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GASTROESOPHAGEAL REFLUX DISEASE IN CHILDREN

Gastroesophageal reflux is categorized as a disease [gastroesophageal reflux disease (GERD)] when reflux is associated with warning signs &/or complications, & requires further evaluation.

It is more common in formula-fed infants than in purely breastfed infants.

There is increased incidence in infants at 4 months of age.

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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