What is GERD?
Gastroesophageal reflux disease (GERD): is a term used to collectively describe the problems and symptoms that occur when acid from the stomach washes up into the esophagus (food tube which brings food from the mouth to the stomach). This can lead to inflammation and irritation of the lining of the esophagus as well as causing the typical symptoms that are generally associated with GERD or acid reflux.  Alternate names: reflux, acid reflux, reflux esophagitis, acid regurgitation, and heartburn.

What are the Symptoms of GERD?
GERD encompasses a wide range of symptoms which include :

  • Heartburn – burning or tightness behind the breastbone or at the top of the belly
  • Acid regurgitation – sour or bitter taste in the throat or mouth
  • Water brash – a hot sensation in the stomach followed by a large amount of watery liquid in the mouth
  • Dysphagia – difficulty swallowing or painful swallowing. The sensation of a lump in the throat or food getting “stuck” after swallowing
  • Note: Asthma, laryngitis and chronic cough are unusual symptoms, but can be caused rarely be caused by GERD

Symptoms typically occur after eating a meal and can be especially noticeable with a large meal or spicy foods. Symptoms often are worse when lying flat, straining or sleeping, but may be relieved by antacids.

What can worsen the symptoms of GERD?
Fatty foods, chocolate, coffee, peppermint as well as alcohol and use of tobacco products can cause or worsen symptoms.  Certain drugs such as Theophylline, Albuterol, and Calcium channel blockers can also cause symptoms of GERD.

Are any other problems or diseases associated with GERD?
Pregnancy is the most common condition associated with GERD. The pressure of the uterus on the stomach can increase the amount of acid “splashing” up into the esophagus, or the increase in GERD may be hormonally mediated.  Diseases characterized by high stomach acid production as well as connective tissue disorders (i.e. scleroderma) are also frequently associated with GERD.  Obesity which causes an increase in abdominal pressure is also thought to contribute to and worsen acid reflux.

Anatomy:
The Esophagus leaves the chest and enters the abdomen through an opening call the diaphragmatic hiatus. Muscular fibers (called crura)of the diaphragm wrap around the esophagus as it passes into the abdomen. When the crura are loose or lax , the stomach can “slip” or “slide” through up into the chest. This is called a hiatal hernia and may contribute to reflux symptoms. An abnormally wide angle of His (the angle between the esophagus and stomach) may lead to an “upside down funnel” which can also anatomically contribute to GERD.

Microscopic Anatomy:
There is normally a physiologic sphincter (a “gate”) between the esophagus and stomach called the LES (lower esophageal sphincter) which serves as a barrier and protects the esophagus from acid. The sphincter cannot be seen. It is simply a high pressure zone at the bottom of the esophagus which keeps gastric contents out. Normally, the lining of the esophagus and stomach are made of different types of cells. The cells which line the esophagus are not as resistant to acid as the cells which line the stomach. This can lead to esophagitis.

What is the actual causes GERD?
Multiple factors: A complex interaction of many problems can cause reflux, including:

  • Esophageal Dysmotility – weak or uncoordinated esophageal contractions (movement)
  • Inadequate saliva production – seen in smokers, in certain diseases and normally seen during sleep. Saliva normally “buffers” any acid which is found in the esophagus.
  • Impaired resistance of esophageal lining – defective protection of the esophagus against acid by the cells which make up the lining of the esophagus.
  • LES dysfunction – poorly functioning sphincter muscle (gate between stomach and esophagus) allowing acid to wash up into the esophagus.
  • Delayed emptying of the stomach – poor motor function of the stomach (not draining into the intestine) allowing acid to “pool” in the stomach.

Problems Caused by GERD
Reflux esophagitis (irritation, injury and inflammation of the esophagus) caused by prolonged exposure to acid and or bile. This may produces pain as well. Unfortunately, reflux esophagitis can progress to Barrett’s esophagus (pre-cancer),stricture, or esophageal cancer later in life.

How many people suffer from GERD?
It is one of the most common conditions affecting the gastrointestinal system.  Anywhere from 36-77% of people have symptoms of GERD (heartburn, regurgitation of acid etc.) spread equally between men and women.

  • 7% have daily heartburn
  • 14-20% have weekly heartburn
  • 15-50% have monthly heartburn

How do you get GERD?
Diet, smoking, obesity, alcohol, pregnancy, hiatal hernia, can all contribute to GERD. Other gastrointestinal disease (Crohn’s, Esophageal atresia, others) may also be a factor. No one single factor that has been identified as the “cause” of this disease.

Diagnostic Tests:
24 hour pH probe is the gold standard test. Upper GI radiologic studies, upper endoscopy (called an EGD), and Esophageal Manometry (measures the motility of the esophagus and the sphincter pressure via a probe placed into the esophagus) are useful adjunct tests.

Treatment:

  • Mild and infrequent symptoms:
    • Non-prescription therapy is often enough. Examples include ranitidine and omeprazole.
    • Avoiding foods that induce reflux (coffee, fat, etc.)
    • Avoid eating close to bedtime, and lying down after meals
    • Elevation of the head of the bed
    • Weight loss (if obese)
    • Over-the-counter antacids as needed
  • Severe or frequent symptoms
    • Ranitide or other H2 Blockers may be used to treat the symptoms of GERD.
    • Metaclopramide is often prescribed to improve gastric emptying, but effectiveness is questionable.
    • Next line is proton pump inhibitor (PPI) such as Prilosec, Protonix, Nexium, Aciphex, or Prevacid will most likely be used.

Surgical Treatment:
Only considered AFTER maximizing their medical treatment for GERD. Typical indications for surgery include :

  • Incomplete relief of their symptoms
  • Development of a stricture or esophageal narrowing
  • Barrett’s Esophagus
  • Relapse of their symptoms after discontinuing medical treatment (after prolonged treatment)
  • Intolerable side effects from the GERD medication

What are my options other than medicines?
Stretta (Radio Frequency) treatments EndoCinch (endolumenal procedure to prevent reflux) – Initially have shown encouraging results, long-term results are unclear at this time.

Surgical Options:
  • Laparoscopic Nissen Fundoplication – a complete (360 degree) wrap of the stomach around the esophagus (most common type)
  • The top part of the stomach is wrapped around the esophagus
  • Diaphragmatic plication is done
  • Hiatal Hernia is repaired if present
  • Toupet Fundoplication – an incomplete (270 degree) wrap of the stomach around the esophagus
  • Dor – Anterior partial wrap (used with Heller Myotomy);
  • Thal – partial wrap.  Less commonly used now.
  • Hill
  • Boix-Ochoa
  • Belsey
  • others

Results:
Laparoscopic fundoplication has been shown to provide excellent/good results in 90% of neurologically normal children.  Results for neurologically impaired children are not as good.

Complications:

  • Injury to an abdominal organ or to the bowel, stomach, or esophagus
  • Bleeding
  • Failure to completely relieve reflux symptoms
  • Difficulty swallowing
  • Inability to vomit (usually temporary)
  • Gas Bloat Syndrome
  • Diarrhea
  • Distended, painful stomach
  • Injury to the nerve that controls movement of the stomach

After surgery:
What are the diet restrictions? A post-fundoplication diet or Post-Nissen Diet is recommended.

FAQs for Fundoplications

Will the fundo interfere with him eating through his mouth?  Not generally.  Patients need to be on a “small bites” or Post-Nissen diet.  They just have to avoid things that might get stuck if there is swelling at the bottom of the wrap.

Do you do this surgery often? Not as often as we used to.  In the early 2000’s we would do this procedure on almost every developmentally delayed patient who aspirated and had GE reflux.  Now we only do it on children that can’t be managed medically and are not a candidate for continuous GJ tube feeds.  All of the surgeons to many laparoscopic GI surgeries, so feel confident that your surgeon can do a laparoscopic fundoplication.  All of our surgeons are fellowship-trained and either board certified or board-eligible in pediatric surgery.

What is the success rate of this surgery/ How well will it work?  It really depends on the patient and their symptoms.  National statistics suggest 70% do well enough to come off meds, 20% still need meds but are much improved, and 10% are not improved.  GE Reflux is not the same as vomiting.  Reflux is a low-pressure movement of stomach contents into the esophagus.  Vomiting is a high pressure, coordinated brain process that involves abdominal muscles as well as the stomach.

Is it a laparoscopic surgery?  Almost all children are candidates for laparoscopic surgery, but ask your surgeon.

What is a hiatal hernia and is the patient more likely to get one after procedure?The “hiatus” is the normal opening of the diaphragm.  The esophagus leaves the chest and enters the abdomen through the hiatus.  A hiatal hernia is when the stomach comes up into the chest through that opening.  It is possible to develop a hiatal hernia after the surgery, but less common with the recent modifications (not freeing the front of the esophagus).

How long is down time after surgery?  Typical hospitalization is one night in the hospital.  Most children can be back in school in a week.

Will patient have difficulty swallowing?It is very common to have food “stick” during the first 3-6 weeks after the surgery.  Difficulty swallowing can persist longer, but is less common.

Can the fundo come undone or rip? How likely?  It is rare for the fundoplication to become completely undo.  Often, over time it can become less effective, however.  This is usually due to stretching of the wrap over time, making it less effective.  Development of a hiatial hernia can also lessen the effectiveness of the wrap.

Will he be able to do therapy soon after? How long to heal?Generally in one week.

As patient grows will the fundo stretch?  In some patients, the fundo works perfectly forever, but in others, they have return of symptoms.  Patients who gag and wretch (dry vomit) seem to have more problems with failure than those that don’t.

What happens if he gets air in his stomach? Can patient burp?  Inability to burp is a common temporary side effect of the surgery.  This causes a bloated, uncomfortable feeling.  If it persists beyond 6 months and/or causes problems, options include dilating the esophagus or revising the fundo.

Where can I find more information?
The best sources of detailed information on GERD in children are NASPGHAN and APSA and the “Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of NASPGHAN and ESPGHAN” which should be published soon.

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