Gastroesophageal reflux in infancy and childhood

Association of vesicoureteral reflux and gastroesophageal reflux disease in children: A population-based study

INTRODUCTION

Practitioners have anecdotally hinted at a possible association between gastroesophageal reflux disease (GERD) and vesicoureteral reflux (VUR). We sought to identify an association in diagnosis between GERD and VUR using a population-based dataset in a well-defined geographic area covered by a single-payer healthcare system.

METHODS

A retrospective review of individuals aged 0-16 years registered in the Nova Scotia Medical Service Insurance database from January 1997 to December 2012 was completed. Presence of GERD and VUR were ascertained based on billing codes. The baseline prevalence of GERD and VUR was calculated for this population for the same time period. Proportions of VUR patients with and without GERD were compared. The risk of being diagnosed with VUR in patients with GERD controlling for sex was calculated.

RESULTS

Of 404 300 patients identified, 6.6% had a diagnosis of GERD (n=27 092), 0.33% had a diagnosis of VUR (n=1348), and 0.08% were diagnosed with both (n=327). Among patients with VUR, the prevalence of GERD was 24.3% compared to 6.6% in patients without VUR (p<0.0001). Among patients with GERD, the prevalence of VUR was 1.2% compared to 0.27% in patients without (p<0.0001). The risk of being diagnosed with VUR was higher in the presence of GERD (odds ratio [OR] 4.49; 95% confidence interval [CI] 3.96-5.09; p<0.0001), irrespective of sex.

CONCLUSIONS

The odds of being diagnosed with VUR is more than 4.5 times higher in an individual with GERD. The clinical significance of this association remains to be explored.

Utility of pH/multichannel intraluminal impedance probe in identifying operative patients in infants with gastroesophageal reflux disease

INTRODUCTION

Gastroesophageal reflux is a common clinical problem in infants, but identifying which infants may benefit from a fundoplication remains a conundrum. Esophageal pH and multichannel intraluminal impedance (MII) measurements are useful diagnostic tools in adults and older children, but their diagnostic efficacy in infants is unclear. Therefore, we reviewed our experience with the combined pH/MII probe in this population.

SUBJECTS AND METHODS

A retrospective review of patients ≤ 6 months of age who were studied with the pH/MII probe from 2006 to 2010 was performed. Test results, interventions, and outcomes were reviewed. Patients were divided into operative and nonoperative groups, and pH probe and MII results were compared.

RESULTS

Fifty-seven patients (53% male) were identified. Mean age at the time of pH/MII probe was 3.1 months. Regarding the operative group (n = 33), 21% had an abnormal pH probe, and 100% had an abnormal MII; 97% had symptom improvement at a mean follow-up of 16 months (range, 0.4-38 months). In the nonoperative group (n = 24), 29% had an abnormal pH probe, and 100% had an abnormal MII. There was no significant difference in reflux index, Boix-Ochoa score, or percentage of acid and non-acid reflux between the two groups.

CONCLUSIONS

The pH and MII studies are poor indicators of pathologic reflux in infants and do not adequately discern which patients will benefit from fundoplication.

Gastroesophageal reflux disease in children and adolescents: when and how to treat

Gastroesophageal reflux (GER) is a common presenting complaint in children and adults, and is a frequent reason for physician consultation. GER disease (GERD), whilst benign in the majority of cases, is frequently a chronic condition that has been shown to result in significantly reduced quality of life in children and adolescents. Furthermore, there is emerging evidence that the prevalence of GERD is rising and may have links to adult obesity and other morbidities. Consequently, accurate diagnosis, appropriate management strategies, and timely referral to specialist services are important principles in the effective management of GERD. Acid-suppressive drugs are effective therapies but are one of the most costly classes of drugs prescribed. Therefore, not only is an accurate diagnosis important to the patient, but it is also of significant interest from a public health and resource utilization standpoint.

Diagnosis of gastroesophageal reflux disease in infants

Gastroesophageal reflux is commonly encountered in the infant population. Most children will outgrow their reflux but some develop pervasive disease and require medical or surgical treatment. Many tools exist for use in the workup of pediatric gastroesophageal reflux disease; however, the most effective method of diagnosis is not clear. Delineating which patients will benefit from more definitive therapy is a remarkable challenge in this group, often borrowing tools and principles from the adult patient population. Therefore, we reviewed the available literature to critically evaluate the merits and limitations of the current diagnostic modalities available for the evaluation of infantile gastroesophageal reflux.

Proton pump inhibitors: actions and reactions

Proton pump inhibitors are the second most commonly prescribed drug class in the United States. The increased utilization of PPIs parallels the rising incidence of reflux disease. Owing to their clinical efficacy and relative lack of tachyphylaxis, PPIs have largely displaced H-2 receptor antagonists in the treatment of acid peptic disorders. The elevation of intragastric pH and subsequent alterations of gastric physiology induced by PPIs may yield undesired effects within the upper GI tract. The ubiquity of the various types of H(+), K(+)-ATPase could also contribute to non-gastric effects. PPIs may influence physiology in other ways, such as inducing transepithelial leak.

Gastrointestinal tract feeding access and the role of fundoplication in combination with gastrostomy

PURPOSE OF REVIEW

Feeding access and associated antireflux procedures continue to be some of the most common operations performed in pediatric patients. This review will discuss the various feeding access procedures available, including minimally invasive techniques, and further elaborate on appropriate indications for a concurrent antireflux procedure as well as alternatives to fundoplication.

RECENT FINDINGS

Gastrostomy and jejunostomy can be successfully placed using endoscopic or laparoscopic techniques with low complication rates. Nissen fundoplication is well described laparoscopically but failure with recurrent gastroesophageal reflux has resulted in the development of other operative alternatives.

SUMMARY

Decisions concerning appropriate long-term feeding access must be individualized, understanding the advantages and disadvantages of gastrostomy and jejunostomy techniques. Laparoscopic Nissen fundoplication is successful for treatment of patients who fail medical therapy of gastroesophageal reflux, but recurrent gastroesophageal reflux is a persistent problem that requires innovative solutions.