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What
is Reflux?
Reflux, or gastroesophageal reflux (GER), occurs when
the contents of the stomach pass back up through the
Lower Esophageal Sphincter (LES) into the esophagus.
This refluxed liquid contains food, stomach acid, enzymes,
which help digest protein, and may contain bile. The
most harmful component of the refluxed liquid is the
stomach acid, which can damage the esophagus. Up to
one third of babies have reflux at some time, but almost
all outgrow the reflux within one year.
What
is Gastroesophageal Reflux Disease (GERD)?
Gastroesophageal Reflux Disease is a more serious form
of reflux. With GERD the refluxed liquids can come completely
up the esophagus and out of the mouth (vomiting or spitting
up), or into the sinuses, or even into the lungs (aspiration).
With GERD, reflux occurs more frequently and can be
much more painful than with GER. Repeated exposure to
stomach acid can cause the esophagus to become red and
irritated (esophagitis), and in severe cases can cause
bleeding and scarring in the esophagus, which can make
swallowing painful and difficult. Repeated vomiting
can damage teeth enamel. In children, the pain of reflux
often leads to food refusal, lack of proper nutrition,
no weight gain, weight loss or failure to thrive, resulting
for severe cases in g-tube or ng-tube feeding. Another
very serious implication of reflux is if refluxed liquid
enters the lungs, potentially causing breathing problems
or pneumonia. If the refluxed liquid enters the sinuses
it can cause sinus infections and swollen adenoids.
In babies with reflux choking or apnea may occur.
Symptoms
of Reflux in Children
When refluxed liquids enter the esophagus the acid begins
to damage the esophagus causing pain when swallowing
and inconsolable crying. When the acid comes up to the
throat the throat can become hoarse and laryngitis may
occur. Babies may spit up frequently, spit up long after
meals, and continue to spit up even as they grow older.
Because eating can be painful, children may refuse food
or accept only a few bites of food during a meal. Because
they may not eat enough, children with reflux may not
have adequate nutrition, may lose or stop gaining weight.
Reflux occurs more often when lying down, so the child
may have trouble sleeping or may wake up frequent. In
some cases refluxed liquids may travel up through the
esophagus and into the lungs, called aspiration. If
aspiration occurs the refluxed liquids in the lungs
may cause infections, coughing, wheezing, recurrent
pneumonia, and asthma.
Causes
of Reflux
The main cause of reflux is a malfunction of the LES
(Lower Esophageal Sphincter). Normally, the LES opens
during swallowing and then closes to keep the stomach
contents in the stomach. With reflux, however, the LES
opens at times not related to swallowing, or stays open
even when swallowing is complete allowing the stomach
contents to travel up into the esophagus. In other cases
the contractions of the esophagus, which normally travel
from the mouth to the stomach, occur erratically, stop
before the food reaches the stomach or don’t occur
with swallowing. Reflux can also occur if the LES is
weak and does not close completely. In other cases reflux
may occur because the stomach is emptying slowly, causing
more pressure to be exerted against the LES and may
make the contractions of the esophagus stronger. Slow
emptying of the stomach may occur due to a malfunction
of the GastroEsophageal Valve (GEV).
Diagnosis
of Reflux
Barium Swallow Study, also known as fluoroscopy –
the child drinks a chalky liquid, which shows up on
an x-ray. The x-ray can show places in which damage
to the esophagus becomes scar tissue making a narrow
passage for food to pass. The x-rays can also show deformities
of the upper digestive tract.
24-hour pH Probe – This is the most reliable test
for reflux. A thin tube is fed through the nose and
placed in the esophagus where the stomach and esophagus
meet. The tube measures acid levels over the course
of 24-hours. If acid levels are consistently high, reflux
is occurring. Also, this test can show if high acid
levels occur when the child cries, coughs or shows other
symptoms of reflux.
Endoscopy – A small, flexible tube with a camera
is fed through the mouth into the esophagus and stomach,
so the doctor can see the lining of the esophagus and
look for damage that may be caused by reflux. Biopsies
of the esophagus, stomach and upper small intestines
can also be taken through the scope.
Milk Scan, or scintigraphy – This test measures
how quickly the stomach empties. The child swallows
a radium-labeled powder, which can be followed through
the digestive tract. This test can also show if aspiration
is occurring.
Treatment
of Reflux
1. Lifestyle Changes
The vast majority of children eventually outgrow reflux,
usually within one year. For these children, lifestyle
changes can be effective in reducing symptoms, such
as crying and pain, and increasing food intake. Certain
foods, such as spicy, fatty or acidic foods may increase
reflux, so they can be avoided. Burping the baby frequently
and giving smaller, more frequent meals may also help.
Thickening food or formula with rice cereal or oatmeal
cereal, which may be easier for a baby to digest than
rice cereal, may keep the food from being regurgitated
out of the stomach. Gravity can also help keep the stomach
contents in the stomach, so keeping the baby upright
after meals, elevating the head of the bed or crib with
wooden blocks or using a wedge, or having the baby sit
in a bouncy seat or infant carrier can all help keep
the baby’s head elevated after meals. It can also
be a good idea to have the child checked for allergies,
which might be making the reflux more severe.
2.
Medications for Reflux
When these lifestyle changes are not sufficient in combating
reflux the child’s doctor may prescribe medications
to help alleviate the symptoms of reflux.
Proton Pump Inhibitors (PPIs) decrease stomach acid
production, which can protect the esophagus from the
damage of stomach acid. PPIs are taken one hour before
a meal, so the medication is at its highest levels during
the meal. Examples of PPIs include omeprazole (Prilosec),
lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole
(Protonix) and esomeprazole (Nexium).
Antacids increase pH of the stomach, neutralizing acid.
Although quick acting, antacids only last 30 minutes
or less, so they must be taken repeatedly throughout
the day, in particular right after a meal and two hours
after a meal as stomach emptying slows. Calcium antacids
can cause acid rebound. Aluminum antacids may cause
constipation, which magnesium antacids may cause diarrhea.
Examples of Antacids include Gaviscon and Tums.
Histamine (H2 receptor) antagonists reduce acid production
by blocking histamine receptors, which stimulate acid
production. Histamine antagonists should be taken 30
minutes after a meal to allow the meal to be digested
by the stomach acid. Histamine antagonists do not help
esophagitis (Painful inflammation and redness of the
esophagus). Because it comes in liquid form, which is
easier for a child to take, Histamine antagonists may
be prescribed more often for children. Examples include
cimetidine (Tagamet), ranitidine (Zantac), nizatidine
(Axid), and famotidine (Pepsid).
Prokinetic agents make the LES close more tightly, reducing
reflux. There is a possibility of adverse reactions
to prokinetic agents. Examples include metoclopramide
(Reglan), cisapride (Propulsid), erythromycin (Dispartab,
Robimycin), and bethanechal (Duvoid, Urecholine).
Pro-motility medications stimulate the muscles of the
digestive tract including esophagus, stomach, small
intestines and colon, but may cause constipation. The
effects of the medication on the sphincter and esophagus
are small, and not very effective. Motility medications
are often paired with other reflux medications. The
medication is taken 30 minutes before a meal and at
bedtime. Examples include Urecholine and Regalin.
3.
Surgical Treatment for Reflux
(Nissen Fundoplication)
If a child does not outgrow reflux and lifestyle changes
and medication are not effective, particularly when
the child is not gaining weight, a doctor may consider
a surgical alternative. In a Nissen Fundoplication the
top of the stomach is wrapped around the esophagus,
creating an artificial sphincter. The strong stomach
muscles can pinch closed the esophagus, keeping the
stomach contents from coming back into the esophagus.
The operation may be completed laprascopically with
a small incision in the abdomen. The vast majority of
patients have less reflux after a nissen, but there
can be complications. Food can get caught in the artificial
sphincter. The food may come down on its own or can
be removed through endoscopy. In other cases the surgery
may cause oral aversion, leading to weight loss.
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