Surgery for gastroesophageal reflux in children with normal pH studies

Esophageal pH monitoring is recognized as the best diagnostic procedure for gastroesophageal reflux (GER) and operation is seldom recommended in the absence of abnormal pH data. To emphasize that operation should not be ruled out for children who may have false-negative pH studies, we report 14 patients operated on for GER in spite of normal pH-monitoring. The mean age was 54 months (range, 18 to 90). Clinical features included vomiting, dysphagia, respiratory disease, anemia, and torticollis. All had radiologic evidence of GER, and 10 had endoscopic and histological esophagitis. Conventional pH-monitoring values were normal but lower esophageal sphincter pressure and propulsive peristalsis were significantly decreased whereas nonpropulsive contractions were predominant. Operation was recommended after an average of 24 months of unsuccessful medical treatment. Independent postoperative assessment showed that 13 of the 14 patients were relieved of their symptoms and dysphagia persists in one. We suggest that the diagnosis of GER should be accepted on the basis of sound clinical judgement plus more than one abnormal test even when pH results are normal. Operation should not be withheld when clinically indicated. There are several explanations for false-negative pH studies, of which alkaline reflux is probably the most important and warrants further investigation in children.