Gastro-oesophageal reflux

Nota:

• main cause

1. --> inapprop relaxation of this mm

1. predominantly fluid diet
2. mainly horizontal posture
3. short intra-abdo length of oesophagus

1. common in 1st year of life
2. most symptomatic reflux resolves spontaneously by 12mths of age
   1. why?
      1. maturation of lower oesophageal sphincter
      2. assumption of upright posture
      3. more solids in diet

1. recurrent regurgitation or vomiting
2. otherwise well
   1. putting weight on normally
      1. but mess, smell, freq change of clothes

1. more common in
   1. cerebral palsy or neurodevelopmental disorders
      1. Mx energetically, surgically if needed
   2. preterm infants
      1. esp if + bronchopulmonary dysplasia
   3. ff surgery for
      1. oesophageal atresia
      2. diaphragmatic hernia

1. haematemesis
2. discomfort on feeding or heartburn
3. iron def anaemia

1. recurrent pneumonia, cough or wheeze
2. apnoea
   1. pre-term infants

1. atypical hx
2. complications present
3. failure to respond to Rx

1. quantify degree of acid reflux
2. normally, oesophageal pH should be >4 most of time

1. weakly acidic or non-acid reflux also measured

1. ID oesophagitis
2. exclude other causes of vomiting

1. not sensitive nor specific
2. to exclude anatomical abnormalities
   1. oesophagus
   2. stomach
   3. duodenum
3. ID malrotation

1. excellent prognosis
2. parental reassurance
3. add inert thickening agents to feeds
   1. Nestargel
   2. Carobel
4. positioning in 30 degree head-up prone position after feeds

1. acid suppression
   1. H2 receptor antagonists
      1. e.g. ranitidine
   2. proton pump inhibitors
      1. e.g. omeprazole
   3. reduce vol of gastric contents
   4. treat acid related oesophagitis
2. gastric emptying agents
   1. e.g. domperidone
   2. poor evidence for use

1. further ix
   1. e.g. cow's milk protein allergy ix

1. indications
   1. children w/ complications unresponsive to intensive medical Rx
   2. oesophageal stricture
2. Nissan fundoplication
   1. fundus of stomach wrapped around intra-abdo oesophagus
      1. abdominal procedure
      2. laparoscopic procedure