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312 Gastro-oesophageal Reflux Disease

It is also useful for delineating the duodenojejugal (DJ) flexure to rule accomplish adequate calorific intake and achieve growth with minimal
out malrotation. vomiting by reducing stomach distention with each feed. This may be
Oesophagogastroduodenoscopy (OGD) is performed to assess the especially useful in infants, most of whom will grow out of their reflux
severity of oesophagitis, and biopsies are taken. Suspicious areas of without major intervention.
Barrett’s changes will also be assessed on histology. All three of the above measures can be additive and should be tried
together where possible.
Other investigations and their indications include:
• A multichannel impedance study can be combined with the pH Pharmacological treatment
study, and may become the “platinum standard” investigation. 6,14,15 It Medical treatment of GORD usually involves therapy with an acid sup-
is thought to increase the sensitivity for reflux by allowing identifica- pressant alongside a prokinetic agent in an attempt to reduce reflux and
tion of nonacid reflux. Impedance detects changes in fluid contents decrease complications. 25–28
in the oesophagus, and can determine the direction of flow to identify Gastrointestinal prokinetics are used to promote gastric emptying,
both acid and nonacid reflux. In patients in whom reflux is strongly reduce episodes of GOR, and improve symptoms. They may also act by
suspected, and for whom all investigations have been normal, an increasing LOS tone. Common therapeutic agents are domperidone and
impedance study may be warranted. Impedance can also be combined erythromycin. Metoclopramide, an antidopaminergic and cholinomimetic
15
with manometry, and together they can improve the understanding drug, is a prokinetic agent that has also been used for medical management
of pathophysiological mechanisms in paediatric GORD. of GORD. However neurologic adverse effects (e.g., tardive dyskinesia)
may occur. Cisapride is another very effective drug in this group, but has
• A radioisotope gastric emptying scan (milk scan) can be used to assess
gastric emptying and identify patients with significant DGE. However, been taken off the market in most countries due to its cardiac side effects
there seems to be little correlation with surgical correction of DGE and and is now available only in a limited-use protocol.
outcome (see point 13 in section on Nissen fundoplication later). The H -recptor blockers (ranitidine, cimetidine) and proton pump
2
inhibitors (omeprazole, lansoprazole) decrease acid output from the
• Bronchoscopy and broncho-alveolar lavage are sometimes used to stomach and reduce both the symptoms and complications of GORD.
26
detect lipid-laden macrophages as evidence of aspiration from reflux Oesophagitis has been shown to significantly improve on antacid therapy
in those with respiratory symptoms. However more recent evidence (particularly proton pump inhibitors). Proton pump inhibitors have
has demonstrated a low sensitivity and specificity of this test. 16 become one of the main arms of maximal medical therapy in treating
• Oesophageal manometry studies may be indicated in those cases of GORD and reversing the complications associated with the disease.
reflux stricture that cannot be distinguished from achalasia. Medical therapy with a thickener (such as Gaviscon), along with a
prokinetic (domperidone) and a proton pump inhibitor have been used
Management for 6 months as a maximal medical treatment to treat the disease. Patients
Medical/Nonsurgical Management who are not responsive to this treatment or need continuing therapy to
control disease can be considered for step-up management (surgery).
Feed thickening Nasojejunal feeding is an alternative to operative intervention
Feed thickening has been shown to reduce the clinical symptoms associ- in those unfit for surgery or when surgery is not available. The
ated with GOR, 17;18 although this has not been proven to be the case in incidence of complications and symptom resolution, however, may
19
preterm infants in the neonatal intensive care unit (NICU). Several thick- not be significantly different between operative intervention and
ening agents are available: jejunal feeding. In appropriate clinical settings, the passage of a
29
• Alginate (Gaviscon ) and pectin are gelling agents that can be nasojejunal feeding tube (with radiological control or confirmation)
®
added to milk feeds and result in a thickened feed that remains in may be enough to allow safe and effective feeding and sufficient time
the stomach easier than liquid feeds. for growth, allowing the infant to “outgrow” GOR. Problems may arise
with the presence of a long-term nasal tube (pressure effects, frequent
®
• Prethickened milk feeds (e.g., Enfamil AR) contain an easy-to-
digest rice starch that thickens in the stomach and is successful in dislodging, and difficulty with feeding regimen) and may push towards
helping reduce symptoms in some children. Carob-bean gum is either a jejunostomy or definitive surgery.
another thickener that is added to prethickened feeds. Surgery
• Simple common household foods can be used as additives to Surgery is usually contemplated only in those who do not improve on
reduce reflux in children. These can include cereals, breads, fruit maximal medical management or need continuing medical treatment.
purées, corn starch, 20;21 and other starches. The main (but not exclusive) indications for surgery include:
• ALTE; 30
Overall, feed thickening offers moderate clinical improvement with less
vomiting and improved weight gain in many infants and children. 22 • presence of a hiatus hernia (GORD will not resolve with medical
Postural changes management);
Changes in posturing immediately postprandial have been shown to • recurrent aspiration and pneumonias;
29
decrease GORD both clinically and experimentally. The upright position is
optimal in the postprandial period in infants and children at home or in gen- • failure of, or need for, continued maximum medical management
31
eral wards. Special nursing seats that maintain an upright position are used (decreases the need for long-term medical management, particu-
to reduce reflux. However upright positioning is not possible in all settings larly in neurologically normal children);
(e.g., in the NICU). Nursing infants in the prone position has been shown to • stricture; and
reduce the instances of reflux, as demonstrated on dual pH and impedance • Barrett’s oesophagus (relative indication).
23
monitors in the lower oesophagus in infants. Others have shown that the
ideal position is determined by the time after feeding, and changes from the Strictures are best treated initially by maximal medical treatment
right lateral in the early postprandial hour to left lateral later on. 24 and dilatations. Dilatations may need to be repeated. Oesophageal
dilatation can be performed either by bougie or balloon dilatation.
Feeding regimen
There seems to be little difference in the incidence of complications
Changes in feeding pattern can be used to achieve a regimen that
(e.g., perforation) between the two approaches; however, balloon
minimises symptoms. Smaller volumes and more frequent feeds can