Q&A: Gastroesophageal Reflux Disease
Alan Leichtner, MD, and Samuel Nurko, MD
What are GER and GERD?
Gastroesophageal reflux (GER)
is the passage of gastric contents into the esophagus. This process
occurs many times a day in healthy infants, children and adults.
However, in certain individuals, reflux can cause serious complications
and is termed gastroesophageal reflux disease (GERD). The recent
finding that chronic gastroesophageal reflux is associated with
an increased risk of esophageal cancer has raised awareness of
GERD in adults.
How common are GER and GERD?
Only recently has data on the prevalence of uncomplicated GER
become available. A parent survey published in 2000 revealed that
50 percent of infants up to 3 months of age regurgitate at least
once a day. The prevalence rate of regurgitation peaks at 67 percent
at 4 to 6 months of age, and then declines to 5 percent in 10-
to 12-month-old infants. Another survey of children 3 to 9 years
of age revealed GERD symptoms of heartburn, epigastric pain, and
regurgitation in 1.8 percent, 7.2 percent, and 2.3 percent of
subjects, respectively. The same symptoms were reported by children
aged 10 to 17 years, 5.2 percent, 5.0 percent, and 8.2 percent
of the time, respectively.
Are certain children at increased risk for GERD?
Children with cerebral palsy and other neurological disorders
have a high incidence of GERD. Down syndrome and certain other
genetic disorders are also associated with GERD. Respiratory disease
may induce GERD either because of alteration of normal mechanisms
to maintain integrity of the gastroesophageal junction or as a
side-effect of agents used to treat bronchospasm.
Congenital anomalies such as esophageal atresia and tracheoesophageal
fistula not only are anatomic abnormalities, but also are accompanied
by altered esophageal motility that predisposes to GERD. Scleroderma
is characterized by decreased esophageal peristalsis and lower
esophageal sphincter pressure, both of which increase the risk
of GERD and esophagitis.
Obesity is a risk factor in adults and probably also in children.
What are the complications of GERD?
It is important for primary clinicians to recognize the wide
range of potential complications of GERD. These include dysphagia
or feeding refusal due to esophagitis or strictures, poor weight
gain, respiratory complications such as nocturnal cough, asthma,
stridor, apnea, and aspiration pneumonia, and the rare Sandifer
syndrome, which is the association of GERD and torticollis.
Complications of GERD, especially respiratory problems, may occur
in the absence of typical symptoms such as vomiting and heartburn.
Children with chronic symptoms of GER should be referred to a
pediatric gastroenterologist for evaluation. Although the long-term
outcome of children with chronic GERD is not know, pre-malignant
metaplasia of the esophageal mucosa, or Barrett’s esophagus,
and other serious complications have been recognized in children.
How are GER and GERD diagnosed?
In infants with uncomplicated regurgitation and older children
with typical heartburn, diagnostic tests are usually not required
and empirical therapy is appropriate. The best standard test for
GER is intraesophageal pH monitoring, which is indicated to
(1) diagnose occult GER
(2) correlate GER episodes with intermittent complications, such
as apnea or wheezing
(3) document GER prior to surgery
(4) determine whether chronic esophagitis is due to GERD or the
newly identified entity of allergic or eosinophilic esophagitis,
and
(5) assess the efficacy of acid-suppressive therapy in intractable
disease.
The fact that the pH probe only detects acid reflux, however,
limits its sensitivity. A promising new test for both acid and
non-acid reflux, based on measurement of intraluminal impedance,
has recently been introduced at Children’s Hospital and is
undergoing evaluation by Samuel Nurko, MD, director of the Motility
Center. The barium swallow and UGI series may reveal gastric or
duodenal obstruction predisposing to GER, or a stricture of the
esophagus, but is not a good test for diagnosing GER itself or
for detecting esophagitis. Upper endoscopy remains the most sensitive
test for diagnosing reflux esophagitis and Barrett’s esophagus.
Occasionally, esophageal manometry studies are indicated to assess
peristalsis and lower esophageal sphincter function.
What’s new in treatment for GERD?
Although GERD typically results from abnormal motility of the
esophagus resulting in inappropriate relaxation of the lower esophageal
sphincter (LES), acid is required to induce esophagitis. By far
the most effective class of acid-suppressive agents for treatment
of GERD is the proton pump inhibitors.
Two of these agents, omeprazole and lansoprazole, have been extensively
tested in children and are well tolerated. However, proton pump
inhibitors remain second line therapy and are indicated when H2-blockers
prove ineffective. A prokinetic agent to prevent inappropriate
relaxation of the LES and accelerate gastric emptying would seem
an ideal agent for GERD, however, no such drug currently exists.
Cisapride was removed from the market because of rare cardiac
arrhythmias and is only available on research protocols. Metoclopramide
and erythromycin have some utility, but significant adverse effects.
Fundoplication remains an important option for intractable reflux
and can now be performed laparoscopically in children. New endoscopic
therapies to improve competence of the gastroesophageal junction
are being tested in adults, but are not available for children.
