Diagnostic Considerations

Vomiting is a symptom associated with many disorders. Accordingly, gastroesophageal reflux cannot be assumed to be the primary problem in infants and children who present with a 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 distention
Onset of vomiting after 6 months of life
Fever, lethargy, hepatosplenomegaly
Macrocephaly, microcephaly, seizures

The 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 workup.

Conditions to consider in the differential diagnosis of gastroesophageal reflux include the following:

Antral web
Intestinal motility disorders, including achalasia, collagen-vascular disorders (e.g. systemic sclerosis)
Eosinophilic esophagitis
Helicobacter pylori associated gastritis
Irritable bowel syndrome
Peptic ulcer disease
Tracheoesophageal fistula

Differential Diagnoses

Workup

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Media Gallery

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 episode (diagonal arrow). The vertical dashed arrow indicates the onset of a normal swallow.
Algorithm for evaluation and "step-up" management of gastroesophageal reflux (GER).
Illustration of the Nissen fundoplication. Note how the stomach is wrapped around the esophagus (360-degree wrap).

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Author

Steven M Schwarz, MD, FAAP, FACN, AGAF Professor of Pediatrics, Children's Hospital at Downstate, State University of New York 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 Association for Physician Leadership, New York Academy of Medicine, Gastroenterology Research Group, American Gastroenterological Association, American Pediatric Society, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Society for Pediatric Research

Disclosure: Nothing to disclose.

Coauthor(s)

Andre Hebra, MD Chief Medical Officer, Nemours Children's Hospital; Professor of Surgery, University of Central Florida College of Medicine

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, Children's Oncology Group, Florida Medical Association, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association

Disclosure: Nothing to disclose.

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, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching. for: Abbott Nutritional, Abbvie, speakers' bureau.

Acknowledgements

B UK 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 UK 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.

Jennifer DA Liburd, MD, Consulting Staff, Assistant Professor of Pediatrics, Department of Pediatric Emergency Medicine, Nyack Hospital

Jennifer DA Liburd, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

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.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, Medscape Reference

Disclosure: Nothing to disclose.