Q&A: Gastroesophageal Reflux Disease
Alan Leichtner, MD, and Samuel Nurko, MD

	Alan Leichtner, MD Interim Chief, Gastroenterology & Nutrition x

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.

	Samuel Nurko, MD Director, Motility Center x

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.

 

Children’s Motility Center
Children’s Hospital Boston recently established a Motility Center for the evaluation and management of disorders resulting from disordered gastrointestinal motility or sensation, including intractable constipation or GERD, achalasia, intestinal pseudo-obstruction, Hirschsprung’s disease, fecal incontinence and irritable bowel syndrome. Staff of the Center also conduct clinical research to assess new diagnostic tests and therapies. The center is directed by Samuel Nurko, MD.

 

Gastroenterology and Nutrition Program

Phone: 617.355.6058
      or: 617.355.3394
Urgent referrals:
617.355.7243, pager #2354

Alan Leichtner, MD
alan.leichtner@tch.harvard.edu
Phone: 617.355.2946

Samuel Nurko, MD
samuel.nurko@tch.harvard.edu
Phone: 617.355.6055