Paediatrics: Oesophageal disorders

Oesophageal disorders

Gastro-oesophageal reflux (GORD)

Gastro-oesophageal reflux occurs when there is inappropriate effort-less passage of gastric contents into the oesophagus. GORD exists when reflux is repeated and severe enough to cause harm. Reflux is very com-mon in infancy and is associated with slow gastric emptying, liquid diet (milk), horizontal posture, and low resting lower oesophageal sphincter (LOS) pressure.

Other causes in infancy and in older children include: LOS dysfunc-tion (e.g. hiatus hernia); ‘rise’gastric pressure (e.g. delayed gastric emptying); external gastric pressure; gastric hypersecretion (e.g. acid); food allergy; and CNS disorders (e.g. cerebral palsy).

Presentation of GORD

•   Gastrointestinal: regurgitation, non-specific irritability, rumination, oesophagitis (heartburn, difficult feeding with crying, painful swallowing, haematemesis), faltering growth (calorie deficiency due to profuse reflux of ingested calories).

•   Respiratory: apnoea, hoarseness, cough, stridor, lower respiratory disease (aspiration pneumonia, asthma, BPD).

•   Neurobehavioural symptoms: e.g. Sandifer’s syndrome (bizarre extension and lateral turning of head, dystonic postures).

·  Complications:

•   oesophageal stricture (dysphagia);

•   barrett’s oesophagus (premalignant intestinal metaplasia);

•   faltering growth;

•   anaemia (chronic blood loss);

•   lower respiratory disease.

Management of GORD

•   History: e.g. effortless regurgitation, relationship to feeds.

•   Examination: including growth, possible anaemia, respiratory.

·  Investigations (appropriate when diagnosis is uncertain, there is a poor response to treatment, or complications occur) may include: upper GI endoscopy; oesophageal biopsy; 24hr oesophageal pH probe; barium swallow with fluoroscopy; radioisotope ‘milk’ scan (aspiration); oesophageal manometry (oesophageal dysmotility); and CXR (associated respiratory disease).

Treatment

Treatment is carried out in a stepwise fashion.

•   Positioning: nurse infants on head-up slope of 30* 9 prone.

•   Dietary: thickened milk feeds (infants); small frequent meals; avoid food before sleep; avoid fatty foods, citrus juices, caffeine, carbonated drinks, ‘alcohol and smoking’.

•   Drugs: gastric acid reducing drugs, e.g. ranitidine or omeprazole (if oesophagitis); Gaviscon^® (contains antacids and an alginate that forms viscous surface layer to reduce reflux); prokinetic drugs, e.g. domperidone; mucosal protectors, e.g. sucralfate; corticosteroids (allergic oesophagitis).

• Surgery: usually Nissen’s fundoplication is performed when medical treatment has failed:

•   Indications for surgery are failed intense medical treatment; oesophageal stricture; Barrett’s oesophagus; severe oesophagitis; recurrent apnoea; lower respiratory disease; faltering growth (FTT).

•   Complications of surgery include: ‘gas bloating’ syndrome; dysphagia; profuse retching; ‘dumping’ syndrome.

Prognosis

Vast majority of infants outgrow symptoms by 1yr. In older children, 50% develop a chronic, relapsing course.

Oesophageal foreign body

This usually occurs in toddlers or older children with neurological or psychiatric conditions. If the object reaches the sto-mach 90% will pass spontaneously. Confirm position with AP and lateral CXR. Remove endoscopically if:

• Dysphagia or drooling persists.

• Object is still in the oesophagus for >12hr.

• Object is sharp (risk of perforation).

• Object is hazardous, e.g. mercuric oxide disc batteries.

Upper oesophageal dysfunction

This disorder is usually due to diffuse CNS dysfunction.

• Presentation: choking, cough, drooling, dysphagia, nasal regurgitation.

• Diagnosis: barium swallow with video-fluoroscopy or oesophageal manometry.

• Treatment: treat primary underlying disorder. Rarely, cricopharyngeal myotomy is helpful.

Achalasia

This rare, idiopathic, condition of obstruction is due to failure of lower oesophageal sphincter relaxation.

• Presentation: vomiting, dysphagia with solids or liquids; FTT; aspiration.

• Diagnosis: barium swallow (dilated tapering lower oesophagus) or oesophageal manometry.

• Treatment: nifedipine (short-term); endoscopic balloon dilatation; Heller’s cardiomyotomy.

Benign oesophageal stricture

Causes include severe GORD; caustic ingestion; and radiotherapy. 

Treatment

Treat the underlying cause, e.g. reduce gastric acid production in GORD; perform balloon endoscopic dilatation.