Gastroesophageal reflux disease in pediatric esophageal atresia: Assessment of clinical symptoms and pH-impedance data

Abstract

Background: Esophageal atresia (EA) is the most common congenital anomaly of the gastrointestinal tract. Gastroesophageal reflux disease (GERD) is a frequent and lifelong problem in these patients. GERD can be asymptomatic and the incidence of esophageal gastric and intestinal metaplasia (Barrett's esophagus) is increased in adults with EA compared with the general population. Timely and accurate diagnosis of GERD is important to reduce long-term problems and this may be achieved by pH-impedance testing.

Aim: To assess symptoms and pH-impedance data in children after EA, in order to identify their specific features of GERD.

Methods: This study was conducted from November 2017 to February 2020 and involved 37 children who had undergone EA via open surgical repair (51.35% boys, 48.65% girls; age range: 1-14 years, median: 4.99 years). GERD diagnosis was made based on multichannel intraluminal impedance/pH study and two groups were established: EA without GERD, n = 17; EA with GERD, n = 20. A control group was established with 66 children with proven GERD (68.18% boys, 31.82% girls; median age: 7.21 years), composed of a nonerosive reflux disease (referred to as NERD) group (n = 41) and a reflux esophagitis group (n = 25). Upper gastrointestinal endoscopy with a mucosal esophageal biopsy was performed on all patients.

Results: The most frequently observed symptom in EA patients with GERD and without GERD was cough (70% and 76.5% respectively). The number of patients with positive symptom association probability in the EA groups was significantly larger in the EA without GERD group (P = 0.03). In the control reflux esophagitis group, prevalence of gastrointestinal symptoms was significantly higher than in the NERD group (P = 0.017). For both EA groups, there was strong correlation with index of proximal events (IPE) and total proximal events (EA with GERD: 0.96, P < 0.001; EA without GERD: 0.97, P < 0.001) but level of IPE was significantly lower than in GERD patients without any surgical treatment (P < 0.001). Data on distal mean nocturnal baseline impedance were significantly different between the EA with GERD group (P < 0.001) and the two control groups but not between EA without GERD and the two control groups.

Conclusion: Mean nocturnal baseline impedance may have diagnostic value for GERD in EA children after open surgical repair. IPE might be an additional parameter of pH-impedance monitoring.

Keywords: Esophageal atresia; Gastroesophageal reflux disease; Mean nocturnal baseline impedance; Nonerosive reflux disease; Pediatric; Proximal reflux; Reflux esophagitis; pH-impedance testing.

Figure 1

Differences in distal mean nocturnal baseline impedance values (kOhm) among the esophageal atresia study groups. Study groups are EA with GERD and EA without GERD. P = 0.0024 by t-test (assuming equal variances). EA: Esophageal atresia; GERD: Gastroesophageal reflux disease.

Figure 2

Mean nocturnal baseline impedance capabilities for gastroesophageal reflux disease diagnosis in patients with esophageal atresia. A: Area under the curve is 0.806, with P < 0.001; B: Diagnostic cut-off is 1.69 kOhm, with sensitivity of 80.0% and specificity of 76.5%. EA: Esophageal atresia; GERD: Gastroesophageal reflux disease; MNBI: Mean nocturnal baseline impedance.

Figure 3

Kruskal-Wallis test (P < 0.001) with post hoc analysis (Dunn’s test) of index of proximal events in study groups. Study groups are: (1) NERD; (2) RE; (3) EA with GERD. ^aP < 0.05. nr: MedCalc numbers the factors. In the output you see a list of factors, with factor label, n and average rank. The factor label is preceded with a number between brackets. The "nr" in "Different (P < 0.05) from factor nr" refers to that number. NERD: Nonerosive reflux disease; RE: Reflux esophagitis; EA: Esophageal atresia; GERD: Gastroesophageal reflux disease.

Figure 4

Kruskal-Wallis test (P < 0.001) with post hoc analysis (Dunn’s test) of mean nocturnal baseline impedance data in the study groups. Study groups are: (1) NERD; (2) RE; (3) EA with GERD; (4) EA without GERD. ^aP < 0.05. nr: MedCalc numbers the factors. In the output you see a list of factors, with factor label, n and average rank. The factor label is preceded with a number between brackets. The "nr" in "Different (P < 0.05) from factor nr" refers to that number. NERD: Nonerosive reflux disease; RE: Reflux esophagitis; EA: Esophageal atresia; GERD: Gastroesophageal reflux disease.