Eur J Pediatr (1992) 151 : 655-657
European Journal of
Pediatrics
9 Springer-Verlag1992
The role of sonography in the evaluation of gastro-oesophageal reflux correlation to pH-metry M. Riccabona 1, U. Maurer 1, H. Lackner 1, E. Uray 2, and E. Ring t Department of Paediatrics, University of Graz, Auenbruggerplatz, A-8036 Graz, Austria 2Department of Paediatric Surgery, University of Graz, Auenbruggerplatz, A-8036 Graz, Austria Received November 6, 1991 / Accepted in revised form January 22, 1992
Abstract. Sonography was c o m p a r e d to p H - m e t r y and/ or o e s o p h a g o m a n o m e t r y to evaluate the accuracy of sonography in the early diagnosis of gastro-oesophageal reflux. Thirty children with a mean age of 72 days (21252 days) were studied. The results showed that specificity of sonographic diagnosis was 87,5% and sensitivity was 100% (with P < 0 . 0 0 1 ) . Sonography also proved helpful in providing both functional and morphological data in addition to p H - m e t r i c results. This study therefore suggests that sonography is useful as the first approach in the diagnosis of vomiting babies as it is non-invasive and provides sufficient diagnostic accuracy. Key words: Gastro-oesophageal reflux - Sonography Accuracy
Introduction Gastro-oesophageal reflux ( G E R ) is a common phenomenon in early infancy [9, 17]. Ph-metry and m a n o m e t r y as well as radiology (barium swallow) are widely accepted as the most reliable investigations for detection of G E R [2-4, 7, 8, 18]. Scintigraphic studies are also used, especially for functional purposes [6]. Sonography is a convenient and non-invasive, non-ionising method, which has already changed paediatric diagnostic approaches in m a n y ways. Only a few studies have examined the role of sonography in the detection of G E R [1, 5, 11, 12, 19, 20]. In the present study we c o m p a r e d the results of the ultrasound examination with pH-metric and manometric findings in order to evaluate the diagnostic accuracy of sonography in G E R .
Correspondenceto: M. Riccabona [Abbreviation: GER = gastro-oesophageal reflux
Patients and methods The study was performed on 30 infants with a mean age of 72 days (21 days-252 days, male : female = 1 : 1). All of them showed vomiting and poor growth, some had oxycardiorespirographic findings suspicious for GER. Sonography was done prior to other investigations. In addition, pH-metry and oesophagomanometry were performed within 14 days after sonographic examination. Six children with hypertrophic pyloric senosis and two infants with sonographically diagnosed hiatus hernia were excluded. The sonographic study was performed with an Acuson 128-E ultrasound device (Mountainview, California, USA), using a 5 MHz-transducer. The infants had received no food for 3-4 h before examination, After evaluating stomach and pyloric morphometry and function, a physiological amount of tea was fed (80 ml-200 ml). Scanning was performed during drinking and continued afterwards for at least 10 min; naturally, all children were awake to avoid the different incidence of GER between sleeping and awake state [14, 16] Ph-metry was done with a flexible pH-electrode and referenceelectrode. The pH-changes were registered over 24 h by an Orion pH-meter (Boston, Massachusetts, USA). Pathological GER was defined as a pH < 4 in more than 3% of monitoring time [2, 3, 8, 9]. Manometry was done under continous pH-metric observation with a 4-holed catheter and continuous registration of breathing for about 3 h. A common cavity phenomenon in more than 1% of examination time was defined as representing pathological GER [7, 8] Patients suffering from pathological GER were treated by positioning and feeding of concentrated food [10, 15]. Further examinations - for example, barium swallow - were only done if symptoms persisted in spite of the forgoing therapy.
Results For sonographical staging two main groups were established: 1. G r o u p I (A and B) showed physiological findings; no G E R or "physiological" G E R (only a few episodes of GER). 2. G r o u p II demonstrated pathological findings: (1) G r o u p IIA: moderate G E R , meaning m o r e than 3 x G E R , without vomiting, relatively short duration of re-
656 In group I (14 patients) sonography and pH-metry gave identical findings (Table 1). However, delay in oesophageal clearance could be sonographically observed in one patient, and manometry showed moderate pathologic oesophageal peristalsis in another patient (Table 1, group
IB).
Fig. 1. Sonographic appearance of GER. M, Stomach; 0, oesophagus
In group IIA (ten patients, mean age 68 days), eight infants showed identical findings on both sonography and pH-metry/manometry. Only two patients with physiological G E R on pH-metry, sonographically showed moderate GER; on manometry they had pathological oesophageal peristalsis (Table 1). In group IIB (six patients, mean age 27 days) all sonographic findings were confirmed by pH-metry. Sonography showed a sensitivity of 100% and a specificity of 87,5% for the detection of G E R with P < 0.001 in the fourfold table test (Table 1).
Discussion
Fig. 2. Altered sonographic appearance of GER. 34, Stomach; O, oesophagus
flux episodes, no or little distention of distal oesophagus, especially after provocation. (2) Group IIB: severe GER, meaning frequent G E R with vomiting, longer duration of reflux episodes, with dilated distal oesophagus, even without provocation manoeuvres (Figs. 1, 2).
G E R is a common phenomenon in babies, but mainly its' sequelae oesophagitis, aspiration and apnoea cause problems [9, 13]. Therefore, the early detection of pathological G E R seems desirable, as conservative management might prevent serious sequelae. An easily available examination adequate for very young primarily affected infants is necessary. Sonography can detect G E R but cannot detect oesophagitis accurately - this must be proven by endoscopy and biopsy [9]. But one can achieve further information by evaluating sonographical appearance. As G E R usually is a quick, shortlasting event, oesophageal clearance as well as subdiaphragmatic oesophageal length and thickness, stomach emptying, and the amount of hiatal dysfunction may offer additional data to define therapeutic regimes [5]. We must, however, emphasize the necessity of standardised procedures: for example, different food does influence both reflux frequency as well as gastric and oesophageal clearance [14-16]. In conclusion our results show that sonography can detect G E R accurately and can achieve a satisfying staging using this sonographic group division for discrimination. In addition sonography can provide both morphological as well as functional data. We therefore suggest using sonography as the first step in the exploration of vomiting babies.
Table 1. Comparison of sonography and pH-metry/manometry in detecting GER Group/Sone
Number
Age (mean)
pH-metry/manometry
I A B II A B
10 4 10 6
(33%) (13%) (33%) (20%)
108 days 83 days 68 days 27 days
No GER No GER, 1 • pathological
Total
30 (100%)
72 days
Sensitivity = 100% ; Specificity = 87.5% ; P < 0.001
8 • GER, 2 • pathological but no GER 6 • GER 14 • GER, 16 • no GER, 3 x pathological peristalsis
Physiological Pathological
657
References 1. Blumhagen JT (1986) Role of ultrasonography in the evaluation of vomiting in infants. Pediatr Radiol 16 : 267 2. Euler AR, Ament ME (1977) Detection of gastroesophageal reflux in the pediatric age patient by oesophageal intraluminal pH probe measurement. Pediatrics 60 : 69-74 3. Euler AR, Byrne WJ (1981) 24 hour oesophageal intraluminal pH probe testing: a comparative analysis. Gastroenterology 80 : 957-961 4. Fotter R, Hoellwarth M, Uray E (1985) The correlation between manometric and roentgenologic findings of diseases of the oesophagus in infants and children. Prog Pediatr Surg 18 14-21 5. Gomes H (1991) Gastroesophageal reflux, comparative study between sonography and pH monitoring. Pediatr Radiol 21: 168-174 6. Guillet J e t al. (1987) Radionucleotide routine assessment of gastrointestinal tract motility diseases in 3000 pediatric patients. In: Csernay L, Schmidt H A E (eds) Nuklearmedizin, European Nuclear Medicine Congress 1987. FK Schattauer Verlag, Stuttgart, pp 428-430 7. Hoellwarth M, Uray E, Pesendorfer P, Rosanelli K, Rosegger H (1986) Oesophageal manometry. Pediatr Surg Int 1:177183 8. Johnson LF, DeMeester TR (1974) 24 hour pH monitoring of the distal oesophagus. A quantitative measure of gastroesophageal reflux. Am J Gastroenterol 62: 325-331 9. Koch A (1986) Der gastro6sophageale Reflux im S~iuglingsalter. Bibliothek fiir Kinderchirurgie. Hippokrates Verlag, Stuttgart, pp 30-42
10. Meyers WF, Herbst Jl (1982) Effectiveness of positioning therapy for gastroesophageal reflux. Pediatrics 69 : 768-772 11. Miller JH, Kemberling CR (1984) Ultrasound scanning of the gastrointestinal reflux: subject review. Radiology 152 : 671-678 12. Naik Dr, Moore DJ (1984) Ultrasound diagnosis of gastroesophageal reflux. Arch Dis Child 59 : 366-367 13. Ohrenstein S, David M (1988) Gastroesophageal reflux and respiratory disease in children. Pediatrics (112) 6 : 847-858 14. Supthen JL, Dillard VL (1988) Effect of feeding volume on early postcibal gastroesophageal reflux in infants. J Pediatr Gastroenterol Nutr 7 : 185-188 15. Vandenblas Y, Sacre L (1987) Milk thickening products as treatment for gastroesophageal reflux. Clin Pediatr (Phila) 26 : 66-68 16. Vandenblas Y, DeWolf D, Deneyer M, Sacre L (1988) Incidence of gastroesophageal reflux in sleep, awake, fasted and postcibal periods in asymptomatic and symptomatic infants. J Pediatr Gastroenterol Nutr 7 : 177-180 17. Willich E (1971) The function of the cardia in childhood. Pediatr Surg 3 : 141-167 18. Willich E (1986) Gastroesophageal reflux: radiological aspects. Pediatr Surg Int 1 : 144-160 19. Worlizek K (1986) Sonographische Diagnostik des fl%sigkeitsgeftillten Magens. Ultraschall Med 7 : 259-263 20. Wright LL, Baker KR, Meny RG (1988) Ultrasound demonstration of gatroesophageal reflux. J Ultrasound Med 7 : 471
European Journal of
Pediatrics
9 Springer-Verlag1992
The role of sonography in the evaluation of gastro-oesophageal reflux correlation to pH-metry M. Riccabona 1, U. Maurer 1, H. Lackner 1, E. Uray 2, and E. Ring t Department of Paediatrics, University of Graz, Auenbruggerplatz, A-8036 Graz, Austria 2Department of Paediatric Surgery, University of Graz, Auenbruggerplatz, A-8036 Graz, Austria Received November 6, 1991 / Accepted in revised form January 22, 1992
Abstract. Sonography was c o m p a r e d to p H - m e t r y and/ or o e s o p h a g o m a n o m e t r y to evaluate the accuracy of sonography in the early diagnosis of gastro-oesophageal reflux. Thirty children with a mean age of 72 days (21252 days) were studied. The results showed that specificity of sonographic diagnosis was 87,5% and sensitivity was 100% (with P < 0 . 0 0 1 ) . Sonography also proved helpful in providing both functional and morphological data in addition to p H - m e t r i c results. This study therefore suggests that sonography is useful as the first approach in the diagnosis of vomiting babies as it is non-invasive and provides sufficient diagnostic accuracy. Key words: Gastro-oesophageal reflux - Sonography Accuracy
Introduction Gastro-oesophageal reflux ( G E R ) is a common phenomenon in early infancy [9, 17]. Ph-metry and m a n o m e t r y as well as radiology (barium swallow) are widely accepted as the most reliable investigations for detection of G E R [2-4, 7, 8, 18]. Scintigraphic studies are also used, especially for functional purposes [6]. Sonography is a convenient and non-invasive, non-ionising method, which has already changed paediatric diagnostic approaches in m a n y ways. Only a few studies have examined the role of sonography in the detection of G E R [1, 5, 11, 12, 19, 20]. In the present study we c o m p a r e d the results of the ultrasound examination with pH-metric and manometric findings in order to evaluate the diagnostic accuracy of sonography in G E R .
Correspondenceto: M. Riccabona [Abbreviation: GER = gastro-oesophageal reflux
Patients and methods The study was performed on 30 infants with a mean age of 72 days (21 days-252 days, male : female = 1 : 1). All of them showed vomiting and poor growth, some had oxycardiorespirographic findings suspicious for GER. Sonography was done prior to other investigations. In addition, pH-metry and oesophagomanometry were performed within 14 days after sonographic examination. Six children with hypertrophic pyloric senosis and two infants with sonographically diagnosed hiatus hernia were excluded. The sonographic study was performed with an Acuson 128-E ultrasound device (Mountainview, California, USA), using a 5 MHz-transducer. The infants had received no food for 3-4 h before examination, After evaluating stomach and pyloric morphometry and function, a physiological amount of tea was fed (80 ml-200 ml). Scanning was performed during drinking and continued afterwards for at least 10 min; naturally, all children were awake to avoid the different incidence of GER between sleeping and awake state [14, 16] Ph-metry was done with a flexible pH-electrode and referenceelectrode. The pH-changes were registered over 24 h by an Orion pH-meter (Boston, Massachusetts, USA). Pathological GER was defined as a pH < 4 in more than 3% of monitoring time [2, 3, 8, 9]. Manometry was done under continous pH-metric observation with a 4-holed catheter and continuous registration of breathing for about 3 h. A common cavity phenomenon in more than 1% of examination time was defined as representing pathological GER [7, 8] Patients suffering from pathological GER were treated by positioning and feeding of concentrated food [10, 15]. Further examinations - for example, barium swallow - were only done if symptoms persisted in spite of the forgoing therapy.
Results For sonographical staging two main groups were established: 1. G r o u p I (A and B) showed physiological findings; no G E R or "physiological" G E R (only a few episodes of GER). 2. G r o u p II demonstrated pathological findings: (1) G r o u p IIA: moderate G E R , meaning m o r e than 3 x G E R , without vomiting, relatively short duration of re-
656 In group I (14 patients) sonography and pH-metry gave identical findings (Table 1). However, delay in oesophageal clearance could be sonographically observed in one patient, and manometry showed moderate pathologic oesophageal peristalsis in another patient (Table 1, group
IB).
Fig. 1. Sonographic appearance of GER. M, Stomach; 0, oesophagus
In group IIA (ten patients, mean age 68 days), eight infants showed identical findings on both sonography and pH-metry/manometry. Only two patients with physiological G E R on pH-metry, sonographically showed moderate GER; on manometry they had pathological oesophageal peristalsis (Table 1). In group IIB (six patients, mean age 27 days) all sonographic findings were confirmed by pH-metry. Sonography showed a sensitivity of 100% and a specificity of 87,5% for the detection of G E R with P < 0.001 in the fourfold table test (Table 1).
Discussion
Fig. 2. Altered sonographic appearance of GER. 34, Stomach; O, oesophagus
flux episodes, no or little distention of distal oesophagus, especially after provocation. (2) Group IIB: severe GER, meaning frequent G E R with vomiting, longer duration of reflux episodes, with dilated distal oesophagus, even without provocation manoeuvres (Figs. 1, 2).
G E R is a common phenomenon in babies, but mainly its' sequelae oesophagitis, aspiration and apnoea cause problems [9, 13]. Therefore, the early detection of pathological G E R seems desirable, as conservative management might prevent serious sequelae. An easily available examination adequate for very young primarily affected infants is necessary. Sonography can detect G E R but cannot detect oesophagitis accurately - this must be proven by endoscopy and biopsy [9]. But one can achieve further information by evaluating sonographical appearance. As G E R usually is a quick, shortlasting event, oesophageal clearance as well as subdiaphragmatic oesophageal length and thickness, stomach emptying, and the amount of hiatal dysfunction may offer additional data to define therapeutic regimes [5]. We must, however, emphasize the necessity of standardised procedures: for example, different food does influence both reflux frequency as well as gastric and oesophageal clearance [14-16]. In conclusion our results show that sonography can detect G E R accurately and can achieve a satisfying staging using this sonographic group division for discrimination. In addition sonography can provide both morphological as well as functional data. We therefore suggest using sonography as the first step in the exploration of vomiting babies.
Table 1. Comparison of sonography and pH-metry/manometry in detecting GER Group/Sone
Number
Age (mean)
pH-metry/manometry
I A B II A B
10 4 10 6
(33%) (13%) (33%) (20%)
108 days 83 days 68 days 27 days
No GER No GER, 1 • pathological
Total
30 (100%)
72 days
Sensitivity = 100% ; Specificity = 87.5% ; P < 0.001
8 • GER, 2 • pathological but no GER 6 • GER 14 • GER, 16 • no GER, 3 x pathological peristalsis
Physiological Pathological
657
References 1. Blumhagen JT (1986) Role of ultrasonography in the evaluation of vomiting in infants. Pediatr Radiol 16 : 267 2. Euler AR, Ament ME (1977) Detection of gastroesophageal reflux in the pediatric age patient by oesophageal intraluminal pH probe measurement. Pediatrics 60 : 69-74 3. Euler AR, Byrne WJ (1981) 24 hour oesophageal intraluminal pH probe testing: a comparative analysis. Gastroenterology 80 : 957-961 4. Fotter R, Hoellwarth M, Uray E (1985) The correlation between manometric and roentgenologic findings of diseases of the oesophagus in infants and children. Prog Pediatr Surg 18 14-21 5. Gomes H (1991) Gastroesophageal reflux, comparative study between sonography and pH monitoring. Pediatr Radiol 21: 168-174 6. Guillet J e t al. (1987) Radionucleotide routine assessment of gastrointestinal tract motility diseases in 3000 pediatric patients. In: Csernay L, Schmidt H A E (eds) Nuklearmedizin, European Nuclear Medicine Congress 1987. FK Schattauer Verlag, Stuttgart, pp 428-430 7. Hoellwarth M, Uray E, Pesendorfer P, Rosanelli K, Rosegger H (1986) Oesophageal manometry. Pediatr Surg Int 1:177183 8. Johnson LF, DeMeester TR (1974) 24 hour pH monitoring of the distal oesophagus. A quantitative measure of gastroesophageal reflux. Am J Gastroenterol 62: 325-331 9. Koch A (1986) Der gastro6sophageale Reflux im S~iuglingsalter. Bibliothek fiir Kinderchirurgie. Hippokrates Verlag, Stuttgart, pp 30-42
10. Meyers WF, Herbst Jl (1982) Effectiveness of positioning therapy for gastroesophageal reflux. Pediatrics 69 : 768-772 11. Miller JH, Kemberling CR (1984) Ultrasound scanning of the gastrointestinal reflux: subject review. Radiology 152 : 671-678 12. Naik Dr, Moore DJ (1984) Ultrasound diagnosis of gastroesophageal reflux. Arch Dis Child 59 : 366-367 13. Ohrenstein S, David M (1988) Gastroesophageal reflux and respiratory disease in children. Pediatrics (112) 6 : 847-858 14. Supthen JL, Dillard VL (1988) Effect of feeding volume on early postcibal gastroesophageal reflux in infants. J Pediatr Gastroenterol Nutr 7 : 185-188 15. Vandenblas Y, Sacre L (1987) Milk thickening products as treatment for gastroesophageal reflux. Clin Pediatr (Phila) 26 : 66-68 16. Vandenblas Y, DeWolf D, Deneyer M, Sacre L (1988) Incidence of gastroesophageal reflux in sleep, awake, fasted and postcibal periods in asymptomatic and symptomatic infants. J Pediatr Gastroenterol Nutr 7 : 177-180 17. Willich E (1971) The function of the cardia in childhood. Pediatr Surg 3 : 141-167 18. Willich E (1986) Gastroesophageal reflux: radiological aspects. Pediatr Surg Int 1 : 144-160 19. Worlizek K (1986) Sonographische Diagnostik des fl%sigkeitsgeftillten Magens. Ultraschall Med 7 : 259-263 20. Wright LL, Baker KR, Meny RG (1988) Ultrasound demonstration of gatroesophageal reflux. J Ultrasound Med 7 : 471
