors (PPIs), e.g. lansoprazole (PO 0.7-1.4 mg/kg/day q24hr), or Esopantoprazole (PO 1-2 mg/kg/day q24 hr), etc. are first drugs of choice for GERD with erosive esophagitis. Empirical PPI therapy may also be used for short trial of 4-8 weeks in symptomatic children beyond infancy. H₂ receptor antagonists, e.g. Rantidine, though provide faster relief, are less effective and indicated only if PPIs are contraindicated.

• Antacids may be used for temporary symptomatic relief, but prolonged use should be avoided in children. Surface protectors, e.g. Sucralfate or alginates are not recommended for routine management of GERD in children.

• Prokinetic agents to enhance gastric emptying, e.g. metoclopramide or Domperidone (Both 0.15-0.2#952; mg/ kg/d q8hr) may be used in moderately severe cases.

• Surgery, i.e. Jundoplication is indicated only in very severe cases, refractory to medical therapy. Commonly used Nissenfundoplication involves wrapping of gastric fundus around intra-abdominal esophagus to act as additional valve, with success rate of gt;90%.

Prognosis: Most cases of GERD outgrow it by the end of first year, though complications, e.g. esophageal strictures, severe GIT hemorrhage, chronic lung disease and failure to thrive are common. GERD is considered as a triggering factor for acute asthmatic exacerbations and an important cause of Difficult-to-treat asthma in children. Some other important esophageal disorders are as follows:

Achalasia is an esophageal motility disorder characte­rized by paucity of normal peristaltic waves and impaired relaxation of gastroesophageal junction, due to decreased number or sensitivity of ganglionic cells.

Clinically, most cases present in adolescence, with swallowing difficulties and GERD, leading to chronic esophagitis, recurrent aspiration and chronic lung disease.

Diagnosis usually rests on barium swallow, which reveals esophageal dilatation with tapering towards gastric junction. Esophageal manometry is diagnostic, showing lack of peristaltic changes and relaxation of lower esophageal sphincter on swallowing.

Treatment is mainly surgical with Heller myotomy or endoscopic balloon dilatation of lower esophageal sphincter, though drugs, e.g. nifedipine may be effective in some cases. Intra-sphincteric injection of Botulism toxin (botox) has been found effective for 4-6 months.

Esophagitis in children may be: (a) Peptic due to GERD, (b) Infective (Candida, HSV), usually in immunocompromised children, or (c) Corrosive; the last being most common, caused by accidental ingestion of household substances, e.g. acids, alkalis, detergents, etc. Clinically, vomiting, retrosternal burning and dysphagia are typical features of esophagitis and severe or persistent esophagitis may cause stenosis with chronic dysphagia. Treatment depends on the cause, though nasogastric lavage or induction of emesis is contraindicated in cases of suspected corrosive poisoning (Ch 27.6).

Esophageal foreign body, e.g. coins ingestion, is common in toddlers due to their inquisitive nature. Ingested bodies are usually lodged at any one of three normal constriction sites in esophagus-below the cricopharyngeal muscle, at the level of aortic arch or just above the diaphragm.

Clinically, these cases may present immediately with suggestive history or later with dysphagia, more pronounced with solids. Radio-opaque bodies are visible on X-rays, though diagnosis of radiolucent ones requires barium swallow or preferably, endoscopy.

Treatment: All symptomatic cases or those with history of ingesting sharp foreign bodies need immediate endoscopic removal, while blunt foreign bodies like coin, single magnet may be observed for up to 14 days for spontaneous clearance, if asymptomatic.

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