Gastroesophageal Reflux

Introduction

The diagnosis and treatment of gastroesophageal reflux disease (GERD) remains one of the most difficult conditions to treat in pediatrics. In the 1950’s, long before the first medications for the treatment of acid secretion were produced, surgeons were writing about the surgical management of GERD. While the initial papers attributed GERD to the presence of hiatal hernia, in 1974 Judson Randolph described 31 patients under one year of age who underwent surgery for GERD diagnosed by symptoms of severe growth retardation from persistent vomiting and aspiration pneumonitis. In their report, they described no mortality and most attained excellent nutritional status and normal growth curves. In the manuscript they write, “All infants below the age of two months who require hospitalization because of malnutrition secondary to gastroesophageal reflux and who do not respond promptly to conservative therapy should be operated on” [1]. Shortly thereafter, Follette et al described fifteen patients with GERD treated surgically with excellent results and similarly concluded “since the results of Nissen fundoplication to correct reflux in infants and young children are highly satisfactory, and since the consequences of persistent reflux may be severe, a fairly aggressive approach should be taken in the management of symptomatic reflux” [2]. Several similar papers followed.

The result of this body of work was the establishment of principles that guided the historical diagnosis and management of GERD.

• diagnosis is by observation of clinical signs and symptoms
• one should treat early and aggressively
• surgical intervention is highly successful

Prior to the introduction of pharmacologic interventions for GERD (e.g. cimetidine – an H2 blocker approved in the UK in 1976, and in adults in the USA in 1979, or omeprazole – a proton-pump inhibitors first marketed for adults in 1988), medical intervention consisted of posture changes and diet modification. Given that options for medical treatment would not be available at all for several years (and to this day in children the majority of medications are not approved in children under one year of age), the prevalence of GERD in children is described between 12 and 35% [3], and the described success of surgical intervention, it is not shocking that surgery for GERD would grow to be the third most common operation performed. In retrospect, however, it seems probable when reviewing the literature that neither the reported indications for surgery nor the assessments of outcome were entirely clear. The first step to understanding GERD and reinterpreting this body of work came in 2009 when an international panel of gastroenterologists created standardized consensus definitions that allowed clinicians and investigators to communicate clearly [4].

• GERD in pediatric patients is present when reflux of gastric contents is the cause of troublesome symptoms and/or complications
• Symptoms of GERD vary by age
• Symptoms due to gastroesophageal reflux (GER) are troublesome when they have an adverse effect on the well being of the pediatric patient.
• Reflux symptoms that are not troublesome and are without complications is not GERD.
• Regurgitation in pediatrics is defined as the passage of refluxed contents into the pharynx, mouth or from the mouth.

• Regurgitation is a characteristic symptom of reflux in infants but is neither necessary nor sufficient for a diagnosis of GERD because it is not sensitive or specific.
• Symptoms of GERD, particularly in infants, may be indistinguishable from those of food allergy

The second step to understanding GERD and reinterpreting this body of work was published in the same year by the same international panel of experts. In “Pediatric Gastroesophageal Reflux Clinical Practice Guidelines”, the authors write that antireflux surgery should be considered only in children with GERD and failure of optimized medical therapy. The problem is that it is difficult to prove that GERD is actually present in a patient. While one can see vomiting, it is in fact difficult to attribute troublesome symptoms such as weight loss, aspiration pneumonia, acute life threatening events or neck and back arching to the presence of gastric content in the esophagus. Moreover, the medical therapy available remains not FDA approved in the majority of the patients undergoing surgical intervention. Finally, our historical understanding of the outcomes is based on highly variable indications making our pathway forward in treating this disease complicated.

gastroesophageal reflux management

infographic from the Practicing Surgeons Curriculum (Eunice Huang)

Content in this topic is referenced in SCOREGastroesophageal Reflux/Barrett’s Esophagus overviewEsophagoscopy overview