GERD

Question 1

What is Gastro-oesophageal reflux disease (GERD)?

Answer 1

GERD occurs when the usual mechanisms to protect the oesophagus and oropharynx from gastric acid (and possibly bile) are overwhelmed, causing damage to the mucosa.

Question 2

What are some common presenting symptoms of GERD in children?

Answer 2

Symptoms of GERD may include:
• Regurgitation/Vomiting: Recurrent spitting up of feeds, either immediately or some time after feeding.
• Respiratory symptoms: Including life-threatening apnoea spells, recurrent lower respiratory tract infections, chronic lung disease, and recurrent tonsillitis/pharyngitis.

Question 3

What does bilious vomiting suggest in the context of vomiting in children?

Answer 3

Bilious vomiting suggests a distal cause of bowel obstruction and requires further investigation to rule out conditions like intestinal obstruction.

Question 4

How can respiratory symptoms manifest in silent GERD?

Answer 4

In silent GERD, respiratory symptoms might be the only presenting signs, including:
• Life-threatening apnoea spells
• Chronic cough
• Recurrent lower respiratory tract infections
• Tonsillitis/Pharyngitis
• Chronic lung disease

Question 5

How is GERD diagnosed in children?

Answer 5

Diagnostic tools include:
• 24-hour pH manometric studies or impedance monitoring
• Nuclear scintigraphy (also called “milk-scan” using radioisotope-labeled milk)

Question 7

What are the potential long-term respiratory effects of untreated GERD in children?

Answer 7

Chronic untreated GERD can lead to chronic lung disease, recurrent respiratory infections, and night-time asthma due to recurrent aspiration of gastric contents into the airways.

Question 8

What is oesophagitis and its potential complication in children with GERD?

Answer 8

Oesophagitis is inflammation of the oesophagus that may lead to scarring and oesophageal stricture over weeks to months, potentially requiring repeated stricture dilation and aggressive anti-reflux treatment, including surgery.

Question 9

What symptoms might indicate pain from oesophagitis in children?

Answer 9

Pain from oesophagitis may cause:
• Poor feeding and failure to thrive
• Abnormal posturing and facial twisting (Sandifer’s syndrome)
• Projectile vomiting after feeds (Rovo-Rialto syndrome)

Question 10

What is Sandifer’s syndrome, and how is it related to oesophagitis?

Answer 10

Sandifer’s syndrome is characterized by abnormal posturing and facial twisting, which may resemble seizures, and it occurs due to pain from oesophagitis.

Question 11

What is Rovo-Rialto syndrome, and how does it present?

Answer 11

Rovo-Rialto syndrome involves pyloric spasm with projectile vomiting after feeds, associated with oesophagitis in children.

Question 12

What is the primary goal of treating oesophageal strictures resulting from oesophagitis?

Answer 12

The primary goal is to achieve and maintain an acceptable oesophageal calibre through repeated stricture dilation and aggressive anti-reflux treatment, including surgery if necessary.

Question 13

What is a potential consequence of GERD that can lead to poor growth and development?

Answer 13

Failure to thrive due to excessive reflux of feeds and inadequate nutrient intake.

Question 14

What anatomical causes should be considered in a child with GERD and failure to thrive?

Answer 14

• Hypertrophic pyloric stenosis (HPS)
• Partial/intermittent midgut volvulus (due to malrotation)
• Oesophageal or intestinal stricture/web

Question 15

What investigations are recommended when an anatomical cause of GERD is suspected?

Answer 15

A contrast meal and follow-through study to evaluate for anatomical obstructions.

Question 16

What neurological factors increase the risk of GERD?

Answer 16

• Immature development (e.g., prematurity)
• Central neurological impairment (e.g., after traumatic or ischemic brain injury)
• Degenerative neurological diseases

Question 17

What anatomical gastrointestinal tract anomalies increase the risk of GERD?

Answer 17

• Hypertrophic pyloric stenosis (HPS)
• Midgut volvulus (especially with associated metabolic alkalosis)
• Hiatal hernia
• Gastric volvulus
• Oesophageal atresia with distorted O-G junction
• Abdominal wall defects (e.g., gastroschisis, omphalocoele, diaphragmatic hernia)

Question 18

What should be ruled out in cases of gross symptomatic reflux?

Answer 18

An underlying anatomical cause should be ruled out.

Question 19

What imaging study is recommended to investigate anatomical causes of GERD?

Answer 19

Contrast oesophagogram and meal with gastric outlet imaging.

Question 20

When is an upper gastrointestinal endoscopy indicated in GERD?

Answer 20

When a stricture is suspected on radiographic imaging or to perform biopsies to establish the cause of the stricture.

Question 21

What conditions can biopsies help differentiate when evaluating GERD strictures?

Answer 21

• Reflux-related oesophagitis
• Candida or CMV oesophagitis
• Previous caustic injury
• Pre-pyloric peptic ulceration
• Congenital web or duodenal web

Question 22

What is the gold standard investigation for diagnosing silent reflux?

Answer 22

pH-manometry with impedance over 24 hours.

Question 23

What are the challenges associated with pH-manometry in infants?

Answer 23

It is labour-intensive, difficult to perform, and can be challenging to interpret in small infants.

Question 24

What additional test may be useful for assessing aspiration pneumonia in GERD?

Answer 24

A contrast swallow to assess for aspiration due to incoordinate swallowing mechanism.

Question 25

What is the purpose of a nuclear medicine scintigraphy (“milk scan”) in GERD?

Answer 25

To assess gastric emptying, detect reflux, and identify aspiration.

Question 26

What anatomical anomalies can a contrast oesophagogram and meal detect in GERD evaluation?

Answer 26

• Oesophageal stricture (congenital or post-reflux oesophagitis) • Hiatal hernia • Gastric outlet obstruction

Question 27

What can histology from tonsillar or oesophageal biopsies indicate in GERD?

Answer 27

Inflammation consistent with GERD.

Question 28

What can bronchoscopic alveolar lavage reveal in cases of suspected GERD-related aspiration?

Answer 28

Presence of food particles, pepsin, or bile.

Question 29

How can a therapeutic feeding trial help in GERD diagnosis?

Answer 29

Keeping the child nil by mouth with continuous nasogastric or nasojejunal feeding may demonstrate improvement in respiratory symptoms and reduction in vomiting.

Question 30

What does a contrast meal study showing a dilated distal oesophagus with gross gastro-oesophageal reflux to the oropharynx suggest?

Answer 30

It suggests a sliding hiatal hernia

Question 31

What is the significance of an abnormal angle of His seen on a contrast meal study in GERD?

Answer 31

An abnormal angle of His (creating an “elephant trunk” appearance of the oesophagogastric junction) indicates a less acute angle, which increases the incidence of reflux

Question 32

What positional modification is recommended for GERD management?

Answer 32

Elevate the head of the bed to 30 degrees and keep the patient in a head-elevated position for 30-60 minutes intra- and post-prandially.

Question 33

What dietary modification can help manage GERD?

Answer 33

Use smaller volume, more frequent feeds and thicken milk feeds with corn-starch or other cereal starch after 4 months of age.

Question 34

What type of feeding may be required in severe cases of GERD?

Answer 34

Continuous nasogastric feeding or post-pyloric feeding via a naso-jejunal tube. This may be converted to a gastrostomy or gastrojejunostomy feeding tube.

Question 35

What is the mainstay of medical treatment for GERD?

Answer 35

Proton-pump inhibitor (PPI) therapy for several months.

Question 36

Which prokinetic agents are commonly used to improve delayed gastric emptying in GERD?

Answer 36

Metoclopramide and erythromycin.

Question 37

What should be optimized before surgical intervention for GERD complications?

Answer 37

Nutritional and respiratory status should be optimized, including nasogastric/nasojejunal feeding and weaning off oxygen support.

Question 38

How are oesophageal strictures managed in GERD?

Answer 38

Repeated dilations may be needed, and sometimes resection and anastomosis. In acute obstruction due to impacted food bolus, emergency endoscopic removal is required.

Question 39

What therapies are used to reduce secondary scarring after oesophageal dilations?

Answer 39

Proton pump therapy, sucralfate barrier therapy, and topical mycostatin to prevent fungal infection.

Question 40

What novel treatment is under development for reducing secondary scarring after dilation?

Answer 40

The use of temporary stents and other therapies aimed at reducing secondary scarring.

Question 41

What are the indications for surgical intervention in GERD?

Answer 41

1. Inability to tolerate bolus oral or nasogastric feeds with failure to thrive 2. Apnoea spells 3. Recurrent lower respiratory tract infections 4. Oesophageal stricture

Question 42

What is the most commonly performed surgical procedure for GERD?

Answer 42

The 360-degree fundal plication (Nissen fundoplication), usually performed laparoscopically.

Question 43

Why is laparoscopic Nissen fundoplication preferred over open surgery?

Answer 43

It allows for faster post-operative recovery with less pain than an open incision.

Question 44

What type of fundoplication wrap is preferred in neurologically intact patients?

Answer 44

A loose wrap (“floppy Nissen”).

Question 45

What type of wrap may be indicated in patients with severe neurological impairment?

Answer 45

A tight wrap, often performed concurrently with a feeding gastrostomy.

Question 46

What are the primary goals of the anti-reflux procedure?

Answer 46

1. Repair any hiatal hernia 2. Increase intra-abdominal oesophageal length 3. Improve the acuteness of the “angle of His” 4. Create a high-pressure zone at the oesophagogastric junction (2-3 cm)

Question 47

What is the reported failure rate of fundoplication after 2 years?

Answer 47

The failure rate ranges from 10 to 50%, particularly in patients with severe neurological impairment.

Question 48

What factors may contribute to the failure of fundoplication?

Answer 48

1. Surgical technique issues 2. Patient-related factors (e.g., worsening kyphoscoliosis)

Question 49

How is a suspected “slipped Nissen” investigated?

Answer 49

Through careful history-taking and a contrast study to evaluate the competence and position of the fundoplication wrap.

Question 50

What is a potential treatment option if redo fundoplication fails in severe cases?

Answer 50

A gastro-oesophageal dislocation with Roux-en-Y limb for oesophageal drainage and gastrostomy feeding into the stomach.

Question 51

What complication related to vagal nerve disruption can occur after fundoplication?

Answer 51

Impaired gastric emptying and “dumping syndrome” (diarrhoea and sweating after meals), usually improving over time.

Question 52

Why should patients who have had a fundoplication avoid fizzy drinks?

Answer 52

They are unable to burp effectively, leading to acute gastric distension.