Gastroesophageal%20reflux%20disease%20in%20children Diagnosis
Diagnosis
- Since gastroesophageal reflux disease occurs with few, if any, abnormal physical findings, a well-taken history is essential in establishing the diagnosis of gastroesophageal reflux disease
- There is no gold standard for the diagnosis of gastroesophageal reflux disease
- Diagnostic tests are used to document pathologic reflux & presence of complications
Evaluation
Clinical Diagnosis Based on Symptomatology
- This classification allows symptoms to define the disease
Esophageal Gastroesophageal Reflux Disease
- Characterized by the constellation of symptoms that may or may not be defined by further diagnostic tests
- Includes vomiting, poor weight gain, dysphagia, abdominal pain, substernal/retrosternal pain, esophagitis
- Esophageal symptomatic syndromes refer to uninvestigated patients with esophageal symptoms but without evidence of esophageal injury
- Include the Typical reflux syndrome defined by the presence of troublesome heartburn &/or regurgitation which are characteristic symptoms of gastroesophageal reflux disease
- Typical reflux syndrome can often be diagnosed without diagnostic testing; however, alarm symptoms should be excluded first
- Esophageal syndromes with esophageal injury include patients with demonstrable esophageal injury (eg reflux esophagitis, stricture, Barrett’s esophagus, adenocarcinoma)
Extraesophageal Gastroesophageal Reflux Disease with Established Associations
- Defined by conditions with an established association with gastroesophageal reflux disease based on population-based studies
- Eg reflux cough syndrome, reflux asthma syndrome, reflux laryngitis syndrome, reflux dental erosion syndrome
- It is rare for extraesophageal syndromes to occur alone without a concomitant manifestation of typical esophageal syndrome
- These syndromes are usually multifactorial, with gastroesophageal reflux disease as only one of the many other potential aggravating factors
Extraesophageal Gastroesophageal Reflux Disease with Proposed Associations
- Defined by conditions whose causal associations with gastroesophageal reflux disease are unclear or lacking in evidence
- Eg sinusitis, pharyngitis, recurrent otitis media, pulmonary fibrosis
Clinical Diagnosis Based on Endoscopic Findings
Erosive Reflux Disease (ERD)
- Defined by presence of esophageal mucosal damage
- Eg: erosive esophagitis, Barrett’s esophagus
Non-erosive Reflux Disease (NERD)
- Defined by absence of esophageal mucosal damage (endoscopy-negative reflux disease)
- More common in Asia
Classification
Endoscopic Classification Criteria
- Classification criteria frequently used for pediatric gastroesophageal reflux disease include Hetzel-Dent, Savary-Miller, & Los Angeles
Classification Criteria | Grade | Findings |
Los Angeles | A | ≥1 isolated mucosal breaks, each ≤5 mm long |
B | ≥1 isolated mucosal break >5 mm long, not continuous with top of adjacent mucosal folds | |
C | ≥1 mucosal breaks bridging the top of adjacent mucosal folds, involving <75% of luminal circumference | |
D | >75% of the luminal circumference with ≥1 mucosal breaks bridging the top of folds | |
Hetzel-Dent | 0 | No mucosal abnormalities |
1 | Erythema, hyperemia, mucosal friability present; macroscopic erosions absent | |
2 | Superficial erosions involving <10% of the mucosal surface of the distal 5 cm of squamous epithelium | |
3 | Ulcerations/erosions involving 10-50% of the mucosal surface of the distal 5 cm of squamous epithelium | |
4 | Esophageal mucosa with deep ulceration present, or confluent erosion involving more than 50% of the mucosal surface of the distal 5 cm of squamous epithelium | |
Savary-Miller | I | ≥1 supravestibular, nonconfluent reddish spots with or without exudates |
II | Confluent, noncircumferential erosive & exudative lesions in the distal esophagus present | |
III | Circumferential erosions in the distal esophagus, covered by hemorrhagic & pseudomembranous exudates | |
IV | Chronic complications (eg deep ulcers, stenosis, scarring with Barrett’s metaplasia) present |
Laboratory Tests
Esophageal pH Monitoring
- Used to quantify the frequency & duration of esophageal acid exposure per episode
- Does not correlate with the severity of acid reflux in gastroesophageal reflux & gastroesophageal reflux disease
- Depends on the total number of reflux episodes, number of episodes with duration lasting >5 minutes, duration of longest reflux episode, & the reflux index (Reflux Index: percentage of the total duration with recorded esophageal pH of <4.0)
- Not recommended for routine use but may be considered in patients suffering from unexplained apnea/non-epileptic seizure-like episodes/upper airway inflammation, atypical asthma, recurrent pneumonia, frequent otitis media, & dental erosion
Multichannel Intraluminal Impedance (MII) Monitoring
- Measures electrical impedance between multiple electrodes placed throughout the esophageal lining
- Detects changes caused by fluid, gas, solid, & mixed boluses, & can detect even small bolus volumes
- Usually combined with esophageal pH monitoring to be able to monitor whether refluxed material is acidic, non-acidic, or weakly acidic
Biopsy
- Required examination after obtaining histologic material during endoscopy
- Histologic abnormalities characteristic of gastroesophageal reflux disease include intraepithelial eosinophilia, basal hyperplasia, spongiosis, & epithelial extensions (rete pegs)
Imaging
Upper Gastrointestinal Tract Contrast Radiography
- Involves administration of contrast medium to obtain a series of images up to the ligament of Treitz to fully visualize the upper gastrointestinal tract
- 31-86% sensitivity; 21-83% specificity for gastroesophageal reflux disease
- Not recommended for routine use but may be useful in differentiating gastroesophageal reflux disease from anatomic abnormalities such as antral web, pyloric stenosis, or intestinal malrotation
Endoscopy
- Indicated for patients with heartburn, hematemesis, melena, epigastric abdominal pain, dysphagia
- Has high specificity (95%) but low sensitivity (<50%) for gastroesophageal reflux disease
- Since proton pump inhibitor therapy is usually started prior to any test, the sensitivity of endoscopy as a diagnostic test for gastroesophageal reflux disease is poor
- 60% of patients with gastroesophageal reflux disease may have non-erosive reflux disease (NERD)
- The first diagnostic test to consider in the presence of alarm symptoms or risk factors for Barrett’s esophagus, in evaluating symptom response to twice-daily proton pump inhibitor therapy, & prior to antireflux surgery
- Routine endoscopy in the general population is not recommended
Esophageal Manometry
- Measures upper & lower sphincter pressures, esophageal peristalsis, & motility of the esophageal mucosa during swallowing
- Not recommended in diagnosing gastroesophageal reflux disease but can be used to study the mechanisms causing gastroesophageal reflux disease in patients, & to rule out other causes of motility problems in the esophagus (eg achalasia, neurologic disorders)
Gastroesophageal Scintigraphy (Milk Scan)
- Utilizes 99mTc-labeled material to scan the gastroesophageal tract in order to evaluate postprandial reflux & gastric emptying
- Helps identify patients with delayed gastric emptying &/or aspiration of refluxed material
- Not recommended for routine use because of low sensitivity (15-59%) & specificity (83-100%) for gastroesophageal reflux disease
Ultrasonography
- Esophageal or gastric ultrasound may be considered when barium contrast study is not available
- May help detect the presence of fluid in the gastroesophageal junction, length & position of the lower esophageal sphincter, & gastroesophageal angle of His measurement
Complications
- Reflux esophagitis
- Aspiration pneumonia
- Otitis media
- Dental erosion