Gastroesophageal Reflux Disease

Stay current is a multimedia publication designed to keep health care professionals up to date with standards of care and new emerging ideas. This chapter is created and edited by Todd Ponksy, Sofia Abdulhai, Aduramo Fremoshi, and Raja Vendra Rao, and is recorded and produced at Akron Children's Hospital in Akron, Ohio. Welcome to State Current in Pediatric Surgery. This is Todd Ponksy recording from Akron Children's Hospital, and today we're going to be talking about a topic I've been hoping to do over the past couple of years. And that is gastroesophageal reflux and talking about the role of the Nissen fundoplication or any surgical intervention. And I've been trying to figure out, how do we do this? And who do we have on the panel? And how do we get down to the workup, diagnosis, and treatment? And, uh, a little story here. I was in Sicily and I met a pediatric gastroenterologist from Boston Children's Hospital. Name was Victor Fox, and I asked him about who he thought would be the the world's expert in this and in his world in pediatric GI. And he didn't hesitate a second and said it would be Dr. Rachel Rosen. And we are very fortunate to have Dr. Rachel Rosen here with us today to speak about a lot of these controversies in pediatric reflux. Dr. Rosen is the Director of the Aerodigestive Center at Boston Children's Hospital. She's Associate Professor of Pediatrics at Harvard Medical School. She's a pediatric gastroenterologist at Boston Children's, but she really specializes in motility. So Rachel, thank you very much for joining us. Thanks for having me. And to make it more fun, we got a surgeon here with us, definitely someone we've had on the the podcast before. Dr. Whit Holcolm. Uh, Dr. Holcolm is the Senior Vice President of Children's Mercy Hospital in Kansas City. He is the Editor and Chief of our Journal, the Journal of Pediatric Surgery, and the author of the textbook that, uh, most of us use in pediatric surgery and definitely, uh, has been on the forefront of the laparoscopic Nissen fundoplication and Mercy, uh, Hospital has been also a point of interest from a surgical reflux, uh, solution as they, they've talked about and and written about all sorts of different surgical therapies for reflux. So I wanted to get some discussion going. This might be different than previous podcast as we might have some disagreement, which, uh, most of you know I love and that helps us figure out what the right thing to do is. So, uh, Whit, thanks for joining us. Glad to be here, Todd. So let's jump right into it and we'll go through a few cases and, uh, we'll we'll try to see what each of you think about, uh, the answers to these questions. So, first, Rachel, let me start with you. Let's say you get called about a six-month-old patient who has had some vomiting, uh, and they've had some respiratory symptoms, coughing, wheezing. And they've also had a little bit of failure to thrive as well. How do you start off working up this patient? Yeah, that's a fairly typical patient that we have in the Aerodigestive Center. So I think from a GI perspective, what we have to figure out first is, is reflux really the issue, which is often the reason that they're referred to us or is there something else going on? And I think in our experience, the vast majority of kids who have vomiting, respiratory symptoms, wheezing, are more likely to have oropharyngeal dysphagia and aspiration during swallowing than gastroesophageal reflux. And I think for us, our first goal is to figure out, you know, what's the real problem? Are we being fooled by, uh, symptoms that could mimic both? And so usually in these kids cases, we rarely would proceed without a video fluoroscopic study to start with, which I know we're talking about reflux, but the number one masquerader that we see in kids this age who have respiratory symptoms and vomiting is aspiration. So that's probably where I would start. And then if that's normal, then we have to go down the the consideration of reflux diagnoses and other things that might be going on. All right, so how do you, where do you go from there? So let's say you do the the swallow study and it's, it shows no, uh, penetration from above. Yeah, so I think then the next step that we have to figure out is, is GI, is there a GI cause for it? And if we think it's reflux, is it just run in the mill reflux based on this child's age, where the peak age of reflux is between four and six months of age, or is there something else like food allergy? Which again, when we think about big masqueraders for us, it's, you know, is this kid have a milk protein intolerance where the presenting symptom is exactly this with vomiting and respiratory symptoms. So and I know we're going to talk about therapies, but one of the things that we would do if we saw this kid out of the bat or off the bat is, you know, do we thicken their feeds? Do we change their formula? Do we start with some of those non-invasive things before we even do any diagnostic testing in a in a child this young? Okay, that, so I like that. So let's say you, you try those methods, you thicken the formula, and they still have persistent symptoms. Yeah, so that, this is where we again tend to go down the multidisciplinary approach where we would potentially scope this patient with both pulmonary and otolaryngology joining in. We would rarely start with a probe in this age group again because what we're interested in is masquerader. We would rarely put a baby like this on proton pump inhibitors. There is more and more evidence in children under the age of one that they're not beneficial because these kids, what they're refluxing is non-acidic gastric content. So when you think about what babies reflux, babies reflux milk. They're fed basically every two to three hours. And when you look at the normal gastric emptying of infants, uh, they still have milk in their stomach for up to two to three hours. It's only once you get to the three hour mark where you start getting acid production. Wow. And so, um, you know, proton pump inhibitors just aren't going to help in this age group where they're really refluxing non-acid reflux. So a pH probe would not be helpful typically in these, in these young kids. Let me stop you there, because already, already I'm so happy we are doing this because I'm already learning here. So, tell me the age group when you say that that acid reflexes, you said it's one to four months, is that what you said? So, in in any kid that's fed every two to three hours, you're not going to see significant acid production because they still have have milk air formula in their stomach. So when we start thinking about acid, we start thinking about kids who have had nothing to eat or drink for three to four hours after a meal. Is when we start seeing the pH probe start to pick up acid, for example. So if you are very interested in that post prandial period where kids are having symptoms and the kid is less than one, you really need to think about how can I measure non-acid reflux? Or how can I measure milk coming up into the esophagus? It's not enough just to do a pH probe and measure acid. Okay, and also, I'm assuming then this, uh, this goes without saying based on what you just said, but the the neonates and the risk of or a premi and the risk of getting necrotizing enterocolitis from, uh, anti-reflux meds. Is that, uh, is that a true stat, is that a true thing? Yeah, I mean, uh, your, your point is an excellent one. We worry about all kinds of infections in this age group. So, you know, studies have shown both with H2 blockers and PPIs, you can get sepsis, UTIs, um, necrotizing enterocolitis. Kids are at increased risk for pneumonias, pharyngitis, upper respiratory infections, and then just GI bugs as well as C-diff. So we're very worried about the microbiome changes in these kids. And so we think very hard about what their differential is before we just throw them on ant acids. This is great. So let me make sure I got this right. The kid, the six-month-old comes to you, uh, you, you do your work for oropharyngeal stuff. Mhm. You try, uh, food allergy treatments, you thicken the feeds, you try those things. What you would not do is treat them with a PPI to see if it helps. Uh, correct. Okay, so that's a big Correct. especially. Sorry. Go ahead. Especially in this case with the where you have respiratory symptoms as a predominant symptom, the last thing you want to do is push them over the edge with more respiratory symptoms by prescribing a proton pump inhibitor. I love this. Okay, and but you would do an endoscopy. Yep. Okay, and what are you looking for on an endoscopy? Yeah, so the main thing I'm really looking for is Eosinophilic esophagitis because what I want to make sure of is that we're not dealing with esophageal inflammation related to food allergy. And I think one of the most controversial things, at least in the pedi GI world is, do you scope before you've tried them on an antacid, or do you scope after you've tried them on a trial? And I think especially in the aerodigestive population where I don't want to start a proton pump inhibitor. I think it's important to scope early. So you have some idea of what's going on. You can give a definitive diagnosis, which if you treat them with proton pump inhibitors, the esophagus in many cases is going to heal and then you don't know what you're treating. Okay, so I I have so many questions that I'm really wondering if we're going to get through all this and may have to do a part two, but I don't want to skip this because I think it's important. You talked about EO, Eosinophilic esophagitis. I'll tell you that we have thousands of listeners from different countries and I'm not sure that this is as prevalent or discussed in every part of the world. Can you give me a brief synopsis of EO and what it is and what we should look out for and how we treat it? Yeah, sure. So eosinophilic esophagitis is an allergic condition of the esophagus that, uh, presents with a variety of symptoms. And kids under the age of five, the biggest, most common presentation is actually chronic cough. So when you're looking at young kids, number one presentation is cough, number two presentation can be vomiting or failure to thrive. So in this kid's case, it's high on my differential diagnosis. Um, when you scope all kids under the age of five or so who are presenting with respiratory symptoms, you'll find this allergic or eosinophilic esophagitis in about 10% of kids. So it's fairly common when we do endoscopies. In older kids, this will present with chest pain, food impactions, dysphagia. Those are the main symptoms in the older kids. So these are the kids that we get called in in the middle of the night because of a chicken impaction or or other food impactions. But in this young age group with this, which is what this case is, the presentation is cough, um, and and growth issues. So, um, couple questions. First, I want to point out to the listeners out there. This has been very new for me, maybe only over the last five years that I've really seen so much of this now. Um, all these, these children coming in, as you mentioned, with food impaction, they, they so frequently turn out to have Eosinophilic esophagitis. And it if you may, in your region may not be a big, uh, problem that's discussed a lot, I can tell you that it's, uh, we're finding it more and more. Um, how do you treat them? Yeah, so I think, um, when you go through kind of the treatment or the diagnostic algorithm, of kids who are presenting, for example, with vomiting, what your point is critical, which is that you really need to scope every kid before they would get a Nissen because you don't want to wrap a kid who has allergic esophagitis or Eosinophilic esophagitis and I, I can't stress that enough. So you do the initial endoscopy, you see that there's eosinophils there. The old tenant used to be, okay, then you treat them with a proton pump inhibitor and you see, does that esophagitis go away? If it goes away, it's reflux, if it doesn't go away, it's eosinophilic esophagitis. Okay. In the, in the new criteria, that's no longer the case. So now there's a whole other category, proton pump inhibitor responsive eosinophilic esophagitis. Okay. So there's now allergic disease that responds to proton pump inhibitors. So the long and short of it is, if you have inflammation of the esophagus, you can treat with a proton pump inhibitor or you may go down the root of changing kids diets, taking out allergens, or even giving them steroids. Okay, and what is it that they eliminate? Is it eggs and, I don't even remember. What what do you eliminate? Yeah. So if you're, if you're betting person, the most likely thing the kids are allergic to is dairy in about 60 to 70% of kids. So this is why in our reflux algorithm, the first thing that we change is to a, uh, non-dairy or protein hydrolysate formula, partially hydrolysate formula or an amino acid based formula. So we take dairy out. That's our first step. Okay. Some some centers do allergy testing, others don't. Others eliminate the big allergens, milk, soy, wheat, egg. Um, so every sector is a little bit different. Got it. And, um, so right now we have this child. We've, we've, uh, done the, the swallows, floral swallow study, we've done these, these allergy, we've done an endoscopy, we've looked for food allergies, we've tried different things. Um, before we move forward and Whit, I want to invite you at any point in time to either chime in if you disagree, agree, or have a question for Rachel, but so far, does this correlate with what you guys do in Kansas City? Well, yes and no. In that, um, one thing Rachel has, uh, talked about, which I think is a great idea, but very few other places have created is a really a multidisciplinary clinic, an aerodigestive clinic so that you're working in tandem with your, uh, otolaryngologists, your GI doctors, perhaps your surgeons. And so I think that's really wonderful. We feel like we have a very close working relationship with our GI doctors, uh, but we have not developed such a multidisciplinary approach that, uh, she and her colleagues have in Boston. So they are to be congratulated. I think she's raised, uh, some good points and, and the reason, and this is really the reason that I don't believe that the surgeons should be the ones doing the workup of these children. So, you know, when I came to Kansas City 18 years ago, a lot of the pediatricians were sending patients directly to the surgeons, uh, for evaluation and management of reflux disease. Some of that was due to the fact that at the time we had, uh, really two GI doctors. Uh, now we have, I don't know, 25 or so. And so in all honesty, they didn't have as much time to be evaluating the, uh, infants and children back then, and now we have a better manpower situation. Uh, so at least if a, if a patient is sent to me initially, which really doesn't happen very much, uh, anymore, then I send them to our GI colleagues for their upfront evaluation. Because I think she's right. I, you know, I don't think that I've ever wrapped a child with Eosinophilic esophagitis, but I certainly don't want to do that. And I don't believe that the surgeon, especially myself, is the best person to be evaluating all these other conditions that may be in play. And so it's, uh, it's my feeling that the patients ought to be worked up and evaluated by the gastroenterologist, perhaps the otolaryngologist. And then if it's felt that they have a disease that's amenable to an operation, in this case, a fundoplication, then the surgeon gets involved. So, so I really agree with what she has said and I congratulate her and her colleagues for establishing such a multidisciplinary approach. And and let me let me, uh, second that. That I want to highlight that point to everyone listening that we also Whit often get sent, maybe babies in the NICU who they call us for to evaluate for a Nissen and they, they are not always consulted GI first. And I think that that's a fantastic point that should become a standard. At least, uh, so if you, if you, a lot of people may disagree with this, but I, I agree that that should, the first step is, why don't you, uh, consult gastroenterology first and then, uh, we'll follow along. So, Rachel, you've done your endoscopy. It's, it does not look like EO. Now what? Yeah, so again, I think what I'm going to tell you is probably not the approach that many centers use, but I can give you kind of what we would do from a next step with a kid like this. If I have a kid who's vomiting and has respiratory symptoms, their scope is normal. I don't want to put them on a proton pump inhibitor. This would be a kid, for example, that I might go straight, for example, to a macrolide to manage their symptoms, which I know sounds a little bit unconventional, but we use a lot of erythromycin in these babies who have respiratory symptoms. So macrolides are helpful. They're, um, motilin agonists. They make the stomach, the antrum of the stomach contract, and they can help with vomiting, but perhaps most importantly, the secondary benefit is it's an anti-inflammatory for the airway and lungs. So if I have a baby who has respiratory symptoms and has vomiting as a predominant symptom, I will often just put them on a macrolide, uh, to help with their vomiting and respiratory symptoms and that's often enough to get them over the hump if the conservative measures like thickening haven't improved their symptoms. So I know it's not the most traditional approach, but it's something that we are now doing pretty mainstream in kids with pulmonary symptoms. So that's, uh, novel to me and maybe our GI people are doing that. So again, I want to repeat, you sounds like if you do suspect it, you haven't quite yet done any kind of study that I've heard thus far to make the diagnosis, so you treat with a macrolide, erythromycin and you watch them and see how they do initially. Is that, and not a PPI. Yeah. That's correct. And I think you get to one of the key points, which is, at what point do you test? And it's really hard because the role, for example, of using a catheter like impedance probe or pH probe, um, the best time to do that is in a kid who has daily symptoms, right? So there's no great normal values for the number of reflux episodes in a patient for pediatrics. Um, and I think that that's what's really hard. So you do a probe and you get a number of reflux episodes. Well, is that normal, abnormal? There's no, there's no great numbers. So the best that we can do is try to correlate symptoms with reflux episodes on the probe. And so in this kid's case where wheezing is the predominant symptom, it's much more intangible than say cough. If this baby had coughing, then that, then I would say, you know what? Let's do a probe and see what we're dealing with because I can correlate cough with reflux episodes. But for a more nebulous symptom like wheezing, it's a trickier, it's a trickier thing. So that's why you're not hearing me say, let's run to testing in this child. Yeah, and and I'll tell you, Rachel, I, I'm curious what Whit says. I over the years have become less interested in any testing. I, I think so many of them have become just not helpful in my decision tree. I'm curious to hear what you teach us here. But more and more we've, I've not found as much value in pH impedance, in the, the milk emptying study, any of these things to help make the diagnosis. And we're going to obviously get into that soon. So, let me ask you, so you do the, when you do the, the macrolide and, um, you change the diet and they're still having failure to thrive and it's been, let's say a month now. Mhm. Now what? Yeah, so again, this is my bias. This is the medical bias, but in my opinion, that's rarely because of gastroesophageal reflux. So I would go down a very big other differential before running to think about something like a surgical intervention for reflux. And ag and again, I think this is just the medical bias that rarely is reflux a problem, especially when I know this kid is at six months of age, the peak age, they should reflux should be improving as solid food is introduced. So if this is reflux, I'm going to try to buy as much time with management. If this kid was nine or 10 months of age, we may be having a different story, but even then reflux in our, in my opinion, is rarely a cause for, for these symptoms. Okay. So still you keep going with the, uh, erythromycin, the the different food changes really in your head. And I don't want to put words in your mouth, Rachel. So correct me if I'm saying this wrong. In your head, reflux is kind of low on the list here. So you're going to really work hard over the months to try to find what else might be causing this other than reflux. So you're not jumping to doing pH impedance or anything right away. Correct. Okay. Correct. Whit, um, and by the way, I want to in a minute go to the most common patient we get, which is the newborn in the NICU. But before we get there, Whit, do you disagree? Agree with anything that's been said so far? Uh, no, I don't. I think that, um, what Rachel has described really are, are changes and modifications that have occurred over the past decade or two and a lot of it's because we learn or we know so much more now than we did, you know, 10 or 20 years ago. So I, I think her approach is is very reasonable. I will just make one correction, Todd and I, I think because you had mentioned that she has not done any testing now, but it was my understanding that she had done an endoscopy, now. Correct. So I just wanted to make sure that the audience appreciated that she has done an endoscopy looking for, uh, eosinophilic esophagitis. And so I would consider that a test that's been done so far. You're right, Whit and and I, I thank you for pointing that out. And actually, so let me use that as another question. Would you get an upper GI to make sure their anatomy is normal? Yeah, so that's a tricky issue, and because our rate of positive upper GIs is pretty low in kids. Exactly. Yep. I think if you're having true failure to thrive and can't get the kid to gain, you're pretty much obligated to get an upper GI to make sure things look okay. And I'm looking as much for malrotation as I am for, you know, a variety of other things. I mean, with if you're going to get your video fluoroscopic study at our hospital, we use that there to look at TFs, in just to make sure again, we're not looking for other diagnoses that are going on. So I think once if you, if you're dealing with a happy spitter who's wheezing, I wouldn't do an upper GI. But if you're trying to feed this kid and can't get the calories in because of the vomiting so significant, then absolutely you're obligated to get some barium imaging. Todd, I think Rachel's made a good point that I think gradually clinicians, whether it's surgeons or gastroenterologists or primary care providers, are getting the message out is that an upper GI is really not a good study for reflux. And