Gastroesophageal Reflux

Gastroesophageal Reflux: Excerpt from The 5-Minute Pediatric Consult

Joel Friedlander, DO, MBe

Gastroesophageal Reflux - BASICS

Gastroesophageal Reflux - description

• Effortless regurgitation of gastric contents. Occurs physiologically at all ages, and most episodes are brief and asymptomatic. Important to identify the rare child with pathologic reflux, to perform appropriate diagnostic studies, and to start effective therapy.
• Divided into pathologic and physiologic processes:
  • Physiologic reflux (normal gastroesophageal reflux [GER] of infancy) is the more common form. Great majority of children outgrow symptoms by age 1 year. GER measured via pH probe is acceptable if it occurs 4–6% in 24 hours after 1 year of age and 12% before, if there are no more than 50 episodes, and there are no prolonged episodes.
  • Pathologic reflux or gastroesophageal reflux disease (GERD) is defined by increased number of reflux episodes according to age-accepted norms with symptoms and/or complications of GER. Often includes complications such as esophagitis, esophageal stricture, failure to thrive, or chronic/recurrent respiratory tract disease.

Gastroesophageal Reflux - epidemiology

Gastroesophageal Reflux - prevalence

10% of adults, 7% of infants (GERD), 2–8% of children

Gastroesophageal Reflux - risk factors

Neurologic disorders (cerebral palsy/quadriplegia), esophageal atresia, tracheoesophageal fistula, cystic fibrosis, asthma

Gastroesophageal Reflux - pathophysiology

Transient relaxation of the lower esophageal sphincter during episodes of increased abdominal pressure. Multifactorial process involving number of reflux events, acidity, emptying, mucosal barriers, visceral hypersensitivity, and airway responsiveness.

Gastroesophageal Reflux - DIAGNOSIS

Gastroesophageal Reflux - signs & symptoms

• Complicated GERD:
  • Vomiting
  • Irritability
  • Chest/abdominal pain
  • Heartburn
  • Blood loss
  • Dysphagia
  • Food refusal
  • Cough, wheezing
  • Obstructive apnea
  • Dysphonia
  • Aspiration pneumonia
  • Posturing (Sandifer syndrome)
• Other suspected complications include chronic or recurrent otitis media and sinusitis.
• GERD may be asymptomatic and still carry risk of complications.

Gastroesophageal Reflux - history

• Infant:
  • Pay attention to feeding volume and frequency in addition to weight gain, failure to thrive, and irritability.
  • Identify episodes of pneumonia, obstructive apnea, chronic cough, laryngitis, stridor, and wheezing.
  • Identify additional signs/symptoms that suggest formula allergy (rash, diarrhea, hematochezia, irritability, failure to thrive).
  • Exclude evidence of bowel obstruction (bilious emesis, polyhydramnios during pregnancy).
  • If vomiting is atypical or associated with other signs/symptoms, it is important to rule out infection, metabolic disease, anatomic abnormality, or neurologic disease.
  • Special questions:
    • Presence of polyhydramnios or bilious emesis?
    • Family history of metabolic disease?
    • Family history of allergies/atopy?
    • Perinatal asphyxia (and other neurologic disorders)?
    • History of prematurity?
• Older child:
  • Identify typical adult GERD complaints (chest pain, heartburn, regurgitation, dysphagia), but recognize that children describe discomfort poorly (isolated abdominal pain).
  • Identify episodes of pneumonia, choking, chronic cough, laryngitis, stridor, and wheezing.
  • Consider evidence suggesting food allergy (rash, diarrhea, reactive airways disease).
  • Special questions:
    • Family history of GERD?
    • Family history of allergies/atopy?

Gastroesophageal Reflux - physical exam

• May be normal
• Growth failure
• Blood in stool
• Reactive airway disease and other manifestations of pulmonary complications
• Anemia
• Erosive dental (molar) disease
• Pharyngeal erythema/edema

Gastroesophageal Reflux - tests

Diagnosis of GERD is made clinically. Testing is only needed to identify questionable cases, potential causes, or complications. Evaluation should include:

• Stool heme-occult
• Growth parameters

Gastroesophageal Reflux - imaging

• Barium swallow or upper GI series: Evaluate anatomy.
• Chest x-ray: Evaluate for recurrent pneumonia.
• Milk scan/gastric-emptying study: Evaluate gastric motility and/or pulmonary aspiration.
• Salivagram: Evaluate for aspiration.

Gastroesophageal Reflux - diag proced-surgery

• Medication trial
• pH probe:
  • Attempts to correlate acid GERD with symptoms over a 24-hour period
  • Simple (single channel)
  • Double channel
  • Combined pH/multichannel intraluminal impedance: New technology that allows detection of both acid and nonacid GERD event, normative data pending
  • pH/thermistor (apnea) study
  • Wireless pH monitoring
• Esophagogastroduodenoscopy
• Laryngoscopy
• Bronchoscopy
• Manometric studies
• Esophageal manometry
• Antroduodenal manometry

Gastroesophageal Reflux - pathological findings

Evidence of esophagitis, Barrett’s esophagus, adenocarcinoma, or stricture

Gastroesophageal Reflux - differencial diagnosis

• Not all pediatric vomiting is reflux. Other causes of vomiting include:
• Cardiac: Congestive heart failure
• Toxin:
  • Lead
  • Fe
  • Medications
• Renal:
  • Obstructive uropathy
  • Uremia
• Infection:
  • Gastroenteritis
  • Urinary tract infection
  • Sepsis
  • Pneumonia
  • Hepatitis
  • Otitis media
  • Pancreatitis
• Neurologic:
  • Meningitis/Encephalitis
  • Intracranial injury
  • Brain tumor
  • Hydrocephalus
  • Subdural hematoma
• Metabolic:
  • Maple syrup urine disease
  • Aminoacidopathies
  • Adrenal hyperplasia
  • Phenylketonuria
  • Galactosemia
  • Urea cycle defects
• Food intolerance:
  • Milk/Soy protein allergy
  • Celiac disease
  • Hereditary fructose intolerance
• Anatomic malformation:
  • Gastric outlet obstruction
  • Pyloric stenosis
  • Volvulus/Malrotation
  • Esophageal atresia
  • Antral/Duodenal web
  • Meconium ileus
  • Enteral duplications
  • Intussusception
  • Trichobezoar
  • Foreign body
  • Incarcerated hernia
• Drugs that affect lower esophageal sphincter pressure:
  • Nitrates
  • Nicotine
  • Narcotics
  • Caffeine
  • Theophylline
  • Anticholinergic agents
  • Estrogen
  • Somatostatin
  • Prostaglandins

Gastroesophageal Reflux - TREATMENT

Several modes of therapy are available, depending on severity, duration of reflux, and complications. Treatment should be individualized, and cost effectiveness should be considered.

Gastroesophageal Reflux - general measures

• Conservative therapy
• Small, frequent feedings
• Thickening of feedings (~1 tablespoon cereal/ounce of formula): Helps with actual vomiting, not with stopping GER.
• Positioning: Prone positioning (not recommended), head elevation in older children only (in infants, it increases GER)

Gastroesophageal Reflux - diet

• Consider use of hypoallergenic formula for patients with associated food allergy
• Dietary restrictions in older child: Caffeine, chocolate, acidic/spicy food, peppermint, but recent adult studies show this is on an individual basis only.

Gastroesophageal Reflux - medication

Gastroesophageal Reflux - first line

H

Gastroesophageal Reflux - second line

• Proton pump inhibitors: For symptoms refractory to HOmeprazole (Prilosec):
  • <2 years: 1 mg/kg/d (daily or b.i.d.)
  • >2 years: <20 kg 10 mg daily >20 kg 20 mg daily
  • Up to 3.3 mg/kg/d have been used
• Lansoprazole (Prevacid):
  • <1 year: 0.4–1.8 mg/kg/d (daily or b.i.d.)–limited clinical experience
  • 1–11 years: <10 kg 7.5 mg daily
  • 10–30 kg: 15 mg daily or b.i.d.
  • >30 kg: 30 mg daily or b.i.d.
• Children often require a higher mg/kg. Side effects (uncommon) include headache, abdominal pain, and diarrhea.

Gastroesophageal Reflux - surgery

Fundoplication (open or laparoscopic)

• Goal: To increase lower esophageal sphincter tone by wrapping portion of gastric fundus around lower esophagus to provide for a more effective barrier to GERD
• Variations may include addition of a gastric emptying procedure (i.e., pyloroplasty) or gastrostomy placement.
• Failure of aggressive medical management in patients with severe complications (i.e., esophageal stricture; large and symptomatic hiatal hernia; high-grade intestinal metaplastic changes, as in Barrett esophagus)
• Complications include:
  • Gas bloating syndrome
  • Intractable retching
  • Bowel obstruction
  • Dumping syndrome
  • Dysphagia
  • Paraesophageal hernia
  • Wrap failure with recurrent GERD (up to 6% failure at 48 months)
  • Limited long-term clinical effectiveness
• Greater morbidity associated with fundoplication in cohort of children with severe physical and mental disabilities

Gastroesophageal Reflux - FOLLOW UP

Recurrent endoscopy for evidence of pathological changes of esophagus

Gastroesophageal Reflux - bibliography

1. Colletti RB, Di Lorenzo C. Overview of pediatric gastroesophageal reflux disease and proton pump inhibitor therapy. J Pediatr Gastroenterol Nutr. 2003;37(suppl 1):S7–S11.
2. Craig WR, Hanlon-Dearman A, Sinclair C, et al. Metoclopramide, thickened feedings, and positioning for gastro-oesophageal reflux in children under two years. Cochrane Database Syst Rev. 2004;(4):CD003502.
3. El-Serag HB, Gilger M, Carter J, et al. Childhood GERD is a risk factor for GERD in adolescents and young adults. Am J Gastroenterol. 2004;99(5):806–812.
4. Israel DM, Hassall E. Omeprazole and other proton pump inhibitors: Pharmacology, efficacy and safety, with special reference to use in children. J Pediatr Gastroenterol Nutr. 1998;27:568–579.
5. Lobe TE. The current role of laparoscopic surgery for gastroesophageal reflux disease in infants and children. Surg Endosc. 2007;27:167–174.
6. McGuirt WF Jr. Gastroesophageal reflux and the upper airway. Pediatr Clin North Am. 2003;50:487–502.
7. Orenstein SR. Gastroesophageal reflux. Curr Probl Pediatr. 1991;May/June:193–241.
8. Pashankar D, Blair GK, Israel DM. Omeprazole maintenance therapy for gastroesophageal reflux disease after failure of fundoplication. J Pediatr Gastroenterol Nutr. 2000;32:145–149.
9. Rudolph CD, Mazur LJ, Liptak GS, et al.; North American Society for Pediatric Gastroenterology and Nutrition. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: Recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001;32 Suppl 2:S1–S31.
10. Spitz L, McLeod E. Gastroesophageal reflux. Semin Pediatr Surg. 2003;12:237–240.
11. Vandenplas Y, ESPGHAN cisapride panel. Current pediatric indications for cisapride. J Pediatr Gastroenterol Nutr. 2000;31:480–489.

Gastroesophageal Reflux - CODES

Gastroesophageal Reflux - icd9

530.81 Esophageal reflux

Gastroesophageal Reflux - FAQ

• Q: How long will my baby suffer with GERD?
• A: Most infantile reflux resolves by 9–12 months of age, but symptoms may persist up to 24 months. If GERD continues after 2–3 years, it is more likely to behave clinically like adult GERD.
• Q: Should all babies with reflux be treated with medication?
• A: No. It is reasonable to 1st try conservative treatments such as thickened feedings and frequent small feedings.
• Q: What are the long-term effects of giving my child antacid medications?
• A: Although the effect of long-term acid suppression remains unknown, most medications used to treat GERD are quite safe. Although safe, there is some new adult research data that suggests a possibility of osteoporosis and pneumonia with many years of treatment. One must also recognize however, that untreated reflux has the potential to lead to serious complications (Barrett esophagus, which can predispose patients to esophageal cancer). When considering safety, not treating reflux may be the more dangerous course of action.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Gastroesophageal Reflux Disease

• Back to disease: Gastroesophageal Reflux Disease: Introduction
• Next Book Extract About Gastroesophageal Reflux Disease: Surveys relating to Gastroesophageal Reflux Disease
• More Book Extracts: All Online Books for Gastroesophageal Reflux Disease

More Medical Textbooks Online about Gastroesophageal Reflux Disease

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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