Diagnostic accuracy of a 3-hr continuous intraluminal pH monitoring of the lower esophagus in the evaluation of gastro-esophageal reflux in infancy

Abstract

Continuous intraluminal pH monitoring of the lower esophagus for 24 hr appears to be the most sensitive diagnostic procedure in evaluating gastroesophageal reflux (GER) at any age. The prolongeds study is, however, fraught with potential complications and poor tolerance in infants. For this reason we evaluated the diagnostic accuracy of this procedure for a 3-hr period. Ninety-eight infants (53 male, 45 female) ranging in age from 23 days to 16.5 mos with a mean of 5 mo, underwent 3-hr continuous pH monitoring of the lower esophagus following esophageal manometry during a 3.5-yr period from July 1978 to December 1980 at our institution. The study was considered abnormal whenever the pH dropped to less than 4 and the clearance time was longer than 30 sec. The occurrence of multiple reflux episodes of more than 10 per hr with a clearance of less than 30 sec when associated with coughing, wheezing, or laryngospasm was likewise considered positive. Seven normal infants (C) 18 with vomiting and diarrhea (V) and 15 with recurrent pneumonia (P) showed no reflux episodes at any time during a 3-hr pH monitoring of the lower esophagus. Endoscopy and esophagogram performed in these patients showed no evidence of GER. All 58 infants who were studied because of vomiting, failure to thrive, or recurrent aspiration pneumonia showed abnormal reflux. In only 1 infant was the study initially negative. A subsequent study was found to be abnormal. Thirty-eight patients responded to medical management (M). Twenty patients required a Nissen fundoplication (S) because of failure of medical management in 8, and severe respiratory complications in 12 (5 of whom had respiratory arrest). Despite sedation with chloral hydrate during the study, 60% of group M and 68% of group S were extremely restless immediately prior to and during reflux. A number of infants were further observed to cough and wheeze with episodes of laryngospasm before and during reflux. No reflux was observed 3–8 wk following conservative treatment (M) and following Nissen fundoplication (S). Details of our technique and results are presented. Our study shows the accuracy of a 3-hr pH monitoring of the lower esophagus in evaluating GER to be close to 100%. Compared to other diagnostic procedures, resting LES pressure of less than 15 mm Hg in this group of patients (groups M and S) obtained by manometry was found in only 35 patients (62%); while esophagogram in 29 infants demonstrated reflux in only 20 patients (69%). It is our distinct observation that this study is not only an accurate diagnostic tool for infants, but is well tolerated with less chance of potential complications.