Gastroesophageal reflux (GER) is an abnormal condition which occurs when the contents of the stomach go back up the esophagus (swallowing tube). The normal configuration of the junction of the esophagus and the stomach allows food to pass down into the stomach, but does not allow it to come back up. If this "valve" does not work well, food (or stomach acid) goes up into the esophagus. Adults feel this as heartburn or the aftertaste of a meal. The manifestations of GER in children are usually different and sometimes life-threatening.
How do I know if my child has gastroesophageal reflux?
GER causes many symptoms in children. The most common presentation is regurgitation of food. While "spitting up" is common in normal infants up to six to nine months, most children outgrow this. When vomiting persists beyond this age or is excessive in amount at any age, it may require medical or even surgical attention.
Persistent regurgitation can cause several problems. One problem is passage of the stomach contents up the esophagus and into the lungs--this is called aspiration. Stomach contents that go into the lungs can cause pneumonia and even sudden death. Secondly, if a significant amount of feedings are lost due to constant regurgitation, then an infant or child is unable to take in and retain enough calories to gain weight and grow--this is termed failure to thrive. Finally, GER can lead to inflammation of the esophagus from irritation by stomach acid--this is called esophagitis. This can cause bleeding or pain.
How is gastroesophageal reflux diagnosed and evaluated?
Many tests are performed to help diagnose gastroesophageal reflux. Your child may have had some or all of these tests performed. The following is a discussion of what each diagnostic test is and how it helps us treat GER.
24-hour pH probe
The most precise way to tell if acid from the stomach is washing back up the esophagus is to measure the acid (pH) in the esophagus over a 24-hour period. In order to do this, a narrow tube is placed into your child's esophagus and the pH is measured for 24 hours. If the pH is less than 4.0 for more than 4-6% of the time, it is abnormal and called "significant gastroesophageal reflux."
Upper GI series
This test involves your child swallowing barium and the radiologist watching it go down the esophagus into the stomach and into the small intestine. This test shows us how well the esophagus and stomach empty and also shows us if there is any blockage of the esophagus, stomach, or intestine, that could be causing food to be regurgitated. For instance, a condition called malrotation of the intestine can cause intermittent intestinal obstruction and can be detected by an upper GI series.
Nuclear medicine gastric emptying study (scintiscan)
During this test your child will be asked to swallow either formula or soft food with a very small amount of a radioactive tracer in it. Following this, your child will be observed to see if the tracer refluxes up into the esophagus or if it refluxes all the way into the lungs. More importantly, it allows us to measure how quickly the stomach empties. When the stomach empties very slowly in a child that is already felt to need an operation for GER, an additional procedure called a pyloroplasty may be done to allow the stomach to empty better.
Occasionally, it is necessary to inspect the esophagus to see if the stomach acid has damaged it. To do this, a small tube with a camera attached to it is passed through the mouth into the esophagus. During this test, your child will either be sedated or under anesthesia. This procedure allows the lining of the esophagus to be inspected. If it is necessary, a small piece of the lining of the esophagus (a biopsy) is removed and viewed under a microscope to assess the degree of injury.
How is gastroesophageal reflux treated?
Treatment of GER involves medical and surgical therapy. Many infants and children improve with dietary changes and medication. Children who have continuous GER despite medication or develop life-threatening complications are often referred for surgical therapy.
Medical therapy includes positional therapy, dietary changes, and medications. Many small infants with minor reflux are improved by changing their position after eating. Placing the child on their stomach with their head up will often reduce the frequency of reflux. In addition to this measure, many pediatricians will recommend thickening of feedings with cereal to reduce GER.
If these measures are not successful, medications are tried. The medications used to treat reflux are of two types. One type of medicine is given to reduce the acid in the stomach. These include Zantac (ranitidine), Tagamet (cimetidine) and Prilosec (omeprazole). The other type of medications are those that help the stomach and esophagus empty and close the valve between the stomach and esophagus. These medications include Reglan (metaclopramide) and Propulsid (cisapride). Many times, these two types of medications are given in combination.
When medications are ineffective, operative therapy is recommended for some infants and children with GER.
The goal of operations for GER is to increase the pressure in the lower esophagus to prevent reflux but still permit food to move down the esophagus into the stomach. This is usually achieved by wrapping the upper part of the stomach around the esophagus--a procedure called a fundoplication. If the stomach is wrapped completely around the esophagus, the operation is called a Nissen fundoplication. Other types of fundoplication involve wrapping the stomach only part of the way around the esophagus.
In children who are greater than about 12 pounds, a fundoplication may be done using a laparoscope. This procedure involves 5 small holes in the abdominal wall, as opposed to a vertical incision in the upper abdomen. Laparoscopic surgery may not be possible in some children if they have had previous abdominal operations or if they require a procedure to improve emptying of the stomach.
When a fundoplication is performed for GER, a gastrostomy tube is frequently placed. Many children with neurological disorders are unable to eat adequately by mouth and require a permanent tube in the stomach. Since the placement of a gastrostomy tube alone can make GER worse, we routinely test for reflux in children who need a gastrostomy and perform a concurrent fundoplication in those children who have reflux--even if was not previously evident. In young children who eat by mouth but require a fundoplication, a gastrostomy may also be placed, at least temporarily, because the fundoplication prevents burping and young children may have difficulty with bloating from swallowed air if there is not a way to vent air from the stomach. When a gastrostomy is placed, there will be a tube coming out of the abdomen about as wide as a pencil. This tube will be changed to a less obtrusive device called a "button," which lies flat of the abdominal wall, after about six weeks.
Complications of fundoplication
Fundoplications are very effective in controlling GER. Reflux recurs about 10% of the time after Nissen fundoplication. Failure of the operation may be more frequent in children with frequent seizures. As many as 15% of children who have a fundoplication will develop an intestinal obstruction from scar formation or adhesions, although this may be less frequent after a laparoscopic fundoplication.
After a successful Nissen fundoplication, a child will not be able to burp or vomit. The inability to burp can cause a problem called gas-bloat where the stomach fills with air that can't be easily expelled. For this reason, we may place a gastrostomy at the time of the fundoplication in young children, even if they are able to eat by mouth. Since children are no longer able to vomit after a Nissen fundoplication, they may have episodes of wretching when they have a reason to vomit--such as the stomach flu. When there is not a gastrostomy tube, the contents of the stomach will usually eventually pass into the intestine in this situation, although some children may need to be brought to the emergency room for placement of a tube in the stomach through the mouth.
The area around the gastrostomy may look red from small amounts of stomach fluid that lead outside or from rubbing of the tube. Infection of the site is very unusual.
The hospital stay
Most children are admitted on the day of the operation, unless they are already in the hospital. The usual hospitalization is three to five days in the absence of other illnesses that mandate a longer stay. Nurses will make every effort to keep your child comfortable and pain-free. The pediatric surgery team will make rounds as a group daily. We are available to answer any questions you may have concerning the progress of your baby.
Your child will not eat immediately after the operation since the stomach may not be functioning normally. During this time he or she will receive intravenous fluids. If the fundoplication was done using a laparoscope, feedings will usually be started the day after the operation. If an open procedure was done, feedings begin after two days. Food will be given either by mouth or through the gastrostomy tube.
Pain control rarely requires more than over-the-counter pain relievers such as Children's Tylenol or Children's Advil. These may be given every four hours as needed.
Any other medications which your child required before the operation should be continued on the regular schedule afterward. Most oral medications can be given immediately after the operation through the gastrostomy.
Children usually have no eating difficulties after going home. If a gastrostomy tube was placed for feedings, you will be instructed in how to give feedings through the tube and what kinds of food may be given.
No restriction of activity is necessary. If your child had a gastrostomy tube placed, you need to take care that it is well-secured so it won't catch on objects or be pulled by your child.
Always wash your hands before touching or cleaning the incision area. Some blood staining of the paper tapes on the incision is common. If the blood is dry and not spreading, the staining is not a problem. If the blood seems fresh, the amount is increasing, or if the paper tape is blood soaked and partially floating above the skin, apply gentle pressure with a clean washcloth for five to six minutes. Then, contact the pediatric surgery resident on call at (909) 558-4000. The problem is usually minor but the surgeon needs to know about it.
No tub baths should be given for at least two days after the operation. Sponge bathing is permitted the day following the operation. Carefully pat dry the incision tapes after bathing.When to call your child's surgeon
- Fever above 101oF that does not come down with Tylenol (mild fever is common)
- Difficulty breathing, with or without a croupy cough
- Active bleeding from the incision
- Redness, swelling, or persistent pain in the incision
- Persistent wretching
- If the gastrostomy tube falls out, call your surgeon and bring your child to unit 2800 at the Medical Center (weekdays) or the emergency room (nights and weekends). The gastrostomy site can close completely within six hours, so it is very important to seek attention for a dislodged tube quickly--don't wait until the morning.
A clinic appointment needs to be scheduled one to two weeks after the operation. Please call (909) 558-4848 to schedule this appointment if an appointment was not made for you before leaving the hospital.