Imaging Studies

An upper gastrointestinal (GI) barium study, though no longer the diagnostic study of choice, may be useful in the evaluation of gastroesophageal reflux (GER) disease (GERD) when performed by an experienced pediatric radiologist. The sensitivity of this study in diagnosing the occurrence of reflux and the presence of esophagitis is low,^[55]but esophageal motility and anatomic abnormalities (eg, hiatal hernia, stricture, malrotation) may be identified.

Gastric-emptying (GE) scintigraphy (milk scan) involves ingestion of a radiolabeled meal (historically, radiolabeled milk), with serial images recorded up to 60 minutes after ingestion. This study may be used to diagnose and quantitate reflux but is primarily used to assess GE and to identify delayed emptying. Late images showing isotope in the lungs indicate pulmonary aspiration.

Both an upper GI barium study and GE scintigraphy may be helpful in the diagnosis of GER, but they are not sensitive. The primary diagnostic tool for GER today is the pH probe study. Impedance/pH monitoring is being investigated as a potentially superior diagnostic modality. Newer technologies that are being studied in pediatric GERD include intraprocedural mucosal impedance technology and the functional luminal imaging probe (FLIP).^[3]

Endoscopy

Endoscopy is used to visualize and obtain a biopsy sample from the esophageal mucosa and to diagnose esophagitis, stricture, and Barrett esophagus. Although there is no validated grading system for children, erosion or ulceration is indicative of esophagitis. Biopsy should be performed in most cases, even if the mucosa appears relatively normal, because there is a significant tendency for histologic grade to exceed visual endoscopic findings.^[56]

Endoscopic ultrasonography (EUS) has been described as an adjunct to endoscopy for evaluating the integrity of Nissen fundoplication in children and adults.^{[57, 58, 59]}

Other Tests

The 24-hour pH probe monitor is the standard diagnostic test for GER. Originally described by Johnson and De Meester in 1974, this test uses a catheter at the lower esophageal sphincter (LES) to measure episodes of reflux over a 24-hour period. An esophageal intraluminal pH of less than 4.0 for at least 15 seconds defines an episode of reflux.

Recorded values include the following:

Total time with pH below 4.0
Upright time with pH less than 4.0
Supine time with pH less than 4.0
Number of reflux episodes longer than 5 minutes
Duration of the longest reflux episode

A composite score is calculated on the basis of these results. This test has since been evaluated and validated in children.^{[60, 61]}This test is more sensitive and specific for acid reflux than barium esophagography.^[55]

Disadvantages of 24-hour pH probe monitoring include the inability to diagnose nonacid reflux and to distinguish primary and secondary (allergy to milk protein or other food) causes of reflux,^[62]the inability to determine the presence or severity of esophagitis, and poor tolerance of the probe in some children.

Esophageal impedance/pH monitoring is a technique that can be used to detect both acid and nonacid reflux. This test uses a probe similar to that used in standard pH monitoring to measure the change in electrical resistance that occurs across its sensors with the passage of intraluminal material.

Advantages of this test include the ability to identify the content, direction, and localization of any reflux.^[63]This test may yield better diagnostic sensitivity than the pH probe in patients treated with antacids. Disadvantages include a lack of standardized pediatric normal ranges^[64]and increased cost relative to the standard pH probe.^[63]

Esophageal manometry is used to assess the contractility of the esophageal body, the upper esophageal sphincter (UES), and the LES. Although not diagnostic for GER, this study may reveal LES hypotension in the setting of reflux or abnormal peristalsis in patients with esophageal dysmotility or severe esophagitis.

Esophageal manometry may also be used to identify children with motility disorders in whom antireflux surgery would be contraindicated. A study by Mattioli et al found no correlation between motility pattern and outcome and did not advocate routine use of this modality.^[65]

Histologic Findings

Endoscopic biopsy may be used to diagnose esophagitis or Barrett esophagus. Infiltration of neutrophils and eosinophils, papillary hyperplasia, and basal-zone thickening are all linked to the diagnosis of GERD.^[66]Barrett esophagus is characterized by intestinal metaplasia of the esophageal mucosa; columnar intestinal epithelium and goblet cells replace the normal squamous epithelial lining of the esophagus. In children with chronic aspiration, lipid-laden macrophages may be visible in bronchoalveolar-lavage specimens.

Treatment & Management

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Media Gallery

Relationship of the phrenoesophageal ligament to the diaphragm and esophagus.
Arterial blood supply and lymphatic drainage of the esophagus.
Nissen fundoplication.
Toupet partial fundoplication.

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Author

Tom Jaksic, MD, PhD Professor, Department of Surgery, Harvard University Medical School; Surgical Director, Center for Advanced Intestinal Rehabilitation, Senior Associate in Surgery, Vice-Chairman of Pediatric Surgery, Children's Hospital Boston

Tom Jaksic, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, College of Physicians and Surgeons of Ontario, Royal College of Physicians and Surgeons of Canada, Society of Laparoscopic and Robotic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Kenneth Azarow, MD Program Director, Pediatric Surgery, Children's Hospital and University of Nebraska Medical Center; Professor, Department of Surgery, Uniformed Services University of the Health Sciences

Kenneth Azarow, MD is a member of the following medical societies: American Pediatric Surgical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Michael G Caty, MD Professor of Surgery and Pediatrics, State University of New York at Buffalo; Consulting Staff, Department of Pediatric Surgery, Children's Hospital of Buffalo

Michael G Caty, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for Physician Leadership, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Association for Surgical Education

Disclosure: Nothing to disclose.

Chief Editor

Robert K Minkes, MD, PhD, MS Professor of Anatomy and Surgery, Founding Faculty, Orlando College of Osteopathic Medicine

Robert K Minkes, MD, PhD, MS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgements

YiMing Avery Ching, MD Research Fellow, Department of Pediatric Surgery, Children’s Hospital of Boston