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DISORDERS OF THE ESOPHAGUS
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GASTROESOPHAGEAL REFLUX & GERD
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Key definitions:
Gastroesophageal reflux (GER) refers to uncomplicated recurrent spitting and vomiting in healthy infants that resolves spontaneously.
Gastroesophageal reflux disease (GERD) is present when reflux causes secondary symptoms or complications.
Esophageal manifestations of GERD include symptoms (heartburn, regurgitation) and mucosal complications (esophagitis, stricture, Barrett esophagus) primarily related to acid exposure in the upper gastrointestinal (GI) tract, primarily the esophagus itself.
Extraesophageal manifestations of GERD include a myriad of clinical disorders that may be linked to reflux, including upper and lower airway symptoms and findings, as well as dental erosions. In most settings, objective confirmation of extraesophageal reflux complications is challenging.
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A. Infants With Gastroesophageal Reflux
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Gastroesophageal (GE) reflux is common in young infants and is a physiologic event. Frequent postprandial regurgitation, ranging from effortless to forceful, is the most common infant symptom. Infant GER is usually benign, and it is expected to resolve by 12–18 months of life.
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Reflux of gastric contents into the esophagus occurs during spontaneous relaxations of the lower esophageal sphincter (LES) that are unaccompanied by swallowing. Factors promoting reflux in infants include small stomach capacity, frequent large-volume feedings, short esophageal length, supine positioning, and slow swallowing response to the flow of refluxed material up the esophagus. Infants’ individual responses to the stimulus of reflux, particularly the maturity of their self-settling skills, are important factors determining the severity of reflux-related symptoms.
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Symptoms such as failure to thrive, food refusal, pain behavior, GI bleeding, upper or lower airway-associated respiratory symptoms, or Sandifer syndrome in infants indicate gastroesophageal reflux disease (GERD).
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B. Older Children With Reflux
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Older children with GERD complain of adult-type symptoms such as regurgitation into the mouth, heartburn, and dysphagia. Esophagitis can occur as a complication of GERD and requires endoscopy with biopsy for diagnostic confirmation. Children with asthma, cystic fibrosis, developmental delay/spasticity, hiatal hernia (HH), and repaired esophageal atresia—tracheoesophageal fistulas are at increased risk of GERD and esophagitis.
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C. Extraesophageal Manifestations of Reflux Disease
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Upper airway symptoms (hoarseness, sinusitis, laryngeal erythema, and edema), apnea or apparent life-threatening events (ALTEs), lower airway symptoms (asthma, recurrent pneumonia, recurrent cough), dental erosions, and Sandifer syndrome have all been linked to GERD, although proof of cause-and-effect relationship is challenging.
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D. Diagnostic Studies
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History and physical examination alone should help differentiate infants with benign, recurrent vomiting (physiologic GER) from those who have red flags for GERD or other underlying primary conditions that may present with recurrent emesis at this age. Warning signs that warrant further investigation in the infant with recurrent vomiting include bile-stained emesis, GI bleeding, onset of vomiting after 6 months, failure to thrive, diarrhea, ...