Gastro-oesophageal reflux in Children and Endoscopic Fundoplication

"Gastro-oesophageal reflux" is a term used to describe a condition where the contents of the stomach "reflux" back up into the gullet - known medically as the Oesophagus. It can affect anybody at any age. In adults it usually causes a feeling of indigestion, "heart burn" or sometimes can cause acid or partially digested food coming back up into the throat. In infants and children the general common symptoms include waking up with abdominal pain, abdominal pain after eating, irritability, refusing to eat, nausea and regurgitation of food to the mouth. This last symptom in particular can happen up to 100 - 200 times a day, which can lead to vomiting and chronic heartburn.

Traditionally, anti-acid medicines are used to relieve symptoms. Although these can help ease the symptoms sometimes, they are not a long-term cure. If not treated effectively, an infant or adolescent can be reliant on anti acid medicines for long periods of time.

The Patient and Her Symptoms

Heather Munro, from London experienced these symptoms from the age of 7 years. Her initial symptoms were stomach pains. Her mum put these down to the Kidney problems that Heather had suffered from previously. Over time these symptoms got worse and Heather started experiencing 'sicky burps' as she described them. These were caused by the backflow of gastric contents into her oesophagus. These burps could happen as often as 20 times per day and they became quite painful, giving the heartburn acid feeling and stomach pains. Not surprisingly these made her feel very uncomfortable.

Heather's appetite became very reduced and she ate little and often. Her Mother became concerned that she was not eating proper meals. If she ate too much she would get a bulge in her abdomen and this often made her sick. Even something like a bowl of soup or beans on toast was too much.

As the symptoms got progressively worse, it started to consume her life. Heather felt very lethargic the whole time - the lack of energy caused by the draining effect of permanent stomachache. Even bending to do her shoes up, laughing too much or coughing made her sick.

Referral from GP to Dr Thomson

When she was 9 Heather and her Mother, Annette, went to see the GP. This appointment was actually made for a different reason - because Heather had also started passing blood in her stools rather than for the symptoms of the later diagnosed gastro-oesopheal reflux. Both Heather and Annette believed that all of the symptoms were linked together and arose from her previous kidney problems. After taking the history and examining Heather carefully, the GP referred Heather to the Gastroenterology Department, where she met Dr Mike Thomson, Consultant Paediatric Gastroenterologist.

At the consultation Heather told Dr Thomson of her stomachaches and 'sicky burps' that she had been experiencing. It was then Dr Thomson diagnosed mild colitis (inflammation of the lower bowel) and gastro-oesophageal reflux.

The Choice of Operation - Open Surgery or Endoscopic Fundoplication

With medicine not proving successful for a long-term cure, the next option was a surgical procedure called 'Nissen Fundoplication'. This involves an operation on the abdomen through a reasonably large incision unless done by keyhole surgery (laparoscopic). The top of the stomach is wrapped around the oesophagus (gullet) - making it act like a valve and stopping the reflux. The complication rate is 15-60% resulting in patients not being able to 'burp', swallowing difficulties and not being able to vomit. With a viral-like vomiting illness this can cause problems in itself. It should be a permanent surgical correction, but between 10-30% of patients will need the procedure to be repeated within 5 years.

However, there is now a new alternative using the endoscope via the mouth. With this new procedure - called 'Endoscopic Fundoplication'- in which there are no abdominal incisions at all and the operation is done through the Endoscope - through the mouth and it is easily repeatable if required at a later date, or easily undone if required.

When Dr Thomson had examined Heather, he initially prescribed medication - Lansoprazole for the acid burps and Ondansetron to prevent her sickness. This treatment worked for a while, but after further discussions with Dr Thomson, they all agreed that surgery was the best option for Heather.

Pre-Surgery Tests

Prior to the surgery Heather was given a pH Study. This tested the level of acidity in her stomach and helped determine how much acid reflux and oesphageal inflammation was present. A standard Endoscopy and Colonoscopy - flexible "telescope" examinations of the stomach and lower bowel - were also conducted to check the inside of the gut. Heather described the Endoscopy test as being ok, but the Colonscopy procedure as "unpleasant" due to the preparation and laxatives involved.

The results of Heather's pH Study showed that she had severe acid reflux causing oesphagitis - inflammation of the oesophagus. This showed that for about 60 - 70% of every day there was acid refluxing from her stomach into in her lower oesphagus causing severe irritation. Results from studies have shown that after the Endoscopic Fundoplication procedure, this usually drops to about 4%.

Heather's Endoscopic Fundoplication

The Endoscopic Fundoplication procedure is done under a general anaesthetic. Most patients are able to have this done as a day case or as an overnight stay. Following the operation, patients are advised to limit physical activity for the first 4 weeks and to avoid any contact sport. Anti sickness medication is required for 48 hours after the procedure and patients are told to avoid lumpy food for the first 4 weeks.

The long-term results of this procedure shows that out of 31 people operated on, 3 of them had to have the procedure repeated at 1-3 years after the operation and 2 have had to have the surgical fundoplication. Only 3 remain taking any medication. No medication is usually needed after the procedure and patients are usually symptom free.

When Heather had her Endoscopic Fundoplication, she had an overnight stay in hospital followed by a week off school. For the first few days she took regular anti-vomiting medicines and was very careful with sports activities when she did return to school.

Heather's Outcome

The operation proved very successful for Heather and since the procedure she has been much happier in herself with much more energy. She only very occasionally experiences her 'sicky burps' and stomach aches, and has no sickness at all. On the rare occasions when Heather does get symptoms, she does take medication to try to stop them - although she actually finds that the symptoms depends on how she feels and the type food she has eaten.

Heather and her Mother say that they would recommend this treatment 100% to anyone who was considering this option. It has changed Heather's life and now she can take part in all normal activities like any other girl of her age. It was a non-invasive procedure with no scars, a quick recovery time, relatively painless and very effective. Heather and Annette could not praise Dr Thomson enough for his advice and support throughout.

Dr Thomson is the only Consultant Paediatric Gastroenterologist that does this procedure on children. The procedure is a third of the cost of standard keyhole surgery, with a shorter hospitalization time and can change a patient's lifestyle.

For more information about Gastro-oesophageal reflux in Children and Endoscopic Fundoplication - Visit the Medical Pages Web Site - www.PaediatricGastroenterologist.co.uk