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Defination
Epidemiology
Classification
Mechanism that protect from GERD
Presentaion
Causes
D.D
Investigation
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Treatment
Conservative
Medical
Surgical : open or laproscopic ( indication ,
contraindication, technique)
Complication of operation
summary
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Definition
the pathologic consequences of 
involuntary passage of gastric
contents into the esophagus
Epidemiology
the most common gastroenterological disorder that leads to referral to
pediatric gastroenterologist during infancy.
Approximately 85% of infants vomit during the first week of life, and
60-70% manifest clinical gastroesophageal reflux at age 3-4 months..
. Resolution of symptoms occurs in approximately 90% of infants by
age 8-10
months.
Symptoms that persist after age 18 months suggest a higher likelihood
of chronic gastroesophageal reflux .
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Age:
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most commonly seen in infancy, with a peak at age 1-4 months. However, it can 
be seen in children of all ages, even healthy teenagers
Classification of GERD
Primary:
physiological:
These patients have no underlying predisposing factors.
Growth and development are normal, and pharmacologic
treatment is typically not necessary.
Pathologic :
Patients frequently experience complications, requiring
careful evaluation and treatment.
Secondary :
This refers to a case in which an underlying condition may
predispose to gastroesophageal reflux. Examples include
asthma and gastric outlet obstruction.
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LA CLASSIFICATION
Grade A: one or more mucosal breaks no longer than 5 mm,
no extends between the tops of the mucosal fold
Grade B: one or more mucosal breaks more than 5 mm
long, noextends between the tops of two mucosal folds
Grade C: mucosal breaks that extend between the tops of
two or more mucosal folds, but are not circumferential
Grade D: one or more circumferential mucosal breaks .
Below Grade A, we added a Grade M (minimal change),
defined as prominent erythema without clear demarcation
or whitish cloudiness of the lower esophageal mucosa
obscuring the longitudinal blood vessels
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Mechanism that protect from GERD
Clear Esophageal
Saliva
Esophageal peristalsis
Gravity
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The angle of His is formed between the esophagus (the tube
arriving at the top of
Prevent Gastric Reflux
Lower esophageal sphincter
Angle of His
Elevated intraabdominal pressure
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Limit Esophageal Injury
Amount of gastric acid
Pepsin
Trypsin
Bile acids
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causes
multifactorial.
Anatomic factors that: The angle of His (made by the esophagus and
the axis of the stomach) is obtuse in newborns but decreases as infants
develop.
The presence of a hiatal hernia may displace the lower esophageal
sphincter (LES) into the thoracic cavity
Resistance to gastric outflow raises intragastric pressure and leads to
reflux and vomiting. Examples include gastric outlet obstruction, and
pyloric stenosis
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Other causes
Other factors that predispose individuals to
gastroesophageal reflux include the following:
Medications (eg, diazepam, theophylline)
Smoking
Alcohol
Poor dietary habits (eg, overeating, eating late at night,
assuming a supine position shortly after eating)
Food allergies
Certain foods (eg, greasy, highly acidic)
Motility disorders
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presentation
Signs and symptoms of gastroesophageal reflux in infants and young children Typical or
atypical crying and/or irritability
Apnea
Poor appetite
Vomiting
Wheezing
Abdominal and/or chest pain
Stridor
Weight loss or poor growth
Recurrent pneumonitis
Sore throat
Chronic cough
Hoarseness and/or laryngitis
Signs and symptoms in older children - All of the above, plus heartburn and history of
vomiting, regurgitation, unhealthy teeth, and halitosis
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D.D
Duodenal Atresia
Esophageal Motility Disorders
Esophagitis
Food Allergies
Gastric Ulcers
Gastritis, Acute
Gastritis, Chronic
Helicobacter Pylori Infection
Hiatal Hernia
Intestinal Malrotation
Tracheoesophageal Fistula
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INVESTIGATION:
Upper Gastrointestinal Contrast Series
Esophageal pH Monitoring:
Gastric scintiscan
Esophageal Monometry
Endoscopy
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Upper Gastrointestinal Contrast Series:
This is used to evaluate the anatomy of the upper GI 
tract.provide a detailed road map of the patient's
to role out other causes of vomiting. anatomy
Problems such as pyloric stenosis, malrotation,
partial duodenal outlet obstruction, hital hernia, and
esophageal
stricture.
Esophageal pH Monitoring:
Esophageal pH monitoring measures the duration 
and frequency of acid reflux
defined as an esophageal pH of less than 4 for a 
period of 15 to 30 seconds
In children, the upper limit of normal is a pH below 
4 less than 5.5% of the time. In infants younger than
1 year, the normal value increases to 12%.
Dual-channel proximal and distal
esophageal pH monitoring is used to
monitor patients with reflux symptoms off
therapy. b: Dual channel distalesophageal
and gastric pH monitoring is used to
monitor patients
Gastric scintiscan
This imaging study, using milk or formula that 
contains a small amount of technetium sulfur
colloid, can assess gastric emptying and can reveal
reflux
Esophageal Monometry
gold standard for assessment of the body of the 
esophagus. It is also mandatory before
antirefluxoperations.
Assesment of the LES 
Endoscopy
To detect complications eg reflux esophagitis,
esophageal stricture, Barrett metaplasia, and
esophageal adenocarcinoma
To detect other gastroesophageal diseases (peptic
ulcer)
Indication for this procedure includes:
All patients prior to fundoplication surgery.
Eldery patient with GERD symptoms.
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Histologic Findings
Useful for diagnosing cancers or causes of 
esophageal inflammation other than acid reflux,
particularly infections.
Only means of diagnosing cellular changes of 
Barrett¶sesophagus.
COMPLICATION
FTT
Esophagitis
Aspiration pneumonia
eroded dental enamel
Esophageal stricture
Esophageal cancer
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Treatment
Conservative 
Medical treatment 
Surgical 
conservative
reassurance is the only treatment needed. 
Conservative measures may include upright 
positioning after feeding, elevating the head of the
bed, prone positioning (infants >6 mo), and
providing small, frequent feeds thickened with cereal
Medical treatment
Histamine H2 Receptor Antagonists:
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decrease acid secretion by inhibiting the H2 receptor 
at the parietal cell of the stomach
cimetidine, ranitidine, and famotidine are effective 
in controlling symptoms and treating esophagitis
Proton Pump Inhibitors :
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PPIs bond and deactivate Hf,K+-ATPase, or proton 
pumps, by crossing parietal cell membranes and
accumulating in secretory canalicul
omeprazole 
Antacids and Surface Agents : 
Antacids neutralize gastric acid and are preferred for 
the short-term relief of GER symptoms
Prokinetic Agents: 
Prokinetic agents increase LES pressure, enhance 
esophageal peristalsis, and accelerate gastric
emptying
Surgical treatment
Indication:
Failure of medical therapy. In children who have
continuing symptoms such as persistent pulmonary
symptom.
Presence of an associated anatomic defect such as a
hiatal hernia.
Neurologically impaired children who have difficulty
feeding and have serious reflux as an associated
symptom.
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contraindication
In some children, reflux is caused by gastric or 
intestinal motility disorders or by gastric outlet
obstruction.
esophageal dysmotility disorders. In children with 
weak or uncoordinated peristalsis of the esophagus
Surgical Techniques
Open Operative Techniques:
Nissen Fundoplication
Thal-Ashcraf Fundoplication
Intervention
Toupet Fundoplication
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Laparoscopic Nissen Fundoplication: 
Pyloroplasty or Antroplasty 
Gastrostomy 
Post op
Some surgeons leave a nasogastric tube in place or 
leave the G-tube to gravity until return of bowel
function. This is not always done, particularly if a
laparoscopic approach is used. The patient should be
started on a clear liquid diet initially (either by
mouth or feeding tube), then slowly transitioned to
formula or soft solids
Complication after operation:
Early complications include retching, gas bloat 
dysphagia, atelectasis, pneumonia, wound infection,
small-bowel obstruction due to adhesions, and
delayed gastric emptying. Dysphagia may result from
postoperative edema and spontaneously resolves.
Late complications include bowel obstruction and 
wrap failure, including wrap disruption, slipped
wrap, herniation of the wrap into the chest, or
excessively tight wrap. Patients in whom the wrap
fails typically present with dysphagia, retching, or
recurrent reflux symptoms. In patients with
suspected wrap failure, an upper GI barium study
may help to evaluate the integrity and anatomy of
the repair, and endoscopy may be used to diagnose
recurrent or persistent esophagitis.
Future
The future of gastroesophageal reflux (GER) therapy includes several 
endoscopic therapies that are gaining favor in adult populations and
that may replace surgery in some patients. These therapies include
radiofrequency ablation (Stretta procedure), the injection of inert
substances at the LES, and endoscopic gastroplication.
In the Stretta procedure, a catheter is used to deliver radiofrequency 
energy, creating thermal lesions deep to the mucosa at the GE
junctionFinally, robot-assisted laparoscopic fundoplication in children
has been reported with good results
SUMMARY
GER is a common disorder in children and often 
requires surgical correction. GER in infants and
children is more complex than adult GER. Failure of
medical management and an inability to wean from
antireflux medications are the most common
indications for the surgical treatment of reflux. A
complete-wrap fundoplication appears to have better
outcomes than partial-wrap fundoplication,although
this contention is controversial. Postoperative
retching and recurrent GER are the most common
and vexing complications of antireflux surgery.