CHAPTER 10: Gastroenterology

ESOPHAGUS AND STOMACH

GASTROESOPHAGEAL REFLUX DISEASE

Gastroesophageal reflux (GER) is a physiologic process of stomach contents regurgitating into the esophagus. Gastroesophageal reflux disease (GERD) occurs when GER is accompanied by disturbing symptoms or complications such as esophagitis, respiratory disease, failure to thrive, and/or neurobehavioral manifestations.

EPIDEMIOLOGY

• In infants, most GER is physiologic and benign

• Functional GER occurs in more than half of all infants

• Most common esophageal disorder

PATHOPHYSIOLOGY

• Transient lower esophageal sphincter (LES) relaxation allows gastric contents to flow retrograde up the esophagus

• Decreased gastric compliance in infants compared to adults

CLINICAL MANIFESTATIONS

• Functional/Simple GER: Silent oral regurgitation, effortless spitting, or forceful vomiting; symptoms peak at 1–4 months and resolve by 12–18 months of age; usually benign

• Complicated GER (GERD): Significant complications develop in about 10% of untreated children

  • ✓ Esophagitis: Crying, irritability, food aversion, heartburn, epigastric or chest pain, odynophagia, hematemesis, anemia, and/or guaiac-positive stools

  • ✓ Respiratory: Laryngospasm, bronchospasm, microaspiration pneumonia

  • ✓ Failure to thrive

  • ✓ Neurobehavioral manifestations: Sandifer syndrome (opisthotonic posturing, head tilting, seizure-like activity); arching; excessive irritability

DIAGNOSTICS

• With uncomplicated GER, no diagnostic tests are warranted. In infants or children with complicated GER, consider:

  • ✓ Upper Gastrointestinal (GI) Series: Defines anatomy; useful to exclude malrotation, pyloric stenosis, webs, atresias, or other anatomic causes; not diagnostic for reflux

  • ✓ Scintigraphy or “Milk Scan”: Detects delayed gastric emptying and/or pulmonary aspiration; not diagnostic for reflux

  • ✓ pH Probe: Gold standard to quantify acid reflux; helps establish causal relationship between reflux and other symptoms

  • ✓ Impedance Probe: Measures movement of air, fluid, and solids in the esophagus through electrical impedance (resistance). Can detect presence of nonacid contents and can be combined with pH probe monitoring. Particularly useful in correlating symptoms with reflux events in patient on acid suppression therapy or in postprandial period when stomach contents likely to be nonacid

  • ✓ Upper Endoscopy: Allows direct visualization of the mucosa and the pathologic diagnosis of mucosal disease related to reflux; basal cell hyperplasia, papillary elongation, and an inflammatory cellular infiltrate seen in esophagitis

MANAGEMENT

• Conservative Therapy: Appropriate as a component of treatment for all GER, and may be sole therapy for uncomplicated GER. These measures may mitigate GER symptoms in about 20% of affected infants

  • ✓ Thicken formula with rice cereal (½–1 tablespoon per ounce)

  • ✓ Hold upright during and after feeds

  • ✓ Sleep with head elevated 30 degrees

    • ■ While prone positioning may mitigate GER symptoms, the association of sudden infant death syndrome (SIDS) with prone positioning of young infants precludes a recommendation of prone positioning as a routine strategy

  • ✓ Formula changes: Allergy to cow’s milk or soy-based formulas is uncommon and unlikely to present with emesis as the sole symptom. Therefore, formula changes are generally not warranted. If cow’s milk protein ...