GER is the commonest indication for performing barium esophagram and upper gastrointestinal series in children. To optimize the examination, the stomach should be filled with the same volume as with a normal feed. If the child refuses to drink sufficient barium, the ingested volume can be increased with formula or fruit juice. The volume can be supplemented with fluid injected through an indwelling gastrostomy tube, or the stomach can be filled through a nasogastric tube which is removed after filling. Nasogastric tubes maintain patency of the lower esophageal sphincter and compromise its function. Tubes must be removed when evaluating for reflux. The barium swallow has only 50% sensitivity and specificity for reflux diagnosis in children (Rudolph et al. 2001). Reflux of barium is not diagnostic of GERD, and nor does absence of reflux rule it out (Rudolph et al. 2001). The most important aspect of the barium examination is to exclude anatomic abnormalities of the esophagus, to define the level of the duodenojejunal junction and to define the cephalad anatomic level of reflux, as well as to document aspiration (Fig. 2.20). Aspiration with reflux may be seen, but is very uncommon (FERNbACH 1994). A carefully performed upper GI series may miss significant GER because of the limited use of fluoroscopic monitoring time and the relatively short duration of the entire examination.
The radionuclide "milk scan" is a sensitive test for diagnosing GER (BLumHAGEN et al. 1980; SEibERt et al. 1983). Milk, formula or juice mixed with Tc 99m sulphur colloid is administered to the child who is then scanned. Radionuclide scanning is continuous, an advantage over fluoroscopy. Radionuclide scanning allows documentation of episodes of GER, and
cephalad extent of GER, as well as the rate of gastric emptying.
GER can be demonstrated sonographically into the distal esophagus (KoumANidou et al. 2004). Gastric contents can be observed as they reflux into the esophagus. This technique is limited because the degree of reflux and proximal extent cannot be evaluated in the chest where the esophagus is obscured by the lungs.
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