This document provides information on gastroesophageal reflux disease (GERD) in infants and children. It discusses the pathophysiology, clinical manifestations, diagnostic evaluation, and management of GERD. Key points include: - GERD is caused by involuntary passage of gastric contents into the esophagus due to incompetence of the antireflux barriers. It can lead to complications like failure to thrive, respiratory issues, or apparent life-threatening events. - Diagnostic evaluations include upper gastrointestinal imaging, 24-hour pH probe monitoring, and endoscopy. Medical management involves positioning, feeding changes, and acid suppression medications. Surgical options are considered for severe cases or those that do not respond to medical therapy

1. Gastroesophageal
Reflux
Dr muataz alani

2. GERD is defined as the pathologic effects of involuntary
passage of gastric contents into the esophagus.
GERD

3. GER
The episodes of GER that are seen in infants and children
are not clinically significant and will have no identifiable
etiology. 60–65% of children with GER will undergo
spontaneous symptom resolution by 2 years of life,

4. (GERD) will result either in :
 Failure to grow appropriate.
 Respiratory complications.
 Apparent life threatening events (ALTE).

5. HISTORY
In the 1950s and 1960s, several surgeons developed operative
approaches for GERD management. Lortat–Jacob, Hill, Belsey,
Nissen, Rosetti, and Thal , initially developed in adults.
Subsequently, they were applied to infants and children with good
success.

6.  1990s, the introduction of proton pump inhibitors (PPIs)
MAKE SIGNIFICANT EFFECTIVNESS IN THE
MEDICAL MANAGEMET.
 1991 when Dallemagne reported his experience with
laparoscopic fundoplication.
HISTORY

7. PATHOPHYSIOLOGY
Incompetence of The Antireflux Barriers that exist
between the lower esophagus and the stomach.

8. In adults, the consequence of this refluxate in the
esophagus is primarily limited to erosive esophagitis,
esophageal stricture, and Barrett esophagitis.
PATHOPHYSIOLOGY

9. In children associated physiologic, anatomic, and
developmental abnormalities coexist
 Neurologic Impairment.
 Poor Swallowing Mechanisms.
 A Hiatal Hernia.
 Esophageal Atresia With Or Without TEF
 Duodenal And Proximal Small Bowel Atresias.
 Congenital Diaphragmatic Hernia(CDH.
 Gastroschisis/Omphalocele.
PATHOPHYSIOLOGY

10. The consequences of GERD in children lead to the same
complications seen in adults (erosive esophagitis,
stricture, and Barrett esophagitis), but also include
pulmonary effects (reactive airway disease and
pneumonia), potential malnutrition secondary to the
inability to maintain adequate caloric intake, and apneic
episodes leading to ALTE spells.
PATHOPHYSIOLOGY

11. Barriers against GERD: LES
Embryologically, the LES arises from the inner circular
muscle layer of the lower esophagus extends onto the
stomach.
The phrenoesophageal membrane holds the LES in
position. The result is a LES that lies partially in the
chest and partially in the abdomen. This positioning is
important for the normal barrier function against GER.

12. Esophageal manometry can identify this transition (which is
known as the respiratory inversion point) from the thoracic
to the abdominal esophagus.
The ability to prevent GER is directly proportional to the
LES pressure (greater than 30 mmHg) and its length
(length is <2 cm)
transient LES relaxations, have been shown to occur
sporadically, unassociated with the swallowing mechanism.
Barriers against GERD: LES

13. INTRA-ABDOMINAL LENGTH OF THE ESOPHAGUS
In one report, an intra-abdominal length
It is believed that failure to mobilize adequate
esophageal length for intra-abdominal positioning during
antireflux operations can lead to less than successful
results or recurrent GER in adults.
Competency
Intra-abdominal
Length In Cm
100%
3–4.5 cm
64%
3 cm
19%
1 cm
Barriers against GERD: IAE

14. However, we now know these
data are not applicable in
infants and children and that
complete mobilization of the
esophagus, in the absence of
a hiatal hernia, is detrimental
in infants and children through
the results of a multicenter,
prospective, randomized trial.
Barriers against GERD: IAE

15. The angle at which the esophagus enters the stomach.
The usual orientation is that of an acute angle, which
creates a flap valve at the gastroesophageal
junction. Although the actual functional component of
the angle of His is not well known, it has been shown
it provide resistance to GER.
Barriers against GERD: the angle of His

16. When a normal angle of His is present, there is a convoluted
fold of mucosa present at the gastroesophageal junction.
This mucosa creates a rosette-like configuration that
collapses on itself with increases in intragastric pressure or
negative pressure in the thoracic esophagus, thus acting as
an additional weak antireflux valve
Barriers against GERD: the angle of His

17. Patients with increased abdominal pressure as a result of
 Neurologically related retching.
 Physiologic effects (obesity, ascites, peritoneal dialysis).
 Anatomic abnormalities (gastroschisis, omphalocele,
CDH).

18. Require Antireflux Surgery
30%
15–20%

19. There are three types of esophageal contractions:
1. Primary contraction waves are initiated with swallowing
and are responsible for the clearance of refluxed
contents in 80–90% of reflux episodes.
2. Secondary waves occur when material is refluxed into
the esophagus and clearance is required, especially
when the reflux occurs during sleep.
3. Tertiary waves have nothing to do with esophageal
clearance and are sporadic, non-propagating
contractions.
Barriers against GERD: Esophageal Motility

20. This prolonged exposure to gastric content can lead to
esophageal mucosal injury and can potentiate the motility
disturbance due to vagal and/or smooth muscle
inflammation or injury.

21. Barriers against GERD
Saliva & positional effects
Saliva Neutralizes refluxed material, also aids in lubricating
the esophageal contents .
Patients with GERD have been found to have decreased
salivary function.
It has also been shown that positional effects of GERD
treatment may be related to gravity assisting in the clearance
of esophageal refluxate.

22. Some pediatric patients with documented GERD have
been shown to have increased acid secretion.
Decreasing the acid volume Increasing the gastric pH
The Role Of PPIS In Controlling GERD

23. Alkaline Bile Reflux
Acid exposure has traditionally been postulated to cause the
most significant injury, but more recent data has also
implicated alkaline bile reflux (bile salts, pepsin, and trypsin)
to increase esophageal mucosal injury.
When combined with acid, bile salts are injurious to the
esophageal mucosa by increasing the permeability of the
esophageal mucosa to existing acid, thus further
potentiating injury.
Pepsin and trypsin are both proteolytic enzymes that can
injured the esophageal mucosa. Both of these enzymes are
more toxic at lower pH levels

24. Clinical Manifestations
Depends on the patient’s age and overall medical
condition.
Persistent regurgitation, in infants, is often physiologic
and can be ‘normal.’
This type of vomiting is termed chalasia of infancy, No
treatment is necessary in patients who have chalasia,
and no diagnostic evaluation should be pursued.
However, it can lead to complications, including
significant malnutrition and growth failure due to
insufficient caloric intake.

25. In infants:
 Irritability due to pain. (Painful esophagitis).
 Discomfort leads to crying.
Clinical Manifestations

26. In children :
 The pain is retrosternal in nature, and often described
as heartburn.
 Dysphagia develops as a result of a narrowed
esophageal lumen, as well as possible esophageal
dysmotility secondary to long-standing mucosal
inflammation.
.

27. Barrett Esophagitis
Barrett esophagitis is a premalignant condition associated
with prolonged GERD.
It occurs when metaplasia develops in the esophageal
squamous epithelium replaced with columnar epithelium.
Its uncommon in infants and children.
Complications :
 Increased risk for adenocarcinoma.
 Stricture (50%).
 Ulcers.

28. Respiratory symptoms
are commonly seen in infants and children
 Chronic cough, wheezing, choking,
 Apnea, or near sudden infant death syndrome
 Recurrent bronchitis or pneumonia.
Esophageal stimulation via acidification of the esophageal
mucosa causes vagally mediated laryngospasm and
bronchospasm, which clinically presents as apnea or
choking or mistakenly as asthma.

29. Hemorrhage
Although uncommon, hemorrhage can be a presenting
symptom of GERD.
Esophagitis, gastritis, and ulcer formation can lead to
hematochezia or melena in a small percentage of infants
or children.

30. Diagnostic Evaluation
Upper gastrointestinal radiography
The aim is not only to determine the presence or absence of GERD,
but to also ensure that there are no other etiologies such as
 Oropharyngeal dysmotility.
 Esophageal dysmotility.
 Esophageal web.
 Esophageal strictures
 Gastric outlet obstruction, or food allergies.
 Distal obstructions, such as duodenal obstruction, antral web.
 Malrotation, as the cause of the reflux symptoms ( 4% ).
These correctable, anatomic causes for GER are critical to rule out
before pursuing further studies.

34. Twenty-four hour pH probe monitoring
24 hour pH probe monitoring has been considered the gold standard
in diagnosing , Boix-Ochoa proposed a revised score that was
applicable to pediatric patients aged 2 months to 3 years old that
is still used today.

35. the 24-hour pH probe monitoring study is recommended
1. Respiratory symptoms, especially ALTE spells or apneic events;
2. Irritability with intractable crying and anorexia.
3. Reactive airway disease or recurrent pneumonia.
4. Children unresponsive to medical measures in whom GER is
suspected.
5.Special considerations should be given to those children who
become symptomatic after fundoplication.

36. The Study generally is not useful or necessary
 Infants with uncomplicated regurgitation.
 Children with esophagitis already diagnosed by
endoscopy and biopsy.
 Children with dysphagia or heartburn thought to be
caused by GER.

37. The pH study is performed by placing an electrode
2–3 cm proximal to the gastroesophageal junction
and measuring the pH in the distal esophagus .

38. Three patterns of reflux have been described in
symptomatic infants, as determined by extended
esophageal pH monitoring:
CONTINUOUS, DISCONTINUOUS, AND MIXED.
Those infants with the discontinuous type rarely required
an antireflux operation, whereas approximately half of
those with the other two types did.

39. some reflux of acid into the lower esophagus occurs while
the intraesophageal pH is still less than 4 due to a
traditional acid reflux episode. This is called ‘acid re-reflux’
(ARR) and will be missed by using only pH-monitoring
techniques.
ARR is most likely to occur in patients with severe
esophagitis, postprandially, and in the recumbent posture.
It is now thought to be a common cause of prolonged
acid contact.
Detecting ARR provides a better estimation of the
incompetence of the antireflux barrier than does
traditional pH probe evaluations.

40. Two methods may be used to evaluateARR
The first is scintigraphy, which directly measures
radiolabeled liquid gastric contents flowing into the
esophagus
The second is multichannel intraluminal impedance
(MII), a method that recognizes the flow of gastric
contents into the esophagus by detecting decreases
in impedance from high (the esophagus) to low (the
stomach) values across electrode pairs placed
throughout the esophagus and in the stomach.

41. Multichannel Intraluminal Impedance (MII)MII has shown
that GERD patients more commonly have liquid-type
reflux events, whereas non-GERD patients generally
have more gas-type reflux events.
Additionally, MII data suggest that treatment with PPIs
does not decrease the amount of reflux but rather
converts the reflux to non-acid or weakly acidic in nature.

42. Esophageal Manometry Is Infrequently Utilized
In The Pediatric Population
the study measures the motility of the esophagus and
the pressure at the LES via a multiple-port pressure
transducer placed in the esophagus and traversing
the LES
pharyngeal swallowing and primary peristaltic
contractions are responsible for the majority of the
esophageal clearance
there is a direct relationship between worsening
esophagitis secondary to GERD and deterioration of
esophageal motility.

43. Endoscopic Evaluation Of The EsophagusAnd
Stomach
Hematemesis, dysphagia, irritability in infants, or
dysphagia with or without heartburn in children, should
have esophagogastroscopy to determine if esophagitis is
present or other complications, such as ulcer formation,
esophageal stricture, and Barrett esophagus
Mucosal biopsy should be performed to stage the severity
of esophagitis or to histologically exclude dysplasia or
malignancy in Barrett esophagus

44. The evaluation for DGE is undertaken using
radionuclide scanning via a technetium-99-labeled
meal. When documented preoperatively,
Neurologically impaired children with GERD have been
shown to have delayed gastric emptying DGE more
often than neurologically normal children. And it is not
recommended that an emptying procedure be performed
for a patient with DGE and GERD unless a second
operative intervention would place the patient at significant
morbidity or mortality.

45. Medical Management
Position and Feeding
Postural and dietary modifications alone will result in
clinical improvement in the vast majority of infants with
GERD.
a diet low in fat and the elimination of chocolate,
coffee, tea, carbonated drinks, and spicy foods.

46. Pharmacologic Therapy
Medical therapy includes the administration of one or
more drugs that increase esophageal peristalsis,
increase LES pressure, increase gastric emptying, or
lessen gastric acid production.
The current recommendation regarding prokinetic agents
in the management of GERD is that there is no beneficial
effect and their use is not advantageous.

47. Acid Alteration
omeprazole A dosage of 0.7 mg/kg/day healed 45% of
patients, and 1.4 mg/kg/day healed another 30%.

48. Operative Management
Operative management usually follows:
1. Failed medical management for
 Growth failure,
 Respiratory symptoms,
 Other symptoms such as pain and esophagitis.
2. Patient in an intensive care unit with underlying
respiratory disease who requires gastrostomy.
3. The neurologically impaired patient with a similar
need for gastrostomy and concern for aspiration.

49. 4. Barrett esophagitis and esophageal stricture are the
two other conditions in which initial operative therapy
is recommended.
5. Regarding a stricture, dilation can be performed at the
time of fundoplication. Subsequent dilations may be
needed in severe cases.

50. Antireflux procedures
Esophageal hiatus is narrowed by sutures that approximate
the crura of the diaphragm.
1.Nissen fundoplication: a short and loose 360-degree wrap
is created around the distal esophagus;
.
2.Toupet fundoplication: a posterior partial wrap is created
by suturing the edges of the stomach to the anterior
esophagus, leaving a space in between.
3.Dor procedure: a partial anterior fundoplication usually
performed following a Heller myotomy.
4. Belsey-Mark IV procedure: a partial wrap is created
through a thoracotomy by progressive invagination of the
esophagus into the stomach.

51. Nissen surgery
To perform Nissen surgery, the distal esophagus, the cardioesophageal
junction, the gastric fundus, and the right and left crura are dissected.
Careful dissection is required to avoid transection of the nerve of
Latarjet, a branch of anterior vagal trunk supplying the pylorus.
After hernia reduction, the right and left crura are approximated with
sutures.
Division of the short gastric vessels may be required to mobilize the
fundus The gastric fundus is mobilized posterior to the
cardioesophageal junction, creating a 360-degree wrap by the
placement of two or three sutures involving stomach-esophagus-
stomach in the anterior portion of the wrap .The anterior and posterior
vagus nerves are usually contained in the wrap and attached to the
esophagus. At the end of the procedure, the wrap must lie below the
diaphragm without tension.

53. Dor and Toupet
Partial Fundoplications (Dor and Toupet)
A partial fundoplication is created with the fundus partially
enveloping the distal esophagus, enabling a reduction in
postoperative dysphagia and gas-related side effects.
A Dor fundoplication is performed anteriorly, and is usually
performed in patients who also require a Heller myotomy
.Toupet fundoplication is performed posteriorly and is best
indicated in patients with impaired esophageal body motility

55. Belsey Mark IV
The Belsey Mark IV fundoplication requires a
thoracotomy. A partial 240-degree anterior
wrap is created by the placement of three
sutures involving stomach fundus and distal
esophagus, resulting in a progressive
invagination of the esophagus into the
proximal stomach. The crura are also
sutured to narrow the esophageal hiatus