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

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