In medicine, "reflux" (from the Latin refluxus "backflow") refers to a pathological reflux from one hollow organ into another. In gastroesophageal reflux, the contents of the stomach (from the Latin stomach (gaster)) flow back into the oesophagus (from the Latin oesophagus). Gastroesophageal reflux (GER) also occurs in healthy children and can be completely normal. Pathological reflux (gastroesophageal reflux disease or GERD) occurs when the number and/or duration of reflux events exceed certain normal values and when the child suffers from the consequences of the reflux. The frequency is estimated at 4-30% in adults and 5-9% in children. In infants, however, the frequency is estimated at around 50%. This is due to the predominant milk feeding and is quite normal in most cases in this age group.


Gastroesophageal reflux disease can have various causes.

1. The muscular activity of the oesophagus (peristalsis) is impaired and cannot properly return the normal output of stomach acid.

2. The lower esophageal sphincter, which separates the esophagus from the stomach, does not function properly.

3. A so-called hiatal hernia leads to an abnormal passage of parts of the stomach through the diaphragm (in the area of the so-called "oesophageal hiatus").

There is often a combination of these factors. The oesophagus also performs its apparently simple task on the basis of very complex nerve control. These are complex nerve pathways that are localized deep in the brain stem. Disorders of this coordination therefore play a significant role, especially in patients with cerebral (brain-related) problems.

 

Symptoms

The spectrum of symptoms is varied, but the following is frequently observed:

1) A common symptom is spitting up or vomiting. The refluxing stomach acid can cause pain and heartburn, lead to sleep disturbances and "crying spells" or "overstretching".

2) The stomach contents can also enter the windpipe as they flow back down the esophagus. Coughing or rattling noises are then observed when breathing. Reflux should also be considered in the case of recurrent lung infections and chronic coughing.

3) Recurrent vomiting and pain lead to a refusal to eat and a weakness to drink. In young children in particular, this can lead to poor weight gain and failure to thrive.

The primary aim of therapy is to prevent the negative effects of stomach acid on the oesophagus. Various medications are used to neutralize stomach acid or inhibit its production (antacids, proton pump inhibitors, H2 blockers). In severe cases, particularly if there is severe reflux, the gastric acid has led to inflammation with scarring (stenosis) in the oesophagus, persistent swallowing difficulties and the children are not relieved of symptoms with medication, surgical intervention is necessary. The operation is usually minimally invasive (laparoscopic). The esophagus is wrapped around with parts of the stomach like a sleeve to create a valve mechanism (so-called fundoplication). In contrast to drug therapy, the cause is treated directly rather than just the symptoms. When the stomach is filled, the sleeve tightens around the oesophagus, thus closing the oesophagus and preventing gastric contents from flowing back into the oesophagus. When patients drink after the operation and the stomach empties towards the small intestine, the sleeve relaxes and food can enter the stomach normally again. These techniques are named after their first describers, with the two most common surgical methods being Thal's fundoplication (270° half cuff) and Nissen's (360° complete cuff).


Initial contact is always made during an outpatient consultation in our pediatric surgery outpatient clinic (see below for contact details). The treatment options will be presented and your questions will be discussed in detail. Please bring all your existing examination results with you to the first outpatient consultation.
However, additional examinations are often necessary, some of which can be carried out close to home. (see Diagnostics)

 

 

24 h pH-metry (acid measurement)

In this test, a very thin cable with 2 measuring sensors is placed through the nose into your child's esophagus. A portable device connected to this measures the pH value, i.e. the acidity, at the lower end of the probe at two measuring points. If acidic gastric juice flows back into the oesophagus, the pH value changes. This allows you to see how long and how often the gastric juice has been rising. However, this method does not provide any information about damage to the mucous membrane of the esophagus or the lungs.


(X-ray) pap swallowing examination

This examination is not carried out to detect reflux, but to detect malformations or diseases that promote reflux (e.g. a diaphragmatic hernia or "hiatal hernia"). To do this, your child must swallow a special porridge that is not permeable to X-rays. The transportation of the porridge through the oesophagus can then be examined on X-ray images, particularly in relation to the diaphragm.


Gastroscopy (gastroscopy or oesophagogastroduodenoscopy ("OGD"))

In individual cases, it may be necessary to perform a gastroscopy to assess damage to the esophageal mucosa. Under general anesthesia, a flexible tube with a camera attached to it is inserted into the esophagus and stomach. If inflamed mucous membrane is seen, tiny samples can be taken from the mucous membrane with small forceps and examined.


Bronchoscopy (examination of the airways)

This examination is similar to a gastroscopy, except that the camera is used to look into the windpipe and its branches (bronchi). This allows you to see whether the rising stomach acid has damaged the mucous membrane of the bronchi. Small samples of mucous membrane can also be taken during this examination.

Fundoplication (anti-reflux surgery)

If gastroesophageal reflux disease has been diagnosed and your child does not improve despite drug therapy, we recommend surgery (anti-reflux surgery or fundoplication). This involves narrowing the passage from the oesophagus to the stomach in such a way that stomach acid is prevented from overflowing into the oesophagus, but at the same time the passage of food into the stomach is not restricted (Fig_2-5). Fundoplication is always performed laparoscopically at our center, regardless of age. Our preferred technique is the Thal fundoplication (270° half-cuff) (Fig. 1-5). The pediatric surgeon makes a small incision in the navel through which a thin tube (trocar) is inserted into the abdominal cavity. Air is blown into the abdominal cavity through the trocar and a camera is inserted (laparoscopy). This allows the entire abdomen to be inspected. Additional working channels (trocars) are then inserted into the abdomen via two or three further 3 mm incisions. During fundoplication, the esophagus is wrapped around parts of the stomach like a sleeve (270°) (Fig. 4+5) to create a valve mechanism. Such an operation can also be performed if a feeding tube or "PEG" has already been inserted into the stomach due to swallowing disorders or in the case of disabled children. It is also possible to perform a gastrostomy in addition to the fundoplication during the same procedure.

After the procedure, your child will initially remain in the recovery area, where you will be able to sit up in bed again. You will then be transferred to the normal ward. A few hours after the operation, your child will usually be able to eat again. A 3-4 day inpatient stay in hospital is usually sufficient for a fundoplication.

 

A follow-up visit to us is only planned after a few weeks. As we only use stitches that dissolve by themselves, the first post-operative check-ups will be carried out by your pediatrician after discharge. However, if any questions remain unanswered or if we consider an earlier follow-up examination to be appropriate in individual cases, you can come back to us at any time.