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DISORDERS OF THE ESOPHAGUS

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GASTROESOPHAGEAL REFLUX & GERD

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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

  • Uncomplicated gastroesophageal reflux (GER) refers to recurrent postprandial spitting and vomiting in healthy infants that resolves spontaneously.

  • Gastroesophageal reflux disease (GERD) is present when reflux causes secondary symptoms or complications.

  • Esophageal manifestations of GERD include symptoms (heartburn, regurgitation) and mucosal complications (esophagitis, stricture, Barrett esophagus).

  • GERD has been implicated in pathogenesis of many extraesophageal symptoms, including upper and lower airway findings. In most settings, objective confirmation of extraesophageal reflux complications is challenging.

  • Upper gastrointestinal (GI) radiograph is useful to rule out other anatomical GI diseases, but it should not be considered an evaluation for reflux or reflux disease.

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Clinical Findings
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A. Infants With Gastroesophageal Reflux
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Gastroesophageal (GE) reflux is common in young infants and is a physiological event. Frequent postprandial regurgitation, ranging from effortless to forceful, is the most common infant symptom. Infant GER is usually benign, and it is expected to resolve by 12–18 months of life.

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Reflux of gastric contents into the esophagus occurs during spontaneous relaxations of the lower esophageal sphincter that are unaccompanied by swallowing. Low pressures in the lower esophageal sphincter or developmental immaturity of the sphincter are not causes of GER in infants. Factors promoting reflux in infants include small stomach capacity, frequent large-volume feedings, short esophageal length, supine positioning, and slow swallowing response to the flow of refluxed material up the esophagus. Infants' individual responses to the stimulus of reflux, particularly the maturity of their self-settling skills, are important factors determining the severity of reflux-related symptoms.

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An important point in evaluating infants with GER is to determine whether the vomited material contains bile. Bile-stained emesis in an infant requires immediate evaluation as it may be a symptom of intestinal obstruction (malrotation with volvulus, intussusception).

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Other symptoms may be associated with GERD in infants, although these situations are far less common than benign, physiologic GER. These clinical presentations include failure to thrive, food refusal, pain behavior, GI bleeding, upper or lower airway-associated respiratory symptoms, or Sandifer syndrome.

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B. Older Children With Reflux
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GERD is diagnosed when reflux causes persistent symptoms with or without inflammation of the esophagus. Older children with GERD complain of adult-type symptoms of regurgitation into the mouth, heartburn, and dysphagia. Esophagitis can occur as a complication of GERD and requires endoscopy with biopsy for diagnostic confirmation. Children with asthma, cystic fibrosis, developmental handicaps, hiatal hernia, and repaired tracheoesophageal fistula are at increased risk of GERD and esophagitis.

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C. Extraesophageal Manifestations of Reflux Disease
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GERD is implicated in the pathogenesis of several disorders unrelated to inherent esophageal mucosal injury. In infants, GERD has been linked to the occurrence of apnea or apparent life-threatening events (ALTEs), although the majority of pathologic cases are not ...

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