Chapter 29 Gastroesophageal Reflux
PATHOPHYSIOLOGY
Considered as one of the vomiting disorders, gastroesophageal reflux (GER) is the retrograde passage of gastric contents into the esophagus, the upper airways, and the tracheobronchial area. Predisposing factors associated with GER are (1) muscle tonicity of the lower esophageal sphincter (LES); (2) age; (3) hiatal hernia, (4) intraabdominal pressure; (5) length of the esophagus below the diaphragm; (6) rate of gastric emptying; (7) drugs; (8) hormones; and (9) spontaneous relaxation of the LES secondary to neurologic involvement. Associated symptoms are pain and/or irritability, spitting up, regurgitation of food (especially of liquid to semiliquid consistency), vomiting, poor weight gain, and respiratory disorders. The reflux of gastric contents can lead to apneic spells in young infants and inflammation, damage (Barrett’s esophagus) and stricture of the esophageal mucosa, failure to thrive, occult blood loss, anemia, aspiration pneumonia with or without wheezing, ear and sinus infection, and sleep disorder. In 85% of infants with GER, the condition is self-limiting, disappearing between ages 6 and 12 months; thus resolution of GER is often a maturational process. However, a child may require surgery (gastric fundoplication; see Medical Management in this chapter) if he or she does not respond to medical management.
LABORATORY AND DIAGNOSTIC TESTS
1. Esophageal pH measurement (less than 4.0 is diagnostic) for 23 hours
2. Electric impedance measurement
3. Endoscopy—to detect presence of gross and microscopic esophagitis and cellular dysplasia
4. Barium esophagram—to detect anatomic abnormalities; often fails to detect intermittent reflux
MEDICAL MANAGEMENT
The treatment of GER reflects the severity of symptoms. Nonpharmacologic treatment and management consists of feeding thickened formula; feeding small, frequent meals; and positioning to avoid increased intraabdominal pressure—either upright without slouching in an infant seat or car seat or in prone position. Placement in an infant seat postprandially is contraindicated because such seats increase intraabdominal pressure. Pharmacologic treatment is primarily acid suppression and neutralization. Acid neutralization drugs such as aluminum or magnesium hydroxide are beneficial. H2 blockers such as ranitidine, famotidine, cimetidine, and proton pump inhibitors (PPIs) such as omeprazole, lansoprazole, are used for acid suppression. Prokinetic agents (metoclopromide and erythromycin) and cholinergic agents (bethanecol) may be added to further prevent reflux activities. In some infants, continuous tube feedings may be used when conventional medical treatment has failed.
When medical management fails to control the symptoms and risk of complications of GER disease increases, the infant or child must be referred to a pediatric gastroenterologist and/or pediatric surgeon for advanced medical management, treatment, and possible surgical intervention. Nissen fundoplication is a major surgical procedure wherein the upper end of the stomach is wrapped around the lower portion of the esophagus, and the fundus is sutured in front of the esophagus to create a circular acute-angle valve mechanism. Family must be aware, depending on the age of the child, that there is a high possibility that repeat fundoplication may be necessary in 3 to 5 years as the child grows older. There is usually a reverse correlation between the age of the child and the number of antireflux surgeries performed. Placement of a gastrostomy tube ensures adequate nutrition and simplifies care.
NURSING INTERVENTIONS
1. Promote adequate nutritional and fluid intake.
2. Observe, monitor, and report signs of respiratory distress; assess for changes in respiratory status.
3. Preoperatively, prepare child and family for surgery.
4. Monitor surgical site for intactness.
5. Prevent abdominal distention.
6. Monitor for signs and symptoms of postoperative hemorrhage.
7. Assist parents in verbalization of feelings—may express anger, guilt, or frustration because they feel inadequate or responsible.
8. Provide developmentally appropriate stimulation activities (see Appendix B).
9. Administer PPIs 15 to 30 minutes before the first meal of the day.
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