eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Gastroesophageal Reflux: Differential Diagnoses & Workup

Author: Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Coauthor(s): Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina; Professor of Surgery and Pediatrics, Medical University of South Carolina
Contributor Information and Disclosures

Updated: May 13, 2009

Differential Diagnoses

Antral Web
Helicobacter Pylori Infection
Duodenal Atresia and Stenosis: Surgical Perspective
Hiatal Hernia
Esophageal Motility Disorders
Intestinal Malrotation
Esophagitis
Intestinal Motility Disorders
Food Allergies
Irritable Bowel Syndrome
Gastric Ulcers
Peptic Ulcer Disease
Gastritis, Acute
Sudden Infant Death Syndrome
Gastritis, Chronic
Tracheoesophageal Fistula

Other Problems to Be Considered

Vomiting is a symptom associated with many disorders. Accordingly, the diagnosis of gastroesophageal reflux (GER) cannot be assumed to be the primary problem in infants and children who present with history of emesis. Warning signals that herald the requirement for additional evaluation include the following:

  • Bilious or forceful vomiting
  • Hematemesis or hematochezia
  • Vomiting with diarrhea
  • Abdominal tenderness or distension
  • Onset of vomiting after 6 months of life
  • Fever, lethargy, hepatosplenomegaly
  • Macrocephaly, microcephaly, seizures
Occurrence of any of these signs and symptoms indicates the need to consider a comprehensive metabolic, neurologic, and/or surgical evaluation, in addition to a gastroenterologic work-up.

Workup

Imaging Studies

In most cases of gastroesophageal reflux (GER), diagnosis can be made from the history and physical examination. Conservative measures can be started empirically. However, if the presentation is atypical or if response to therapy is minimal, further evaluation is warranted.

  • Upper GI imaging series
    • This is used to evaluate the anatomy of the upper GI tract, but contrast imaging studies are neither sensitive nor specific for gastroesophageal reflux.
    • Imaging may be useful in the evaluation of gastric emptying time, which may be delayed in gastroesophageal reflux.
  • Gastric scintiscan
    • This imaging study, using milk or formula that contains a small amount of technetium sulfur colloid, can assess gastric emptying and can reveal reflux (although not the degree or severity). However, its major diagnostic role is in the assessment of pulmonary aspiration.
    • A major error in performing scintigraphy is not performing a delayed scan over the pulmonary bed. Gastroesophageal reflux–related aspiration may occur as an early or late postprandial phenomenon. Accordingly, in addition to the "acute" (ie, 1 h) scintiscan, patients should be rescanned after 24 hours, in order to assess delayed pulmonary soilage by refluxed gastric contents.
  • Esophagography
    • In cases of mild gastroesophageal reflux, diagnosis is made by clinical assessment and is confirmed by the response to therapy. This modality, conducted under fluoroscopic control, may reveal the integrity of esophageal peristalsis; however, it should not be used to assess the degree and severity of gastroesophageal reflux.
    • Strictures can be demonstrated by esophagography.
    • Chronic esophageal mucosal injury secondary to gastroesophageal reflux involves a mucosal/submucosal inflammatory cell infiltrate as well as basal cell hyperplasia. In severe cases, this may appear as a ragged mucosal outline on radiography.

Procedures

  • Intraesophageal pH probe monitoring
    • A continuous esophageal pH probe in the distal esophagus documents the severity and frequency of reflux. Although a very sensitive technique, some controversy persists with respect to precise criteria for differentiating "physiologic" from "pathologic" gastroesophageal reflux. More recently, dual pH probe monitoring is being used to assess both distal and proximal esophageal reflux in an attempt to correlate gastroesophageal reflux with both laryngeal and pulmonary symptoms.
    • Although pH monitoring has become a widely overused modality, it remains the criterion standard for quantifying gastroesophageal reflux.
    • Advantages in using this procedure include quantification of reflux and the ability to establish a temporal relationship with atypical symptoms (eg, obstructive apnea) and reflux events.
    • Esophageal pH monitoring is not indicated in cases of obvious gastroesophageal reflux but is useful in demonstrating an association between reflux and symptoms in atypical presentations and in grading the risk of esophagitis.
  • Manometry
    • This is becoming a more accessible tool for use in infants and children.
    • It is used to assess esophageal motility and lower esophageal sphincter (LES) function.
  • Esophagogastroduodenoscopy
    • This modality is useful in patients who are unresponsive to medical therapy.
    • It allows for visualization of the mucosa for diagnosis of peptic ulcer disease, Helicobacter pylori infection, strictures, and peptic esophagitis. It provides access to obtain biopsies for histopathologic examination.
  • Intraluminal esophageal electrical impedance (EEI).
    • This recently developed test is useful for detecting both acid reflux and nonacid reflux by measuring retrograde flow in the esophagus.
    • Gastroesophageal reflux episodes as brief as 15 seconds may be measured (see Media file 1).

      The image is a representation of concomitant intr...

      The image is a representation of concomitant intraesophageal pH and esophageal electrical impedance measurements. The vertical solid arrow indicates commencement of a nonacid gastroesophageal reflux (GER) episode (diagonal arrow). The vertical dashed arrow indicates the onset of a normal swallow.

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      The image is a representation of concomitant intr...

      The image is a representation of concomitant intraesophageal pH and esophageal electrical impedance measurements. The vertical solid arrow indicates commencement of a nonacid gastroesophageal reflux (GER) episode (diagonal arrow). The vertical dashed arrow indicates the onset of a normal swallow.

    • In adult studies, impedance measurements have been used in conjunction with 24-hour intraesophageal pH monitoring in order to provide a more complete picture of bolus movement in the esophagus.
    • EEI has not been thoroughly validated, and normal values have not been determined in the pediatric age group.

Histologic Findings

  • Histologic signs of peptic esophagitis include basal cell hyperplasia, extended papillae, and mucosal eosinophils.
  • The number of mucosal eosinophils may be important because finding more than 20 per high-powered field (hpf) has recently been associated with eosinophilic (allergic) esophagitis rather than peptic esophagitis.

More on Gastroesophageal Reflux

Overview: Gastroesophageal Reflux
Differential Diagnoses & Workup: Gastroesophageal Reflux
Treatment & Medication: Gastroesophageal Reflux
Follow-up: Gastroesophageal Reflux
Multimedia: Gastroesophageal Reflux
References
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References

  1. Bhatia J, Parish A. GERD or not GERD: the fussy infant. J Perinatol. May 2009;29 Suppl 2:S7-11. [Medline].

  2. Rudolph CD. Supraesophageal complications of gastroesophageal reflux in children: challenges in diagnosis and treatment. Am J Med. Aug 18 2003;115 Suppl 3A:150S-156S. [Medline].

  3. Mousa H, Woodley FW, Metheney M and Hayes J. Testing the association between gastroesophageal reflux and apnea in infants. J Pediatr Gastroenterol Nutr. 2005;41:169-177. [Medline].

  4. Gold BD. Gastroesophageal reflux disease: could intervention in childhood reduce the risk of later complications?. Am J Med. Sep 6 2004;117 Suppl 5A:23S-29S. [Medline].

  5. Chao HC, Vandenplas Y. Effect of cereal-thickened formula and upright positioning on regurgitation, gastric emptying, and weight gain in infants with regurgitation. Nutrition. 2007;23:23-28. [Medline].

  6. [Best Evidence] Horvath A, Dziechciarz P, Szajewska H. The effect of thickened-feed interventions on gastroesophageal reflux in infants: systematic review and meta-analysis of randomized, controlled trials. Pediatrics. Dec 2008;122(6):e1268-77. [Medline].

  7. Diaz DM, Winter HS, Colletti RB, et al. Knowledge, attitudes and practice styles of North American pediatricians regarding gastroesophageal reflux disease. J Pediatr Gastroenterol Nutr. 2007;45:56-64. [Medline].

  8. Rudolph CD, Mazur LJ, Liptak JS et al. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001;32:S1-S22. [Medline].

  9. Hassall E. Decisions in diagnosing and managing chronic gastroesophageal reflux disease in children. J Pediatr. Mar 2005;146(3 Suppl):S3-12. [Medline].

  10. Diaz DM, Gibbons TE, Heiss K et al. Antireflux surgery outcomes in pediatric gastroesophageal reflux disease. Am J Gastroenterol. 2005;100:1844-1852. [Medline].

  11. Rabinowitz SS, Piecuch S, Jibali R, Goldsmith A and Schwarz SM. Optimizing the diagnosis of gastroesophageal reflux in children with otolaryngologic symptoms. Int J Pediatr Otorhinolaryngol. 2003;167:621-626. [Medline].

  12. Rosen R, Lord C and Nurko S. The sensitivity of multichannel intraluminal impedance and the pH probe in the evaluation of gastroesophageal reflux in children. Clin Gastroenterol Hepatol. 2006;4:167-172. [Medline].

  13. Orenstein SR. Management of supraesophageal complications of gastroesophageal reflux disease in infants and children. Am J Med. 2000;108 (4A):139S-143S. [Medline].

  14. Gold BD. Outcomes of pediatric gastroesophageal reflux disease: in the first year of life, in childhood, and in adults. J Pediatr Gastroenterol Nutr. 2003. 2003;37:S33-S39. [Medline].

  15. Nelson SP, Chen EH, Syniar GM, Christoffel KK. Prevalence of symptoms of gastroesophageal reflux during childhood: a pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med. Feb 2000;154(2):150-4. [Medline].

  16. Salvatore S, Hauser B, Vandemaele K. Gastroesophageal reflux disease in infants: how much is predictable with questionnaires, pH-metry, endoscopy and histology?. Journal of Pediatric Gastroenterology and Nutrition. 2005;40:210-5. [Medline].

  17. Ton M, Suwandhi E and Schwarz SM. Gastroesophageal Reflux. Pediatr Ann. 2006;35:259-266. [Medline].

  18. Vandenplas Y. Gastroesophageal Reflux : Medical treatment. J Pediatr Gastroenterol Nutr. 2005;41:S41-S42. [Medline].

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Further Reading

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Keywords

GER, gastroesophageal reflux disease, GERD, motility, heartburn, physiologic GER, lower esophageal sphincter, LES, esophagus, transient LES relaxation, tLESR, failure to thrive, erosive esophagitis, esophageal stricture formation, chronic respiratory disease, Barrett esophagus, esophageal mucosal dysplasia, asthma, gastric outlet obstruction, reactive airway disease, laryngeal inflammatory disease, otitis media, otalgia, chronic sinusitis, heartburn, apnea, bradycardia, pneumonitis, waterbrash, Sandifer syndrome, opisthotonus, torticollis, laryngitis, halitosis, pharyngitis, hiatal hernia, gastroparesis, pyloric stenosis, apparent life-threatening event, ALTE, treatment, diagnosis

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Contributor Information and Disclosures

Author

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor

Coauthor(s)

Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina; Professor of Surgery and Pediatrics, Medical University of South Carolina
Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Jayant Deodhar, MD, Associate Professor in Pediatrics, BJ Medical College, India; Honorary Consultant, Departments of Pediatrics and Neonatology, King Edward Memorial Hospital, India
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

B U K Li, MD, Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin
B U K Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-Downstate Medical Center
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor

Chief Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

 
 
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