Pediatric rumination subtypes: A study using high‐resolution esophageal manometry with impedance

Abstract

Background The differential diagnosis of intractable reflux in children includes rumination syndrome but confirming the diagnosis using antroduodenal manometry is invasive, costly and requires anesthesia. High resolution esophageal manometry with impedance (HRM-MII) overcomes these limitations and the goal of this study is to validate the use of HRM-MII as a diagnostic tool for rumination and to describe the subtypes of pediatric rumination. Methods We reviewed the HRM-MII tracings of 21 children presenting with symptoms of intractable reflux in whom rumination was being considered. Patients underwent a standard and post-prandial HRM-MII. Peak intraluminal esophageal pressures, baseline gastric and thoracic pressures, and the timing of the R wave relative to LES relaxations and bolus flow were recorded. Chi square analyses were used for comparison of proportions and means were compared using t-tests or non-parametric equivalent. Key Results Forty one (55.5%) primary and 33 (44.5%) secondary rumination episodes were seen. Three types of primary rumination were identified: 1) LES relaxation without retrograde flow preceding the R wave (51% of episodes); 2) LES relaxation after the R wave (20% of episodes); and 3) R waves with no LES relaxation (29% of episodes). Eleven patients had rumination episodes with a peak gastric pressure <30 mm Hg. A total of 44 (60%) rumination episodes occurred during the standard HRM-MII, and 30 (40%) occurred during or after the meal. Conclusions and Inferences HRM-MII can accurately diagnose rumination in children. We identify three types of primary rumination which may provide insight into therapeutic response.

What is the role of high‐resolution oesophageal manometry in paediatrics?

“…These include: i) primary rumination of gastric juice, ii) secondary rumination following a reflux episode and/or iii) supra-gastric belching whereby air is repeatedly sucked into the oesophagus and expelled. [29][30][31] The typical protocol to investigate rumination includes a light meal and then a period of observation to detect rumination episodes. Recent studies have also suggested a role for HRM for biofeedback treatment of this condition.…”

An ANMS‐NASPGHAN consensus document on esophageal and antroduodenal manometry in children

“…Whenever possible, additional viscous and solid food swallows are also performed, because subtle motility abnormalities can be uncovered with different textures . If high resolution esophageal manometry is being paired with impedance, all liquids and solids need to have ions to detect impedance changes so added salt or salt water may be required …”

“…34 If high resolution esophageal manometry is being paired with impedance, all liquids and solids need to have ions to detect impedance changes so added salt or salt water may be required. 35 To assess swallowing function, the patient is given the liquid/ At the end of the single swallows, deglutitive inhibition is measured with the use of repetitive swallows, or with the use of the Rapid Drink Challenge, in which 100-200 mL of fluid are swallowed. 34,36,37 While there are no pediatric studies documenting normal esophageal and bolus pressures in children undergoing the rapid drink challenge, adults studies suggest it increases the sensitive to detect motility disorders, and do support its use to unmask subtle abnormalities which may include abnormalities in pressurization in the esophageal body, elevations in intra-esophageal bolus pressures and elevations in the pressure gradient across the EGJ, all of which may explain the dysphagia.…”

“…34,36,37 At times it may also reveal better peristaltic activity. 34,36,37 Finally, when rumination is being considered, patients should also consume a symptom-evocative meal after which the patient is observed for 30 minutes to an hour for the development of symptoms 35 as 40% of rumination episodes are only seen after a meal. 35 There is no routine indication for provocative medications during esophageal manometry in children.…”

“…There is lower esophageal sphincter relaxation with retrograde flow before the R wave. Adapted from Rosen et al35 absence of a mechanical obstruction. The diagnosis is mostly clinical.…”