Gastroesophageal%20reflux%20disease%20in%20children 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

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

Endoscopic Classification Criteria

• Classification criteria frequently used for pediatric gastroesophageal reflux disease include Hetzel-Dent, Savary-Miller, & Los Angeles

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)

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

• Reflux esophagitis
• Aspiration pneumonia
• Otitis media
• Dental erosion