Pediatric Gastroesophageal Reflux Surgery Clinical Presentation

Updated: Mar 11, 2016
  • Author: Tom Jaksic, MD, PhD; Chief Editor: Robert K Minkes, MD, PhD  more...
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Presentation

History and Physical Examination

Many healthy infants have physiologic reflux. Approximately 40% of healthy infants have at least one episode of emesis a day, with more than 5 mL of nonbilious emesis per episode. [35, 36] These minor reflux episodes (spit-ups) usually resolve by the time the patient reaches the age of 6 months and do not cause any serious sequelae. In some children, gastroesophageal reflux (GER) is pathologic, leading to irritability, apnea, recurrent pneumonia, respiratory dysfunction, esophagitis, or failure to thrive.

Generally, a thorough history and a careful physical examination elicit signs and symptoms of reflux. In addition, an infant or child may have a history of frequent emesis, aspiration events, asthma, or feeding difficulty. A careful assessment of growth parameters and nutritional status is an important component of the physical examination and preoperative evaluation. Because one of the indications for antireflux surgery is failure to thrive, operative candidates may be malnourished.

The presenting symptoms of gastroesophageal reflux disease (GERD) in infants and children differ from those seen in adults and vary with age. Anorexia and feeding difficulty correlate with erosive esophagitis on endoscopy and are common presentations in children aged 1-5 years. [37] Infants may present with frequent regurgitation in addition to feeding difficulties. [38]

Feeding difficulties in infants were evaluated in a study investigating the clinical outcomes of GERD treatment. [39] According to a retrospective review of 28 infants with feeding difficulty prior to GERD treatment, posttreatment evaluation with both endoscopy and a videofluoroscopy demonstrated marked functional improvement in infant swallowing.

GERD has been closely linked to respiratory problems due to recurrent aspiration of gastric contents. [40] A Pediatric Health Information System Database analysis of 12,067 patients found that GERD was the most common discharge diagnosis in patients admitted with an apparent life-threatening event. [41] Reflux should also be ruled out in a child with recurrent pneumonia or chronic nocturnal cough. Considerable controversy remains as to whether GERD is causally or temporally associated with sudden infant death syndrome (SIDS). [42, 43]

The relationship of GERD with childhood asthma is more defined, and the prevalence is thought to be 40-60%. [44, 45] In a prospective evaluation of pediatric patients with GER and asthma, investigators demonstrated a significant reduction in the use of bronchodilators and inhaled steroids after treatment for reflux disease. This effect was not seen in control patients with asthma and no diagnosis of GER. [46]

Some authors dispute the association between GER and lung disease. [47] The use of multichannel intraluminal impedance has permitted further investigation into the role of nonacid reflux in the pathogenesis of GER-related respiratory disease. An examination of 28 children with persistent respiratory symptoms despite antacid therapy demonstrated that symptoms were more frequently associated with nonacid reflux. [48]

A follow-up study of 24 children with asthma found a higher correlation between asthma and reflux detected by impedance (which is able to detect both acid and nonacid reflux) in comparison with detection by pH probe alone (acid reflux). [49]

Esophageal mucosal damage from gastric acid exposure is common in patients with GERD and can lead to esophagitis or esophageal stricture. Barrett esophagus, a premalignant process characterized by replacement of the normal squamous cells of the lower esophagus with columnar cells typically found in the stomach, has been linked to chronic reflux in older children. It has been surmised that this metaplasia is due to constant acid exposure during times of healing. [50] Barrett esophagus necessitates serial follow-up with endoscopy and biopsy.