Gastroesophageal Reflux

GER: Definition & Pathophysiology - Reflux Rundown

• Gastroesophageal Reflux (GER):
  • Physiological passage of gastric contents into esophagus.
  • Affects >50% infants <3 months; peaks at ~4 months (~70%).
  • Usually resolves by 12-18 months.
• Gastroesophageal Reflux Disease (GERD):
  • GER causing troublesome symptoms (e.g., FTT, cry/fuss, esophagitis) or complications.
• Pathophysiology - Multifactorial:
  • TLESRs (Transient Lower Esophageal Sphincter Relaxations): Primary cause; inappropriate LES relaxation.

    ⭐ TLESRs, not chronically low basal LES tone, are the predominant mechanism of GER in most infants and children.

  • LES Dysfunction: ↓ basal LES pressure, shorter intra-abdominal LES.
  • Impaired Esophageal Clearance: Ineffective peristalsis.
  • Delayed Gastric Emptying: ↑ gastric volume.

GER: Clinical Features - Spit Happens

• Infants ("Happy Spitters"):
  • Effortless, non-bilious regurgitation.
  • Normal growth. Resolves by 12-18 months.
• Older Children/Adolescents:
  • Heartburn, regurgitation, epigastric pain.
  • Extraesophageal: chronic cough, hoarseness.

• ⚠️ Alarm Signs (Suspect GERD/Other):
  • Forceful, bilious, bloody vomiting.
  • FTT, weight loss.
  • Feeding refusal, irritability.
  • Hematemesis, melena.
  • Respiratory: apnea, recurrent pneumonia.
  • Onset >6mo / persists >18mo.
  • Dysphagia/odynophagia.

⭐ Sandifer syndrome: A rare manifestation of GERD in infants, characterized by abnormal posturing of the head, neck, and trunk (opisthotonus, torticollis).

GER: Diagnostic Workup - Scope It Out?

• Clinical diagnosis for uncomplicated GER.
• Investigate if RED FLAGS:
  • FTT, forceful/bilious vomit, hematemesis.
  • Dysphagia, apnea/ALTE.
  • Onset >6mo, persists >12-18mo, failed therapy.
• Investigations:
  • EGD + Biopsy: For esophagitis, complications (strictures), alarm symptoms. Visualizes mucosa, histology.
  • 24-hr pH-metry/MII-pH:
    • pH-metry: Quantifies acid reflux (RI >7% infants, >4% children).
    • MII-pH: Detects acid & non-acid reflux.
  • Barium Swallow: Rules out anatomical defects. Not for GER dx.

⭐ Endoscopy + biopsy: key for esophagitis, complications, or alarm symptoms if empiric therapy fails.

GER: Management & Complications - Tummy Tamers

Management Strategy: Stepwise approach.

Complications:

• Esophagitis (can lead to bleeding, anemia)
• Peptic stricture (dysphagia)
• Failure to thrive (FTT)
• Respiratory:
  • Recurrent aspiration pneumonia
  • Chronic cough, wheeze
  • Apnea / BRUE (Brief Resolved Unexplained Event)
• Sandifer syndrome
• Dental erosions
• Barrett's esophagus (rare in children)

⭐ Sandifer syndrome: characterized by abnormal, dystonic posturing of the head, neck, and trunk (arching, torticollis) associated with GERD episodes.

High‑Yield Points - ⚡ Biggest Takeaways

• Physiologic GER: Common in infants, resolves by 12-18 months; "happy spitters".
• GERD: Pathologic, causes poor weight gain, irritability, respiratory complications.
• Sandifer syndrome: GER with torticollis and abnormal posturing.
• Diagnosis: Primarily clinical; 24-hr pH monitoring is gold standard if needed.
• Management: Step-up approach - lifestyle (thickened feeds, positioning) then PPIs.
• Red flags: Bilious vomiting, GI bleeding, forceful vomiting, FTT.
• Consider cow's milk protein allergy as a mimic or contributor_._