Gastroesophageal Reflux & Gerd

Key Features

Essentials of Diagnosis

• Gastroesophageal reflux (GER): Frequent postprandial regurgitation, ranging from effortless to forceful

• Gastroesophageal reflux disease (GERD)

  • Regurgitation into the mouth

  • Heartburn

  • Dysphagia

• Extraesophageal manifestations of GERD

  • Implicated in the pathogenesis of several disorders unrelated to esophageal dysfunction

  • Has been linked to the occurrence of apnea or apparent life-threatening events in infants

• Warning signs that warrant further investigation in the infant with recurrent vomiting

  • Bile-stained emesis (a warning sign for intestinal obstruction)

  • Gastrointestinal (GI) bleeding

  • Onset of vomiting after 6 months

  • Failure to thrive

  • Diarrhea

  • Fever

  • Hepatosplenomegaly

  • Abdominal tenderness or distention

  • Neurologic changes

General Considerations

• GER

  • Refers to uncomplicated recurrent spitting and vomiting in healthy infants that resolves spontaneously

  • Factors promoting reflux in infants include

    • Small stomach capacity

    • Frequent large-volume feedings

    • Short esophageal length

    • Supine positioning

    • 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

• 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) primarily related to acid exposure in the upper GI tract, primarily the esophagus itself

• Extraesophageal manifestations of GERD include a myriad of clinical disorders that may be linked to reflux, including upper and lower airway symptoms and findings, as well as dental erosions

Clinical Findings

• GER in infants

  • Frequent postprandial regurgitation, ranging from effortless to forceful

  • Reflux of gastric contents into the esophagus occurs during spontaneous relaxations of the lower esophageal sphincter that are unaccompanied by swallowing

  • GERD is indicated when following symptoms develop

    • Failure to thrive

    • Food refusal

    • Pain behavior

    • GI bleeding

    • Upper or lower airway-associated respiratory symptoms

    • Sandifer syndrome

• GERD in older children

  • Regurgitation into the mouth

  • Heartburn

  • Dysphagia

  • Children with asthma, cystic fibrosis, developmental handicaps, hiatal hernia, and repaired tracheoesophageal fistula are at increased risk for GERD and esophagitis

• Extraesophageal manifestations of GERD

  • While proof of cause-and-effect is challenging, the following have been linked to GERD

    • Hoarseness

    • Sinusitis

    • Laryngeal erythema

    • Edema

    • Asthma

    • Recurrent pneumonia

    • Recurrent cough

    • Dental erosions

    • Sandifer syndrome

Diagnosis

• An upper GI series

  • Should be considered when anatomic etiologies of recurrent vomiting are considered

  • However, should not be considered to be a test for GERD

• Esophagoscopy and mucosal biopsies are useful to evaluate for

  • Mucosal injury secondary to GERD (Barrett esophagus, stricture, erosive esophagitis)

  • Nonreflux diagnoses that present with reflux-like symptoms, including eosinophilic esophagitis

• Endoscopic evaluation is not requisite for the evaluation of all infants and children with suspected GERD.

• Intraluminal esophageal pH monitoring (pH probe) and combined multiple intraluminal impedance and pH monitoring (pH impedance probe) are indicated to

  • Quantify reflux,

  • Evaluate for objective evidence of symptom associations with regards to atypical reflux presentations