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Ravelli, A. M.; Richards, C. A.*; Spitz, L.*; Milla, P. J.**
Department of Pediatrics University of Brescia, Ospedale Civile, Brescia (Italy); Dept. of Surgery* and **Gastroenterology, Inst. of Child Health, London (UK).
Recurrent vomiting with aspiration and failure to thrive is common in children with neurological handicap. It is usually ascribed to gastroesophageal reflux (GER) and indeed GER is present in about 75% of such patients. The response to medical treatment is usually poor and most patients require anti-reflux surgery. Following fundoplication, however, many children experience severe retching and postprandial discomfort, and we have previously suggested that fundoplication unmasks or makes worse a more widespread disorder of gastrointestinal motility and/or a persistent activation of the emetic reflex. In order to test this hypothesis and to try to detect patients who are at higher risk of developing symptoms after fundoplication, we recorded gastric antral electrical control activity (ECA) before and >3 months after Nissen fundoplication in 12 children with neurological impairment (age range 0.19-11.3 years). They had refractory acid GER with a mean reflux index of 38.1% (range 5.4%-65.2%), 11/12 had free reflux of barium (5 with hiatus hernia), and 7/8 had esophagitis. Fasting and postprandial ECA frequency was measured using surface electrogastrography over a one hour period. The electrical signal was low-pass filtered at 0.33 Hz, digitalized at 1 Hz, and subjected off-line to running spectral analysis using an autoregressive modelling technique. Pre-operatively, ECA occurred at a normal frequency of 2.7-3.0 cycles per minute (cpm) in 5 patients (Group A), whereas 7 patients (Group B) had a gastric dysrhythmia: 5 unstable ECA with no dominant frequency, 1 tachygastria at 9.0 cpm and 1 bradygastria at 2.2 cpm. Following fundoplication, in Group A 2 patients were asymptomatic, 2 had persistent GER requiring repeat fundoplication and 1 developed a dysrhythmia and retching. In Group B, gastric ECA showed further deterioration in 3 patients, all of whom developed severe retching, and the dysrhythmia persisted unchanged in 4, 2 of whom had retching and 1 wrap migration. Thus, in patients with successful control of GER, post-operative retching was present in 5/6 (83%) with pre-operative dysrhythmia (Group B) and 1/3 (33%) with normal pre-operative gastric ECA (Group A). In 4 patients, the gastric ECA had deteriorated following surgery.
Amongst neurologically impaired children with GER, those who have a gastric dysrhythmia are at higher risk of developing severe symptoms of retching following Nissen fundoplication. Anti-reflux surgery may also induce dysrhythmia. Electrogastrography may be helpful in detecting such patients, for whom alternative therapeutic strategies should be considered.
Munich, June 5-8, 1996
© Lippincott-Raven Publishers
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