Contribution of fibreoptic endoscopy to diagnosis and management of children with gastro-oesophageal reflux

Reliability of radionuclide gastroesophageal reflux studies using visual and time-activity curve analysis: inter-observer and intra-observer variation and description of minimum detectable reflux

Radionuclide studies have gained wide acceptance in the evaluation of infants and children with gastroesophageal reflux (GER). For correct interpretation of scan results, knowledge of inter-observer and intra-observer variability and minimum detectable reflux volume is essential. In this study, we evaluated the methodological issues underlying the visual assessment of GER and time activity curve analysis. An in vitro model of stomach and oesophagus was established to determine the minimum detectable reflux by placing various volumes and concentrations representing the diluted activity in the stomach. In the clinical part 99 patients were imaged for 1 h after oral administration of 99mTc sulfur colloid. Eleven patients were excluded from the study either due to incomplete clinical data or suboptimal image quality. Frames of 16 s each, and time-activity curves which were generated after drawing regions of interest from the oesophagus, were read three times by an experienced nuclear medicine physician and a resident in training. On the phantom study, the concentration, volume and duration were the determining factor for the visualization of reflux. In the clinical part, the overall incidence of GER in 88 patients was 69%. The mean intra- and inter-observer reproducibility (kappa values) was 0.76 and 0.7065, respectively. Agreement was slightly higher in the analysis of time-activity curves (0.767 and 0.731). Our results indicate that GER may be reproducibly analysed on scintigraphy by the same and different observers with varying levels of training. Its visualization is associated with reflux duration, volume and dilution factor of radioactivity.

Incidence and management of gastroesophageal reflux after repair of congenital diaphragmatic hernia

During a period of 6 years, 31 of 54 infants with congenital diaphragmatic hernia survived and were evaluated to study incidence and management of gastroesophageal reflux. At 6 months' follow-up 16 patients had gastroesophageal reflux proven by upper gastrointestinal series; at 12 months' follow-up 11 patients. Three patients having gastroesophageal reflux did not respond to medical treatment and underwent Nissen fundoplication. We conclude that after successful treatment, congenital diaphragmatic hernia is likely to be complicated by gastroesophageal reflux. We could not define a predictive feature for gastroesophageal reflux in the individual patient surviving congenital diaphragmatic hernia.

Intestinal permeability to chromium-51 ethylenediamine tetraacetic acid in children with chronic obstructive respiratory disease: relationship with clinical and duodenal biopsy findings

Intestinal permeability (IP) to 51-Cr ethylenediamine tetraacetic acid was investigated in 47 children with chronic obstructive respiratory disease (CORD). Endoscopic duodenal biopsies were performed in 22 of these patients. IP was significantly increased in CORD patients when compared to either control children or adults (P less than 0.001). Mean +/- 1 SD were 4.3 +/- 1.71%, 2.5 +/- 0.78%, and 2.3 +/- 0.77% in the three groups, respectively. IP was not related to the presence of atopy. Significant differences in IP results were found between CORD children with abdominal pain (4.5 +/- 1.4%) and both control children and CORD patients without abdominal pain (2.5 +/- 0.78% and 3.2 +/- 1.49%, respectively). A significant correlation was found between small bowel injury on the one hand and IP on the other hand (P less than 0.02). Furthermore, small bowel injury was significantly related to the presence of abdominal pain (P less than 0.05). We speculate that in CORD patients with abdominal pain, a factor exists that causes small bowel injury responsible for both abdominal pain and increased small bowel permeability. Food intolerance could, presumably, play a role in the mucosal damage-linked IP increase found in the subset of CORD patients who complain of abdominal pain.

Gastroesophageal reflux in children. Clinical profile, course and outcome with active therapy in 126 cases

A clinical profile and the course and outcome with therapy of 126 infants and children with gastroesophageal reflux (GER), diagnosed at a median age of 2.5 months and followed for 1.5 to 3.5 years is presented. Features included repeated regurgitation or rumination (99%), signs suggesting esophageal pain (49%, excessive crying "colic," sleep disturbance, Sutcliffe-Sandifer syndrome, respiratory symptoms 42%), failure to thrive (18%), and minor hematemesis (18%). Feeding problems and maternal distress were common, associated with child abuse in four cases. Therapy was initially conservative (posture, thickening of feeds, antacids, bethanechol), augmented by cimetidine in those with proven esophagitis (n = 34, 0.27%). Most (81%) were symptom-free by 18 months of age (55% by 10 months of age); 17 percent had fundoplication with good results; 2 percent have persisting symptoms beyond 2 years of age (1% failed surgery). No deaths were recorded. Surgery was performed for recurrent apneas/aspiration (6%), refractory esophagitis or stricture (5%), and failed medical management (7%). Esophagitis was a significant determinant to outcome, and the importance of selective early endoscopy is emphasized. GER is a cause of considerable morbidity in infants but, with active therapy, is self-limiting in the majority. Certain distinctive clinical signs indicate those patients who require detailed investigation and to whom more aggressive therapeutic efforts should be directed.

Cow's milk protein allergy and gastro-oesophageal reflux

Evidence for cow's milk allergy was looked for prospectively in 15 children with recurrent vomiting. Whereas radiological examination showed gastro-oesophageal reflux to be present in all patients, 3 out of 15 children presented an enteropathy associated with an increased number of IgE plasmocytes in small intestinal biopsy tissue. These three patients did not improve with conventional medical therapy but a striking improvement occurred within 24 h on a cow's milk-free diet. We conclude that diagnostic confusion between gastro-oesophageal reflux and cow's milk allergy can occur and that the presence of IgE plasmocytes in small intestinal biopsy tissue indicates IgE-mediated cow's milk protein allergy. All cases of "intractable" gastro-oesophageal reflux should be suspected of cow's milk allergy and investigated accordingly.

Value of tests for evaluation of gastroesophageal reflux in children

The accuracy of five tests for the diagnosis of gastroesophageal reflux in children was performed in 93 symptomatic children with gastroesophageal reflux and 16 nonreflux patients. These tests include the barium esophagram, the Tuttle test, extended esophageal pH monitoring, esophagoscopy, and esophageal biopsy. Esophagoscopy was less sensitive in detecting reflux in patients than any other test (P = less than 0.001), and biopsy was more likely to identify reflux patients than the barium swallow (P = less than 0.02), but there was no test superior to others. The severity of esophagitis noted at endoscopy or the presence of eosinophils or neutrophils in the mucosa was not associated with a decreased possibility that one other test would be normal or that surgical repair of the reflux would be performed. Patients with extended esophageal pH test scores markedly elevated were less likely to have another negative test (P = less than 0.01) and more likely to have surgical repair of gastroesophageal reflux (P = less than 0.001). Obtaining two tests of esophageal function that agree increases the certainty of diagnosis, and use of several tests are indicated if the results of a single test do not support the clinical impression.

Chronic bronchopulmonary disease and gastroesophageal reflux in children

Fifty-four children who had chronic bronchopulmonary disease (CBPD) were investigated for the incidence of gastroesophageal reflux (GER). An activity score for CBPD and a numerical reflux score using criteria from a pH probe study were established. Results of barium esophagography, endoscopy, and prolonged esophageal pH probe monitoring were abnormal in 67, 78, and 53% of the patients, respectively. A significant relationship was found between the CBPD activity score and the reflux score; this strongly suggests that, in the patients studied, GER was responsible for the bronchopulmonary symptoms. Antireflux therapy resulted in an improvement of the CBPD activity score in all patients who had abnormal reflux scores. The mean CBPD activity score was 4.4 and 1.3 before and after antireflux therapy, respectively (P less than 0.01). Most patients who had normal reflux scores did not improve on antireflux therapy.

Antacids and cimetidine treatment for gastro-oesophageal reflux and peptic oesophagitis

Thirty three children aged 2 to 42 months (mean 9 months) with gastro-oesophageal reflux and peptic oesophagitis took part in a treatment trial comparing cimetidine (20 mg/kg/day) with an intensive regimen of antacids (Maalox, 700 mmol (mEq)/1 X 73 m2/day). All children were evaluated clinically and by radiology, acid reflux test, and endoscopy. After 12 weeks of treatment all were again evaluated clinically, by pH measurement, and endoscopy. Twenty nine children, 15 on antacid and 14 on cimetidine, completed the trial. Eight patients on antacid and seven on cimetidine were cured; five on antacid and six on cimetidine improved; and two patients on antacid and one on cimetidine underwent surgery. Both groups of children showed a statistically significant reduction in the score of clinical, pH, and endoscopic variables after treatment. Lower oesophageal sphincter pressure before treatment did not correlate significantly with the final total score. Antacids in large quantities are as effective as cimetidine in medical treatment of gastro-oesophageal reflux and peptic oesophagitis.

Routine studies of swallowed radionuclide transit in paediatrics: experience with 400 patients

Scintigraphic studies of swallowed 99m Tc-sulphur colloid mixed with a few millilitres of liquid, performed on 400 paediatric patients of all ages, allowed visualisation of foregut function and measurement of oesophageal transit time and gastric emptying proportions. This non-invasive and physiological procedure requires a standard gamma camera with computing facilities and was performed as an outpatient routine. It proved very effective for the detection of gastro-oesophageal reflux and aspiration of refluxed liquid in patients of all ages but especially in neonates. The relevance of these scintigraphic results to oesophagitis, repeated respiratory problems, cyanotic and apnoeic spells and alternative methods of investigation is described.

Epicardial oesophageal duplication with hiatal hernia in a case of Turner's syndrome

The authors of this paper report the first case of epicardial oesophageal duplication causing hiatal hernia in a patient afflicted with Turner's syndrome, and they discuss its possible etiology.

Gastroesophageal reflux

It is now widely recognized that gastroesophageal reflux causes a number of symptoms in children. Numerous tests have been developed and document the presence of GER, but none is infallible, partially because some reflux is a normal phenomenon. A carefully obtained history and esophagram are the two most useful and available clinical tools. Other tests are useful if there is no agreement between history and esophagram, if specific problems need to be documented (esophagitis), or if more certain documentation is desired because of atypical disease or in anticipation of surgery. If two tests of esophageal function agree, presence or absence of GER is diagnosed with a high degree of accuracy. At present, there is no test that will consistently demonstrate that reflux is causing respiratory symptoms. Most cases of GER in infants will respond to therapy or benign neglect by the time the babies are 18 months of age. This is in contrast to the adult situation, where reflux exists for decades and therapy is directed at the chief symptom, heartburn. Unless there are life-threatening complications or strictures, an intensive course of medical therapy is indicated. Positional therapy is presently the keystone of medical therapy, but is less effective and harder to institute in older patients. Use of thickened feedings may have some benefit. If heartburn or esophagitis is present, attempts to neutralize gastric contents are indicated. Some experience is developing in the use of drugs to control reflux, and a trial of bethanechol is warranted in difficult cases. Since most cases will improve by 18 months of age, therapy is required for only a limited time. At present, surgery is quite safe and is very effective in controlling reflux, although there is no clear consensus on how prolonged and severe symptoms must be to justify surgery in the absence of life-threatening complications.

Long-term effect of Nissen fundoplication in young puppies

Nissen fundoplication effectively prevents gastroesophageal reflux in children. However, the long-term effect of this operation on the distal esophagus of infants and children is unknown, and a fear has been expressed that wrap-around operations on a small infant esophagus would constrict growth of the lower esophagus and cause late partial obstruction. In this study, the long-term effect of Nissen fundoplication was evaluated. There were 20, 1-2-wk-old puppies operated upon; 10 underwent Nissen fundoplication and 10 had only a sham operation to serve as a control group. Three puppies in each group had esophageal manometry and barium studies of the esophagus preoperatively and at various times postoperatively. The diameter of the esophagus was measured in all dogs during the operation. All fundoplications were done with a #20F dilator inside the esophagus. Two dogs in each group were sacrificed at 1, 2, and 3 yr of age, and the remainder were sacrificed at 4 yr of age. At autopsy, there was no difference in the diameter of the esophagus in the dogs with Nissen fundoplication compared with the sham-operated dogs. Barium studies in the fundoplicated group showed no dilation of the esophagus compared to the sham-operated group. Both groups grew normally and there were no differences in weight at the time of sacrifice. It seems that Nissen fundoplication does not affect growth of the distal esophagus in young puppies, and that body weight and linear growth are not altered by this operation.

Gastroesophageal reflux in infants and children comparative accuracy of diagnostic methods

To assess the diagnostic accuracy of methods employed for detection of gastroesophageal reflux, 30 infants and children with symptoms of GER were evaluated by upper gastrointestinal series, gastroesophageal scintiscan, measurement of mean resting lower esophageal sphincter pressure, esophageal intraluminal PH measurement (acid reflux test), and endoscopy. Fifteen control patients were also evaluated by the above studies. GER was demonstrated by UGI in 15 and by GE scintiscan in 17 study patients. LESP less than 15 mm Hg was noted in 12 and a positive acid reflux test was obtained in 29 study patients. Esophagitis was detected in two (of 30) study patients radiographically and in 15 (of 21) study patients by upper gastrointestinal endoscopy. Pulmonary aspiration of gastric contents was not detected by the radionuclide method. None of the 15 control patients had GER demonstrated with any of the above methods. These studies indicate that (1) the acid reflux test correlates most closely with symptoms of GER; (2) THE GE scintiscan is complementary to the UGI in the diagnosis of GER, i.e., the combination increases sensitivity; (3) normal LESP does not necessarily exclude GER; and (4) endoscopy is superior to the UGI in detecting the presence of esophagitis.