Respiratory manifestations of gastroesophageal reflux disease in pediatric patients

Laparoscopic Nissen Fundoplication: An Excellent Treatment of GERD-Related Respiratory Symptoms in Children-Results of a Multicentric Study

INTRODUCTION

Respiratory manifestations of gastroesophageal reflux disease (GERD), particularly chronic cough, are being recognized with increased frequency in children. This survey aimed to investigate the efficacy of laparoscopic Nissen fundoplication for treatment of GERD-related respiratory symptoms not responsive to medical therapy in neurological normal children.

MATERIALS AND METHODS

We collected data of children with GERD-related respiratory complaints not responsive to medical therapy who underwent laparoscopic Nissen fundoplication in four European centers of Pediatric Surgery over a 10-year period. We excluded children with neurological impairment.

RESULTS

A total of 220 laparoscopic Nissen procedures were performed in the period 2005-2015. Twenty-four (12 boys and 12 girls, average age 9.5 years) out of the 220 patients (10.9%) presented with chronic cough and other respiratory manifestations, including asthma, reactive airway disease, and recurrent pneumonia. Average operative time was 65 minutes (range 45-100). As for postoperative complications, two tight wraps requiring endoscopic dilatation (IIIb Clavien) and two relapses of GERD for slipped Nissen requiring reoperation (IIIb Clavien) were recorded. None of these complications occurred in the group of patients with GERD-related respiratory symptoms. At follow-up evaluation, respiratory symptoms disappeared with a significant improvement of quality of life scoring (I Grade Visick) in 22/24 patients (91.6%).

CONCLUSION

Our results confirm that GERD should be investigated as one of the possible etiologic factors in any child with persistent respiratory complaints. In patients with symptoms not responsive to medical therapy, laparoscopic Nissen fundoplication is the treatment of choice with a very high success rate (>90% in our series), a very low morbidity, a significant improvement in airway symptoms, and a marked reduction in the need for medications.

Radiographic and Endoscopic Measurements of Esophageal Length in Pediatric Patients

Objectives:

Knowledge of the length between the upper esophageal sphincter (UES) and the lower esophageal sphincter (LES) in pediatric patients is essential for intraluminal impedance and dual pH probe recordings.

Methods:

We measured the vertical distance between the true vocal cords (TVCs) and the LES in chest x-rays (CXRs) of 118 children (ages, 6 weeks to 13 years) and measured the vertical distance between the UES and the LES during endoscopy in 31 patients (ages, 14 months to 17 years) and correlated the measurements to height, weight, and age.

Results:

Esophageal length correlated best with patient height (R = 0.96 by CXR, R = 0.88 by endoscopy) and less well with weight (R = 0.87, R = 0.67) and age (R = 0.94, R = 0.86). Linear regression analyses using radiographic measurements revealed that esophageal length (TVC to LES) can be estimated from a patient's height by the following equation: 1.048 + 0.167 × height (in centimeters). With the upper pH probe placed in the hypopharynx at the TVC level and the inferior probe placed in the esophagus 3 to 6 cm above the LES, the patients were divided into 6 groups corresponding to the currently available number of sizes of dual pH-impedance probes. With the patients' heights between 71.5 and 161.3 cm, 64.7% to 100% of patients were within 1 cm of the desired location with preselected probes. Confirmation of placement was performed with CXR.

Conclusions:

A pediatric patient's height can be used to estimate the esophageal length (TVC to LES) and facilitate the selection of dual pH—impedance probes. Our method decreases the risk of morbidity while increasing the accuracy of the study of extraesophageal reflux disease.

Supraesophageal Reflux: Validation of a Symptom Questionnaire

OBJECTIVES: To develop and validate a questionnaire for supraesophageal manifestations of reflux (SER) that will facilitate its study in clinical and research settings.

STUDY DESIGN: The Supraesophageal Reflux Questionnaire (SERQ) and previously validated Reflux Symptom Index (RSI) were subjected to multiple types of validity testing, including content validity, concurrent validity, reproducibility, and predictive validity.

RESULTS: The concurrent validity and reproducibility of both instruments was good to excellent for most items tested. The predictive validity of the SERQ was superior to the RSI when it included the covariates of history of sinusitis, use of over-the-counter antacid medications, age, gender, and body mass index.

CONCLUSIONS: The SERQ will serve as both a useful clinical and research tool by offering not only SER symptom information, like the RSI, but also information about the patient's medical history and medication usage that will facilitate use of the SERQ in research protocols.

EBM rating: B-2b

The impact of reflux burden on Pseudomonas positivity in children with cystic fibrosis

OBJECTIVES

Nonacid gastroesophageal reflux (GER), particularly in patients taking acid suppression, has been implicated as a cause of respiratory infections. We hypothesize that children with cystic fibrosis (CF) and a higher nonacid reflux burden have greater rates of Pseudomonas aeruginosa (Pa) infection than patients with a lower reflux burden.

STUDY DESIGN

We reviewed the multichannel intraluminal impedance (pH-MII) tracings of 35 patients with CF between 2003 and 2010. We compared the reflux profiles between those patients who were Pa positive and Pa negative.

RESULTS

The mean age was 13.5 ± 5.8 years. Twenty-seven patients (76%) were Pa positive. Ninety seven percent of patients were taking proton pump inhibitors during pH-MII testing. The mean percentage of time pH was <4 was 8.5 ± 12%. Pa patients had a significantly higher total, acid and proximal nonacid reflux burden (P < 0.009). There was a negative correlation between nonacid reflux burden and FEV1 (r = -0.397, P = 0.03) and between total number of reflux events and FEV1 (r = -0.474, P = 0.009). After adjusting for age and FEV1, total reflux burden remains significantly associated with Pa positivity (P = 0.055).

CONCLUSIONS

Increased reflux burden may predispose patients to Pa infection and worse lung function.

Characteristics of gastroesophageal reflux and potential risk of gastric content aspiration in children with cystic fibrosis

OBJECTIVES

Increased gastroesophageal reflux (GER) is common in children with cystic fibrosis (CF). We studied the occurrence of acid, weakly acidic (WA), and weakly alkaline (WALK) reflux in children with CF and evaluated a possible surrogate marker for risk of gastric content aspiration.

PATIENTS AND METHODS

Twenty-four children with CF underwent impedance-pH monitoring for detection of acid (pH < 4), WA (pH 4-7), and WALK-GER (pH > or = 7). In 11 children, cough was objectively recorded with esophageal manometry and the symptom association probability was calculated to determine the reflux-cough relation. Presence of bile acids (BA) was measured in the saliva of 65 patients with CF and 23 healthy children, respectively.

RESULTS

Sixteen of the 24 children had increased GER (esophageal acid exposure). The majority of reflux events were acidic in nature. WA reflux was less common and WALK reflux was rare. The sequence reflux-cough was found in 8 of the 11 children and 1 of 11 children had a positive symptom association probability for reflux-cough. The sequence cough-reflux was found in only 3 of the 11 children. Only a small fraction of the total esophageal acid and volume exposure was secondary to cough. Twenty-three of the 65 children with CF had BA in saliva compared with none of the healthy controls.

CONCLUSIONS

Although WA-GER is uncommon, acid GER is prevalent in children with CF. It is a primary phenomenon and is not secondary to cough. One third of the children with CF have BA in saliva, which may indicate an increased risk for aspiration. However, the impact of salivary BA and potential aspiration on CF pulmonary disease needs further investigation.

Apnea-associated reduction in lower esophageal sphincter tone in premature infants

OBJECTIVE

To characterize esophageal motility during episodes of prolonged apnea in premature infants.

STUDY DESIGN

We retrospectively reviewed combined manometric and physiological monitoring studies performed in tube-fed premature infants from 1994 to 2002. Apnea was defined as a respiratory pause of >20 seconds. For each apneic event, pharyngeal swallowing, esophageal motility, and lower esophageal sphincter (LES) pressure were assessed before, during, and after apneic episodes.

RESULTS

Twelve episodes of apnea (duration, 20 to 120 seconds) were identified in 7 infants (34 to 37 weeks postmenstrual age (PMA); study weight, 1950 to 2380 g). During the apneic episodes, swallowing increased (median[interquartile range], 0[0,0], 5[4,7], and 1[0,2] swallows/minute before, during, and after apnea, respectively; P < .05), esophageal pressure wave sequences (PWS) increased (1[0,2], 5[3,6], and 2[1,3] PWS/minute before, during, and after apnea, respectively; P < .05) and LES pressure decreased (16[12,21], 6[5,8], and 27[12,32] mmHg before, during, and after apnea, respectively; P < .05).

CONCLUSION

In premature infants, apnea is associated with reduced LES tone, potentially increasing the likelihood of reflux occurring after the onset of apnea.

Comparison of the effect of a cornstarch thickened formula and strengthened regular formula on regurgitation, gastric emptying and weight gain in infantile regurgitation

The purpose of this study was to evaluate the efficacy of a specially selected cornstarch-supplemented formula on clinical symptoms, gastric emptying and weight gain in infants with regurgitation. We performed a prospective randomised trial evaluating the therapeutic efficacy of two different formula feedings (cornstarch-thickened formula, group A; 25% strengthened formula, group B) in 81 young infants with regurgitation/vomiting > or = 3 times/day. A Tc-99 m milk scintigraphy was performed at inclusion and after 2 months to quantify gastric emptying time; all studied infants underwent a 2-month period of clinical follow-up evaluating regurgitation and body weight gain. At inclusion, group A and B had a similar age and weight. After the 2-month period of intervention, regurgitation and vomiting had both greater decrease (both P < 0.001 at 1 and 2 months) in group A (from a score of 4.19 +/- 1.71 to 0.93 +/- 0.42) than in group B (from a score of 4.15 +/- 1.68 to 2.89 +/- 1.16). Non-regurgitation symptoms (irritability, cough, choking, night-waking) decreased (P = 0.045 at 1 month and 0.017 at 2 months) in group A (from a score of 18 at baseline to 3 after 8 weeks) as compared to group B (from a score of 18 at baseline to 11 after 8 weeks). Weight increased more in group A (29.1 +/- 3.9 g/day over 8 weeks) versus group B (23.6 +/- 3.5 g/day over 8 weeks) (P < 0.01 at 1 and 2 months) Gastric emptying improved significantly in group A as compared with group B (all P < 0.001 for T1/2, and residual volume at 60 and 90 min). Ingested feeding volume was significantly larger in the group receiving cornstarch-thickened formula, both at 4 weeks (109.4 +/- 24.5 vs. 98.5 +/- 23.6 mL/meal) (P: 0.042) and at 8 weeks (137.6 +/- 27.9 vs. 115.7 +/- 26.5 mL/meal) (P < 0.001). Cornstarch-thickened formula feeding decreases the frequency of regurgitation/vomiting, provides better body weight gain and has an accelerated gastric emptying in comparison to a 25% strengthened regular formula in infants with regurgitation.

Endoscopic findings in children with stridor

Congenital and acquired airway diseases are responsible for upper respiratory distress and stridor in children. In neonatal intensive care units, we have seen increased survival in premature babies, but also a high incidence of airway complications related to intubation, which present as stridor.

Aim

To review endoscopic findings in children with stridor.

Study design

a cross-sectional cohort study.

Methods

A retrospective analysis was done of 55 cases of children with stridor who underwent endoscopic exams, between January 1997 and December 2003.

Results

69% were aged below one year. The main indications for endoscopy were post-extubation stridor (63.63%) and evaluation of neonatal stridor (21.82%). Many associated diseases were seen, including lung diseases (60%), neurological condition (45.4%), and GERD (40%). The main endoscopic findings and indications for tracheotomy were subglottic stenosis (27.27%) and airway inflammatory process (21.82%) occurring in children under five years old. Congenital disorders were more frequent in children under age one year.

Conclusion

Neonatal stridor has many causes; those related to tracheal intubation are more frequent in hospitals that treat more complex diseases. Pediatricians and otorhinolaryngologists should know the main causes of stridor and perform detailed clinical evaluations to determine case severity. The endoscopic examination, must be meticulous.

Oesophageal replacement in children with indolent stricture of the oesophagus

OBJECTIVE

To evaluate the indications for and results of oesophageal replacement for acquired oesophageal stricture in children.

METHODS

This was a descriptive interventional study. Between 1987 and 2003, patients who had peptic or corrosive stricture were included in the study. Age and gender were analysed and any history of ingestion of caustic agents or untreated reflux was noted. Types of symptoms such as progressive dysphagia to solids and liquids and extent of respiratory infections were evaluated. Nutritional deprivation was also measured. Success or failure of dilatation at the time of endoscopy was taken into account. The criterion for oesophageal replacement was recurrence of stricture within 3 weeks of the previous dilatation. Patients were prepared with general supportive care. Feeding gastrostomy was performed in 12 patients who were severely malnourished. No patients underwent oesophagectomy of the strictured oesophagus. Short- and long-term complications were recorded.

RESULTS

Of the 54 patients, 34 were male and 20 were female. Colonic conduit and reverse gastric tube were used in 27 patients each. Three patients had leak and were treated conservatively. Six patients developed anastomotic stricture but benefited remarkably from periodic dilatation and, in the long-term, remained symptom-free. Results were generally very gratifying.

CONCLUSION

Most patients who require oesophageal conduit do well and catch up with their growth and development.

The yield of esophageal pH monitoring during polysomnography in infants with sleep-disordered breathing

This study evaluates the yield of adding simultaneous esophageal pH monitoring to polysomnography (PSG) in 41 infants with unexplained sleep disordered breathing. The relationships of respiratory events to episodes of gastroesophageal reflux (GER) were analyzed. The major causes for referring the infants were cyanotic episodes (22%), apneas (20%), and choking events (15%). PSG was abnormal in 8/41 (20%). Abnormal pH studies were observed in 12/41 (29%) infants. In 4/12 (33%), respiratory events correlated with GER episodes. Adding simultaneous pH monitoring to PSG may identify associated conditions and thus focus treatment.

Cine magnetic resonance imaging for evaluation of focal tracheomalacia: innominate artery compression syndrome

BACKGROUND

The contribution of an 'aberrant innominate artery' to respiratory distress syndromes has been a matter of debate nearly since the introduction of this concept. Recent advances in dynamic imaging are proving to be of value in assessing tracheal function in patients with respiratory distress. We therefore evaluated patients with innominate artery compression syndrome using the cine magnetic resonance imaging (CMRI) modality.

OBJECTIVES

To apply the CMRI modality to evaluate patients with respiratory distress who exhibited tracheal compression at the level of the innominate artery.

METHODS

A cohort of three patients in respiratory distress underwent bronchoscopy, followed by CMRI using a Siemens 1.5T Vision system.

RESULTS

These three patients exhibited tracheal compression at the level of the innominate artery in agreement with their findings during bronchoscopy. All three exhibited dynamic tracheal compression that varied with the respiratory cycle. The degree of tracheal compromise was readily appreciated using the dynamic, real-time CMRI modality. Due to the severity of symptoms, the two children underwent innominate arteriopexy with complete resolution of their symptoms.

CONCLUSIONS

CMRI provides extremely rapid acquisition of images, as well as integrated information regarding relationships of mediastinal structures. By providing functional imaging of tracheal patency during the respiratory cycle, CMRI may provide additional insight into innominate artery compression syndrome as more patients are evaluated.

Is endoscopic follow-up needed in pediatric patients who undergo surgery for GERD?

BACKGROUND

This study evaluated the role of endoscopy in the postoperative management of pediatric patients who undergo fundoplication for GERD.

METHODS

Medical records of 109 otherwise healthy children who underwent operation for GERD from 1979 to 1996 were reviewed. Patients with respiratory symptoms or esophageal stenosis were excluded. All patients underwent endoscopic surveillance with endoscopy being performed in the early (within 1 year) and late (between 1 and 2 years) postoperative periods. Specifically evaluated were the appearance of the wrap and evidence of esophagitis. The risk of a recurrence of esophagitis based on wrap appearance and the presence of clinical symptoms in patients with endoscopic evidence of esophagitis were also evaluated.

RESULTS

At early endoscopy 3 patients with an intact wrap and 8 with a defective wrap had esophagitis (not significant). At late endoscopy, 5 patients with an intact wrap and 17 with a defective wrap had esophagitis (p < 0.05).

CONCLUSIONS

An intact wrap does not prevent recurrence of GERD. Such an occurrence is even more likely when endoscopy demonstrates a defective wrap. For all patients who have undergone fundoplication, endoscopic evaluation at 1 to 2 years is recommended to detect esophagitis in the absence of symptoms so treatment can be initiated before symptoms occur.

Subglottic stenosis complicated by allergic esophagitis: case report

Allergic esophagitis is a known entity that had been described in patients with dysphagia. It has not been previously described in association with subglottic stenosis. We report the case of a 2-year-old girl with symptoms suggestive of allergic esophagitis who suffered from subglottic stenosis that recurred despite surgical measures. Her esophageal pH monitoring results were normal, and she did not respond to antireflux medications. She did respond dramatically to corticosteroid therapy with improvement of both her esophageal and laryngeal symptoms. Allergic esophagitis as a clinical entity is discussed.

A teenager with an annoying cough

Chronic cough is a stressful condition and can lead to extensive investigations. Bronchial asthma and postnasal drip syndrome are common causes, but sometimes the origin of cough is outside the respiratory tract (1,2). Such a relatively simple test as esophageal pH probing may suggest appropriate (antireflux) therapy.

Pediatric gastroesophageal reflux and laryngopharyngeal reflux

Pediatric gastroesophageal reflux (GER) and laryngopharyngeal reflux (LPR) have gained better recognition over the past few years. GER and LPR usually present as regurgitation, emesis, epigastric pain, failure to thrive, esophagitis, or stricture. Many patients suffer respiratory disorders associated with reflux. Classification of reflux, pathophysiology, manifestations of reflux, diagnosis, and management of the disease are discussed in this article.

Severe non-obstructive sleep disturbance as an initial presentation of gastroesophageal reflux disease

A 2.5-year-old child presented with a sleep disturbance initially diagnosed as a behavioral problem. The child had several atypical symptoms of gastroesophageal reflux disease (GERD). The sleep disturbance resolved quickly after treatment of GERD. GERD is a disease with protean manifestations which is becoming of greater interest to the pediatric otolaryngologist. We discuss diagnosis of this entity.

Respiratory complications of gastrointestinal diseases

Further advances in the ability to diagnose GER disease by use of ambulatory pH monitoring have unveiled a host of extraesophageal manifestations of GERD. These include pulmonary symptoms of asthma, recurrent pneumonia, cough or bronchitis, and infant apnea. Many of these symptoms may be the sole presentations of GER in these patients. It is important that the clinician is aware of these atypical presentations of GERD. The expanding use of ambulatory pH monitoring is helping to clarify the underlying pathophysiology of these disorders as well as to improve the ability to diagnose the atypical manifestations of GERD.