Evaluation and treatment of gastroesophageal reflux in infants and children

Gastroesophageal reflux (GER), defined as passage of gastric contents into esophagus, and GER disease (GERD), defined as symptoms or complications of GER, are common pediatric problems encountered by both primary and specialty medical providers. Clinical manifestations of GERD in children include vomiting, poor weight gain, dysphagia, abdominal or substernal pain, esophagitis and respiratory disorders. On the other hand, recurrent vomiting is the symptom of hydronephrosis, brain tumor, food allergy, uremia, other metabolic disease, obstruction of intestine etc. It is very important for clinicians dealing with children and infants to understand GERD. The evaluation and treatment of gastroesophageal reflux in infants and children were reviewed here.     

Clinical significance of 24-hour intraesophageal pH monitoring in GERD patients

24-hour intraesophageal pH monitoring(24-pH-M) is a method of choice to measure the esophageal acid exposure, and evaluate a patient's lifestyle who has reflux symptoms. The 24-pH-M is indicated to the cases who have at least one of the following signs/symptoms; endoscopy negative GERD(gastroesophageal reflux disease), atypical clinical course for reflux disease, atypical symptoms of GERD, and those who are subjected to have surgical treatment. In the 24-pH-M, not only the duration of gastroesophageal reflux(GER), but also reflux and symptom association should be evaluated. The 24-pH-M is useful to investigate the diagnosis and treatment of GERD including reflux esophagitis.     

Nursing responsibility in the diagnosis, care, and treatment of the child with gastroesophageal reflux.

Gastroesophageal reflux (GER) has been known to occur in infants but was thought to be normal. As a result of increased recognition of GER and a clear documentation of GER with extended (18 to 24 hour) esophageal pH monitoring, several severe complications of GER in children have become apparent. An immature cardiorespiratory system is susceptible to some complications of GER such as apnea, choking, recurrent cough or wheezing, and recurrent aspiration pneumonia. Noncardiorespiratory complications include weight loss, esophagitis, anemia, irritability, posturing, malnutrition, and developmental delays. Nursing assessment contributes to a complete clinical picture and the subsequent treatment choice of the physician. To form an accurate assessment of the child with suspected GER, the nurse must be aware of the symptoms and complications of this condition and must precisely execute diagnostic studies, particularly extended esophageal pH monitoring. Nursing responsibilities also include providing a safe yet stimulating environment for the child, teaching parents to participate in the child's care, supporting parents through hospitalization, and preparing both the parents and child for discharge and follow-up care at home.     

Nursing responsibility in the diagnosis, care, and treatment of the child with gastroesophageal reflux

Gastroesophageal reflux (GER) has been known to occur in infants but was thought to be normal. As a result of increased recognition of GER and a clear documentation of GER with extended (18 to 24 hour) esophageal pH monitoring, several severe complications of GER in children have become apparent. An immature cardiorespiratory system is susceptible to some complications of GER such as apnea, choking, recurrent cough or wheezing, and recurrent aspiration pneumonia. Noncardiorespiratory complications include weight loss, esophagitis, anemia, irritability, posturing, malnutrition, and developmental delays. Nursing assessment contributes to a complete clinical picture and the subsequent treatment choice of the physician. To form an accurate assessment of the child with suspected GER, the nurse must be aware of the symptoms and complications of this condition and must precisely execute diagnostic studies, particularly extended esophageal pH monitoring. Nursing responsibilities also include providing a safe yet stimulating environment for the child, teaching parents to participate in the child's care, supporting parents through hospitalization, and preparing both the parents and child for discharge and follow-up care at home.     

Definition and classification of GERD

Gastro-esophageal reflux disease(GERD) is a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Traditionally, it was defined as a condition in which either or both of reflux esophagitis and reflux symptoms can be identified. The Montreal definition expanded the category of GERD to complications of esophagitis and extra-esophageal symptoms with or without established evidence on the correlation with GERD. Symptomatic patients those who lacks the evidence of mucosal breaks are called as NERD. Functional heartburn, defined in Rome III, is similar in symptoms but different in the responsiveness to PPIs. Increasing knowledge will clarify what the gastroesophageal reflux really causes health problems.     

Gastroesophageal reflux disease: presentation and assessment of a common, challenging disorder

Although gastroesophageal reflux disease (GERD) is frequently referred to as a continuous spectrum, it is more useful to consider GERD as 2 discrete entities with several subsets that differ in pathophysiology, clinical presentation, natural history, and therapy. One entity is classic severe acid reflux with erosive esophagitis and its complications. Barrett's esophagus is an important subset of this group, with markedly increased acid exposure and an increased risk of adenocarcinoma. The second entity is nonerosive reflux disease (NERD) with minimal or no esophagitis. Patients with NERD do not develop local mucosa complications, like stricture or Barrett's esophagus, but their symptom severity can equal that of erosive esophagitis. Acid is involved in the symptoms of many but not all NERD patients. This acid dependence is evident either as an increase in esophageal acid reflux or a hypersensitivity to acid, and both generally respond well to proton pump inhibitor (PPI) therapy. NERD patients who are not acid-dependent have what is called functional heartburn; GERD-like symptoms are present, but there is no obvious involvement of refluxed acid. An important subset of GERD is refractory GERD, which consists of patients who fail aggressive PPI therapy. Parallel findings with other refractory syndromes can be anticipated; however, there are indications that psychosocial factors play a major role in refractory GERD, and these patients may benefit more from an integrated biopsychosocial approach. Diagnosis of GERD is usually made on clinical grounds, often supplemented by a therapeutic trial with antisecretory agents. Endoscopy is reserved for patients with alarm symptoms, such as dysphagia, anemia, or weight loss, or to detect Barrett's esophagus. Endoscopy is not useful to exclude the diagnosis of GERD because it will be negative in 70% of cases in primary care. Ambulatory 24-hour esophageal pH monitoring is necessary only when the diagnosis is in doubt, the patient fails medical management, or surgery is contemplated.     

The clinical evaluation of structured questionnaire for reflux esophagitis

Reflux esophagitis is suspected on clinical grounds and confirmed by a variety of endoscopical, roentgenological and physiological investigations, which are obviously inapplicable to an epidemiological survey. Questionnaire for the diagnosis of reflux disease(QUEST) can reduce bias introduced by observer variability, is practical, inexpensive, and noninvasive. QUEST also has good sensitivity and specificity for reflux esophagitis, so it's one of the useful diagnostic tools for reflux esophagitis. It, however, needs to be modified for the diagnosis of gastroesophageal reflux disease (GERD). Questionnaires to measure Quality of Life(QOL) quantitatively can be applied to the assessment of the severity of diseases or drug efficacy, and they are useful especially for the evaluation of endoscopy-negative GERD.     

Gastroesophageal reflux: practical management of a common, challenging disorder

Gastroesophageal reflux (GER) occurs in 2 distinct forms that differ in pathophysiology, clinical presentation, natural history, and therapy: mild GER (with no or minimal esophagitis) and classic, severe reflux (at risk for erosive esophagitis). A minority of subjects (< 20%) have the classic, potentially severe pattern of GER caused by reduced lower esophageal sphincter (LES) pressure and prolonged acid reflux, particularly at night, but also during the day. Evaluation and management must be catered to patients with this pattern of reflux. In contrast, symptoms in mild reflux (the majority) often occur during the day after meals in an upright posture (upright reflux); resting LES pressure is usually normal (reflux episodes are related to transient relaxation of the LES) and little reflux occurs at night. Acid reflux, which occurs mostly during the day, overlaps with the normal range and esophagitis is rare; however, symptoms can be distressing. Optimal management is controversial because no outcome trials have been conducted to address management in primary care settings. However, clinical clues can help differentiate mild and severe reflux and guide management decisions. This article provides a detailed approach to current management of GER syndromes.     

Significance of PPI-test in the diagnosis of GERD

Gastroesophageal reflux disease (GERD) is defined as 'Chronic symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus'. Reflux esophagitis refers to a subgroup of GERD patients with histopathologically demonstrated characteristic changes in the esophageal mucosa. Besides, GERD includes symptoms without endoscopic findings (endoscopic negative GERD) and extra-esophageal symptoms. Therefore, GERD cannot be diagnosed only by endoscopy. Three methods are indispensable in the diagnosis of GERD; endoscopy, evaluation of patient symptoms and acid reflux. Since 'Symptom relief is well correlated with the degree or suppression of gastric acid secretion in GERD', symptom in relation to acid reflux can be evaluated by PPI-test. Characteristics of PPI-test including extra-esophageal GERD diagnosis are discussed in this review.     

Characteristics of a combined course of duodenal ulcer and gastroesophageal reflux disease

Duodenal ulcer (DU) and gastroesophageal reflux disease (GERD) are often combined. A combination of these wide-spread diseases invariantly effects their pathogenesis, clinical manifestations, diagnostics, and requires correction of methods of their treatment. The authors observed 41 patients suffering from DU combined with GERD (main group) and 25 patients with DU alone (control group). A higher level of intragastral acidity with cardial "acidification", more prominent disturbances in duodenal, gastral and esophageal motor activity leading to duodenal spasm, duodenogastral and gastroesophageal reflux (DGR; GER) were found in the main group. Heartburn as the main clinical sign of GERD appears, as a rule, only in the presence of reflux-esophagitis (RE) confirmed by morphological study of bioptats from the lower part of esophagus independently of an endoscopic form of GERD, positive or negative. In cases of combined duodenal ulcer and GERD certain signs of disturbances in psychoemotional and vegetative spheres were revealed, such as hypochondrial changes, moderate changes in cerebral hemodynamics (vertebrobasilar basin). Administration of eglonil, an atypical neuroleptic with prokinetic activity, as part of complex treatment leads to reduction and/or disappearance of heartburn, DGR, GER, morphological signs of RE, and improvements in the psychoemotional and vegetative status in patients with combined DU and GERD, as well as improvement in quality of life.     

Supraesophageal complications of gastroesophageal reflux

Supraesophageal complications of GERD have become more commonly recognized or suspected by physicians. However, the direct association between these complications and GERD has often been difficult, if not impossible, to establish. Furthermore, the majority of patients with suspected supraesophageal complications of GERD do not have either the characteristic symptoms of heartburn and regurgitation or the definitive findings of esophageal inflammation, which would help reinforce the suspicion of a connection between the supraesophageal complications and GERD. Frequent acid reflux has been shown in patients with various bron-chopulmonary, laryngopharyngeal, or oral cavity disorders. GERD is one of the most common gastrointestinal complaints in the population. It is possible that the supraesophageal problems and acid reflux are mutually independent disorders that occur in the same person. The suspected mechanisms of GERD-related supraesophageal complications appear to be directed through two pathways: by a vagal reflex between the esophagus and tracheobronchial tree triggered by acid reflux or by microaspiration that causes contact damage to mucosal surfaces. The most useful diagnostic modality available to the clinician to aid in the diagnosis of supraesophageal GERD complications is the ambulatory pH recording technique. However, the sensitivity and specificity of this test for recording esophageal or pharyngeal acid reflux events has been critically challenged. Despite the many clinical studies that support the theory that GER has a role in suspected supraesophageal complications, only 1 long-term prospective controlled study of a large group of patients with asthma has shown the positive effects of the elimination of acid reflux. With the focus now on "outcomes medicine," there is a serious need for appropriately designed, controlled studies to answer the many questions surrounding a cause-and-effect association between acid reflux and supraesophageal disorders. Because of the lack of convincing proof between acid reflux and suspected supraesophageal complications, the physician must resort to an intent-to-treat strategy as both a primary therapy and a diagnostic trial. High-dose PPI therapy for prolonged periods is the recognized conservative therapy. Operative therapy (i.e., fundoplication operation) is the procedure of choice when overt regurgitation occurs or when medical therapy, although successful, is not practical for long periods. Controlled, well-designed clinical trials and more sophisticated techniques to measure and quantify acid reflux are crucial in the future to help determine which patients with suspected supraesophageal complications actually have acid reflux as a primary cause. The medical community needs to be alerted to the possibility of an association between GERD and supra-esophageal complications so that patients with a GERD-related complication will be recognized and effectively treated.     

Gastroesophageal reflux in infants and children.

Gastroesophageal reflux is a common, self-limited process in infants that usually resolves by six to 12 months of age. Effective, conservative management involves thickened feedings, positional treatment, and parental reassurance. Gastroesophageal reflux disease (GERD) is a less common, more serious pathologic process that usually warrants medical management and diagnostic evaluation. Differential diagnosis includes upper gastrointestinal tract disorders; cow's milk allergy; and metabolic, infectious, renal, and central nervous system diseases. Pharmacologic management of GERD includes a prokinetic agent such as metoclopramide or cisapride and a histamine-receptor type 2 antagonist such as cimetidine or ranitidine when esophagitis is suspected. Although recent studies have supported the cautious use of cisapride in childhood GERD, the drug is currently not routinely available in the United States.     

Gastrointestinal hemorrhage in paralyzed and neurologically impaired patients: Contribution of reflux esophageal disease

The role of gastroesophageal reflux (GER) and reflux esophagitis in the pathogenesis of gastrointestinal hemorrhage was assessed in 13 male patients with chronic paralysis or neurologic impairment. Nine of the 13 patients initially presented for barium meal examination to evaluate anemia, hematemesis, heme-positive stools, or melena. Six of the 9 had radiographic evidence, confirmed by upper gastrointestinal (GI) endoscopy, of esophagitis with or without stricture without other upper GI tract lesions. Notably absent were antecedent symptoms of GER such as heartburn or dysphagia. Careful examination of the esophagus, although difficult, must be an integral part of the evaluation for anemia and/or gastrointestinal blood loss in paralyzed patients.     

Diagnosing gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common condition with a variety of clinical manifestations and potentially serious complications. This article reviews available methods for diagnosing GERD. A clinical history of the classic symptoms of GERD, heartburn or acid regurgitation, is sensitive enough to establish the diagnosis in patients without other complications. Esophagogastroduodenoscopy is the best way to evaluate suspected complications of GERD, but endoscopic findings are insensitive for the presence of pathological reflux, and therefore they cannot reliably exclude GERD. The "gold standard" study for confirming or excluding the presence of abnormal gastroesophageal reflux is the 24-hour ambulatory esophageal pH monitoring test, and this study should be used for the evaluation of refractory symptoms and extraesophageal manifestations of GERD. A formal acid-suppression test is helpful in the evaluation of the atypical GERD symptom of noncardiac chest pain. Optimal use of currently available tests for GERD may allow for more efficient diagnosis and better characterization of the pathological manifestations associated with GERD.     

Pathophysiology of GERD: mechanisms of gastroesophageal reflux and prolonged esophageal acid exposure time

GERD is characterized by excessive esophageal acid exposure time. This suggests that either the rate of gastroesophageal reflux (GER) is higher and/or that the esophageal acid clearance time is longer. Transient LES relaxation (TLESR) is the single most common mechanism underlying GER in both normal subjects and patients with GERD. Whether or not the rate of TLESRs is higher in patients with GERD remains unclear. It is in the sitting or upright position that acid reflux mainly occurs, however, there seems to be no difference in the rate of TLESRs between both groups. The rate of TLESRs accompanied by acid reflux has been consistently shown to be significantly greater in patients with GERD than in normal subjects. Other mechanisms of reflux in patients with severe GERD are a hypotensive LES and ineffective esophageal motility which is found in severe GERD and which impairs bolus clearance of acid and thus increases acid contact time with the esophageal mucosa.     

Barrett's esophagus

Gastroesophageal reflux disease (GERD) is a condition commonly managed in the primary care setting. Patients with GERD may develop reflux esophagitis as the esophagus repeatedly is exposed to acidic gastric contents. Over time, untreated reflux esophagitis may lead to chronic complications such as esophageal stricture or the development of Barrett's esophagus. Barrett's esophagus is a premalignant metaplastic process that typically involves the distal esophagus. Its presence is suspected by endoscopic evaluation of the esophagus, but the diagnosis is confirmed by histologic analysis of endoscopically biopsied tissue. Risk factors for Barrett's esophagus include GERD, white or Hispanic race, male sex, advancing age, smoking, and obesity. Although Barrett's esophagus rarely progresses to adenocarcinoma, optimal management is a matter of debate. Current treatment guidelines include relieving GERD symptoms with medical or surgical measures (similar to the treatment of GERD that is not associated with Barrett's esophagus) and surveillance endoscopy. Guidelines for surveillance endoscopy have been published; however, no studies have verified that any specific treatment or management strategy has decreased the rate of mortality from adenocarcinoma.     

Gastroesophageal reflux disease: clinical manifestations.

Gastroesophageal reflux disease (GERD) is generally a lifelong illness that affects many people, but its significance is often underestimated. Chronic abnormal gastric reflux results in erosive esophagitis in up to 60% of patients with GERD. Esophageal stricture, Barrett's esophagus, and esophageal adenocarcinoma are the most serious complications of GERD. Although heartburn and acid regurgitation are the most common complaints, extraesophageal symptoms such as noncardiac chest pain, laryngitis, coughing, and wheezing can be manifestations of GERD. Unfortunately, the severity of symptoms is not a reliable indicator of the severity of erosive esophagitis. Endoscopy is the preferred method to diagnose and grade erosive esophagitis, and various classification systems are used to grade disease severity. The Los Angeles Classification is a valid and widely accepted system to evaluate the severity of erosive esophagitis. The immediate goals of treatment are to provide effective symptomatic relief and to achieve healing in patients with esophageal damage. The treatment regimen often begins by prescribing a therapy to reduce gastric acid secretion. A proton pump inhibitor is the preferred agent for many patients. Because GERD is a chronic, relapsing disease, long-term maintenance therapy is usually necessary to relieve symptoms, prevent complications, and improve the quality of life in patients with GERD.     

Gastroesophageal reflux in children: a guide for the advanced practice nurse

Gastroesophageal reflux (GER) is one of the most common gastrointestinal problems in infants and children. Unfortunately, the diagnosis of GER is often made after development of serious complications, placing the child at medical and developmental risk. Early recognition by primary care providers is essential in preventing these serious, sometimes life-threatening complications of untreated GER. This article reviews the pathophysiology, clinical manifestations, diagnostics, and treatment modalities of GER along with developmental considerations. As a health care provider, the advanced practice nurse is in an ideal position to provide a complete assessment, develop a realistic plan of care, coordinate interventions, assess outcomes, and offer support to the family of the child with GER.     

Primary care for GEDR

Current approach for the treatment of gastroesopageal reflux disease (GERD) was reviewed. The most effective treatment of erosive esophagitis or symptomatic GERD is to reduce gastric acid secretion with either an H2 receptor antagonists (H2RA) or a proton pump inhibitor (PPI). The PPI lead to more rapid healing and symptom relief than H2RA. Despite treatment with PPI, some patients with GERD continue to have symptoms or endoscopic evidence of esophagitis. Nocturnal acid breakthrough may be one of the mechanisms responsible for the refractory GERD. There are two approaches to the initial medical treatment of gastroesophageal reflux disease ('step down' therapy or 'step up' approach). Although there are arguments in favour of both approaches, the former is considered to be preferable these days.     

Pretreatment endoscopy--pro & contra: endoscopy is needed before treatment in all patients with gastroesophageal reflux disease

Most current endoscopic guidelines do not recommend the use of routine esophagoscopy in the evaluation of patients with typical symptoms of gastroesophageal reflux disease (GERD), unless alarm features are present. In patients with known reflux esophagitis, esophagoscopy is considered to have no role either in the further management or follow-up. Screening of reflux patients for Barrett's esophagus is not considered to be cost-effective. On the basis of a critical review of the available literature, and of some recent papers in particular, we disagree with these suggestions. We would argue, on the contrary, that a negative esophagoscopy can provide the GERD patient with reassurance, and that esophagoscopy allows targeted therapy to be offered if it is positive for esophagitis. When Barrett's esophagus is diagnosed, it usually leads to a surveillance program being initiated. The potential benefits of endoscopy for the patient's quality of life are probably underestimated when financial issues alone are taken into account. Even if it is true that a large percentage of GERD patients do not have endoscopic abnormalities (those with nonerosive reflux disease), surrogate tests such as the proton-pump inhibitor test or symptom questionnaires do not provide a more accurate diagnosis. We would therefore suggest that, at least in the specialist setting, all patients with suspected GERD should undergo accurate symptom analysis as well as endoscopic evaluation before treatment is started.