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. (See PMID 29470322 for clinical practice guidelines published in J Pediatr Gastroenterol Nutr 2018;66:516–554.)

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 LES relaxation allows gastric contents to flow in a retrograde direction up into the esophagus.

• Decreased gastric compliance in infants as compared with adults

Clinical Manifestations

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

• Gastroesophageal reflux disease: Significant complications develop in about 10% of untreated children.

  • ✓ Esophagitis: Crying, irritability, food aversion, heartburn, epigastric or chest pain, dysphagia/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

• GERD in older children and adolescents: heartburn, regurgitation

Differential Diagnosis

• Infant: pyloric stenosis (forceful emesis), malrotation (bilious emesis), allergic proctocolitis of infancy (accompanied by bloody stools), eosinophilic esophagitis, colic

• Older children: Eosinophilic esophagitis, functional dyspepsia, Helicobacter pylori infection, peptic ulcer, achalasia, rumination, hiatal hernia

Diagnostics

• With uncomplicated GER, no diagnostic tests are warranted.

• GERD is a clinical diagnosis but several tests may be situationally helpful to consider:

  • ✓ Upper gastrointestinal 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: Uses electrical impedance (resistance) to measure movement of air, fluid, and solids in the esophagus. Can detect 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 are 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.

  • ✓ Thicken formula with rice cereal (½–1 tablespoon per ounce) (may improve overt regurgitation)

  • ✓ Smaller-volume feeds (goal is to avoid overfeeding but still maintain ...