GASTROESOPHAGEAL REFLUX DISEASE
DEFINITION:
The return of an abnormal quantity of gastric contents into the
esophagus resulting in gastrointestinal, respiratory, and/or
neurobehavioural manifestations.
EPIDEMIOLOGY:
- incidence: ?
- age of onset:
- provocative factors:
- supine positioning
- smoking
- certain foods and medications (see Management)
PATHOGENESIS:
- all infants and children reflux occasionally
- brief episodes of postprandial reflux is normal
- must differentiate physiologic from pathogenic reflux
2. Pathogenic Regurgitant Reflux
- differs from physiologic reflux in two ways:
2. Pathogenesis
- a disturbance of the normal functioning of the esophagus and
related structures results in defective antireflux barrier
CLINICAL FEATURES:
- failure to thrive
- malnutrition
- esophagitis
- feeding problems
- irritability
- hematemesis
- anemia
2. Respiratory Manifestations
- apnea (obstructive)
- chronic cough
- wheeze
- pneumonia (chronic or recurrent)
- cyanotic spells
- others - stridor, hiccups, hoarseness
- reflux with respiratory complications are more likely to
be observed in association with certain disorders in both
infants and children, i.e., esophageal atresia, Cystic
Fibrosis, Bronchopulmonary Dysplasia, Tracheoesophageal
- Fistula
3. Neurobehavioural Manifestations
- arching and stiffening
- hyperextenstion of the neck or markedly flexed to one side
(torticollis of Sandifer Syndrome)
2. Children/Adolescence
- chest pain (heartburn [pyrosis])
- dysphagia (difficult swallowing)
- hallitosis (refluxate in mouth)
- odynophagia (painful swallowing)
- waterbrush (flow of salty saliva into mouth)
- hematemesis
- anemia (iron-deficient)
2. Respiratory Manifestations
- recurrent or chronic pneumonias
- recurrent wheeze
- chronic cough
- others - stridor, hoarseness
INVESTIGATIONS:
- placement of a pH probe into the distal esophagus to moniter
the total time that there is acid (pH <4) in the distal
esophagus
- considered the "gold standard" for the diagnosis of
pathogenic reflux
- quantifies the frequency and duration of acid reflux for
prolonged periods
- detects a temporal relationship between episodes of reflux
and discrete signs and symptoms (neurobehavioural
manifestations)
- identifies "at risk" conditions, i.e., sleeping, coughing
- limitations:
- cannot detect nonacid reflux
- 24 hours in duration
- limited availability
2. Scintigraphic Monitering
- adding of radiolabelled (technetium 99m sulfer colloid) to
feed
- detects postprandial reflux and gastric emptying
3. Barium Esophagram/Upper GI Fluoroscopy
- performed following a barium meal
- provides a crude quantification of the frequency and
duration of reflux
- less sensitive for aspiration reflux
- rules out structural and functional anomalies fo the upper
GI tract, i.e., strictures, hiatal hernias, pyloric stenosis,
etc.
4. Endoscopy +/- Esophageal Biopsy
- detects esophagitis (erosions, ulcerations), strictures,
gastric peptic disease
5. Esophageal Manometry
- detects specific motility anomalies and low LES pressure
- does not detect reflux
6. Chest X-Ray
- aspiration and/or recurrent pneumonias
MANAGEMENT:
- based on history, physical, and investigations
2. Education
- discuss diagnosis with parents and explain physiologic from
pathogenic reflux
3. Goals of Therapy
- to eliminate the detrimental effects of reflux -
gastrointestinal, respiratory, and/or neurobehavioural
manifestations
4. Treatment Options
- 60-65% of infants with severe reflux will be asymptomatic
without therapy by 2 years of age
2. Therapy
5. Management Strategies
6. Prognosis
- more resistant to complete resolution with good response
to medical therapy but relapse when discontinued
INTERNET LINKS:
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