Pediatric Current Medical Diagnosis &
Treatment: Ch 21: GI Tract
What is gastroesophageal reflux (GER)? - ANSWER Uncomplicated recurrent
spitting and vomiting in healthy infants.
What is gastroesophageal reflux disease (GERD)? - ANSWER Reflux that causes
secondary symptoms or complications.
What are the esophageal manifestations of GERD? - ANSWER Symptoms
(heartburn, regurgitation) and mucosal complications (esophagitis, stricture, Barrett
esophagus) primarily related to acid exposure in the esophagus.
What are the extraesophageal manifestations of GERD? - ANSWER Clinical
disorders linked to reflux, including upper and lower airway symptoms, dental
erosions.
What are the typical features of gastroesophageal reflux in infants? - ANSWER
Frequent postprandial regurgitation, ranging from effortless to forceful.
When is infant GER expected to resolve? - ANSWER By 12-18 months of life.
What causes reflux in infants? - ANSWER Spontaneous relaxations of the lower
esophageal sphincter (LES) unaccompanied by swallowing.
What factors promote reflux in infants? - ANSWER Small stomach capacity,
frequent large-volume feedings, short esophageal length, supine positioning, slow
swallowing response.
What determines the severity of reflux-related symptoms in infants? - ANSWER
Infants' individual responses to the stimulus of reflux and the maturity of their self-
settling skills.
What are some symptoms of gastroesophageal reflux disease (GERD) in infants? -
ANSWER Failure to thrive, food refusal, pain behavior, GI bleeding, upper or lower
airway-associated respiratory symptoms, or Sandifer syndrome.
What are some symptoms of GERD in older children? - ANSWER Regurgitation
into the mouth, heartburn, and dysphagia.
What is a possible complication of GERD in older children? - ANSWER
Esophagitis.
,What diagnostic procedure is required to confirm esophagitis? - ANSWER
Endoscopy with biopsy.
Which children are at increased risk of GERD and esophagitis? - ANSWER
Children with asthma, cystic fibrosis, developmental delay/spasticity, hiatal hernia
(HH), and repaired esophageal atresia—tracheoesophageal fistulas.
What are some extraesophageal manifestations of reflux disease? - ANSWER
Upper airway symptoms (hoarseness, sinusitis, laryngeal erythema, and edema),
apnea or apparent life-threatening events (ALTEs), lower airway symptoms (asthma,
recurrent pneumonia, recurrent cough), dental erosions, and Sandifer syndrome.
What are some warning signs in infants with recurrent vomiting that warrant further
investigation? - ANSWER Bile-stained emesis, GI bleeding, onset of vomiting after
6 months, failure to thrive, diarrhea, fever, hepatosplenomegaly, abdominal
tenderness or distension, or neurologic changes.
What is an upper GI series used for? - ANSWER To investigate anatomic
etiologies of recurrent vomiting, not for diagnosing GERD.
What is the purpose of acid-suppressant therapy in older children with heartburn or
frequent regurgitation? - ANSWER Diagnostic and therapeutic
When should a child be referred to a pediatric gastroenterologist for evaluation of
GERD? - ANSWER If symptoms require ongoing acid suppressant therapy or if
symptoms fail to improve with empiric therapy
What are some nonreflux diagnoses that can present with reflux-like symptoms? -
ANSWER Eosinophilic esophagitis (EoE)
What is the purpose of esophagoscopy and mucosal biopsies in evaluating GERD? -
ANSWER To evaluate for mucosal injury secondary to GERD or nonreflux
diagnoses including EoE
Is endoscopic evaluation necessary for all infants and children with suspected
GERD? - ANSWER No
What are the indications for intraluminal esophageal pH monitoring? - ANSWER
To quantify reflux and evaluate for objective evidence of symptom associations
What is the difference between pH probe and pH impedance probe? - ANSWER
pH impedance probe also measures multiple intraluminal impedance
When may pH impedance studies have a higher diagnostic yield? - ANSWER In
evaluating for respiratory or atypical complications of reflux disease or breakthrough
reflux symptoms while on acid-suppressant therapy
At what age does reflux spontaneously resolve in 85% of affected infants? -
ANSWER 12 months
,What factors coincide with the resolution of reflux in infants? - ANSWER
Assumption of erect posture and initiation of solid feedings
How can regurgitation volume be reduced in infants? - ANSWER Offering small
feedings at frequent intervals and thickening feedings with rice cereal
Is there evidence to support empiric use of acid suppression in infants with
unexplained crying or fussy behavior? - ANSWER No
What is GERD? - ANSWER Gastroesophageal reflux disease, a condition where
stomach acid flows back into the esophagus.
Why may empiric acid suppression not be appropriate in neonates with suspected
GERD? - ANSWER Because careful attention to potential factors leading to
symptoms and/or objective testing is needed.
What are the therapeutic options for treating suspected esophageal or
extraesophageal complications of acid reflux in older infants and children? -
ANSWER Histamine-2 (H2)-receptor antagonists or proton pump inhibitors (PPIs).
What has PPI therapy been shown to do in the treatment of GERD? - ANSWER
Significantly heal both esophageal mucosal injury and symptoms within 8-12 weeks.
What are potential risk factors associated with long-term PPI therapy? - ANSWER
Risk for infection (pneumonia, Clostridium difficile-associated diarrhea) and an
increased risk for osteoporosis in adults.
Are there standardized recommendations for prophylaxis or surveillance for
complications in pediatric patients on long-term PPI therapy? - ANSWER No, but
one should consider weaning or discontinuing treatment if it is no longer required.
Is there sufficient evidence to support the routine use of prokinetic agents for
treatment of pediatric GERD? - ANSWER No.
Is spontaneous resolution likely in older children with GERD and those with
underlying neurodevelopmental disorders? - ANSWER Less likely.
How can episodic symptoms of GERD be controlled? - ANSWER With intermittent
use of acid blockers.
What may be required for those with persistent symptoms of GERD? - ANSWER
Chronic acid suppression.
What are some complications of reflux esophagitis or chronic GERD? - ANSWER
Feeding dysfunction, esophageal stricture, and anemia.
Is Barrett esophagus common in children? - ANSWER No, it is very uncommon.
In which patients may Barrett esophagus occur? - ANSWER Patients with an
underlying primary diagnosis that offers high risk for GERD.
, What does Figure 21-1 show? - ANSWER Esophagitis associated with GERD.
What is the appearance of the mucosa in Figure 21-1? - ANSWER Erythematous
with loss of vascular pattern.
What does the endoscopic view of the esophagus show? - ANSWER Irregular dark
streaks trailing down the inside lining.
Is there a downloadable slide for Figure 21-1? - ANSWER Yes.
Is there a favorite figure for Figure 21-1? - ANSWER Yes.
What is the size of the downloadable slide for Figure 21-1? - ANSWER PPT.
What is antireflux surgery? - ANSWER Surgical procedure to treat GERD.
When is antireflux surgery considered? - ANSWER When medical therapy fails or
has severe complications.
What are potential complications after antireflux surgery? - ANSWER Dumping
syndrome, gas bloat syndrome, retching or gagging, wrap failure.
What are the common symptoms of GERD in infants? - ANSWER Feeding
dysfunction, dysphagia, esophageal food impaction, heartburn.
What should be ruled out before diagnosing Eosinophilic Esophagitis (EoE)? -
ANSWER Other causes for esophageal eosinophilia.
What are the two most common complications of EoE? - ANSWER Esophageal
food impaction and esophageal stricture.
What are the effective treatments for EoE? - ANSWER Elimination of food
allergens or swallowed topical steroids.
What is EoE? - ANSWER Eosinophilic Esophagitis, affects boys, GERD-like
symptoms
What are common initial presentations of EoE in young children? - ANSWER
Feeding dysfunction, abdominal pain, vomiting, regurgitation
What are common symptoms of EoE in adolescents? - ANSWER Solid food
dysphagia, food impactions
When should EoE be considered as a diagnostic possibility? - ANSWER If a child's
symptoms are unresponsive to GERD management
What are some common features of the esophageal mucosa in EoE? - ANSWER
Thickening, mucosal fissures, strictures, rings
Treatment: Ch 21: GI Tract
What is gastroesophageal reflux (GER)? - ANSWER Uncomplicated recurrent
spitting and vomiting in healthy infants.
What is gastroesophageal reflux disease (GERD)? - ANSWER Reflux that causes
secondary symptoms or complications.
What are the esophageal manifestations of GERD? - ANSWER Symptoms
(heartburn, regurgitation) and mucosal complications (esophagitis, stricture, Barrett
esophagus) primarily related to acid exposure in the esophagus.
What are the extraesophageal manifestations of GERD? - ANSWER Clinical
disorders linked to reflux, including upper and lower airway symptoms, dental
erosions.
What are the typical features of gastroesophageal reflux in infants? - ANSWER
Frequent postprandial regurgitation, ranging from effortless to forceful.
When is infant GER expected to resolve? - ANSWER By 12-18 months of life.
What causes reflux in infants? - ANSWER Spontaneous relaxations of the lower
esophageal sphincter (LES) unaccompanied by swallowing.
What factors promote reflux in infants? - ANSWER Small stomach capacity,
frequent large-volume feedings, short esophageal length, supine positioning, slow
swallowing response.
What determines the severity of reflux-related symptoms in infants? - ANSWER
Infants' individual responses to the stimulus of reflux and the maturity of their self-
settling skills.
What are some symptoms of gastroesophageal reflux disease (GERD) in infants? -
ANSWER Failure to thrive, food refusal, pain behavior, GI bleeding, upper or lower
airway-associated respiratory symptoms, or Sandifer syndrome.
What are some symptoms of GERD in older children? - ANSWER Regurgitation
into the mouth, heartburn, and dysphagia.
What is a possible complication of GERD in older children? - ANSWER
Esophagitis.
,What diagnostic procedure is required to confirm esophagitis? - ANSWER
Endoscopy with biopsy.
Which children are at increased risk of GERD and esophagitis? - ANSWER
Children with asthma, cystic fibrosis, developmental delay/spasticity, hiatal hernia
(HH), and repaired esophageal atresia—tracheoesophageal fistulas.
What are some extraesophageal manifestations of reflux disease? - ANSWER
Upper airway symptoms (hoarseness, sinusitis, laryngeal erythema, and edema),
apnea or apparent life-threatening events (ALTEs), lower airway symptoms (asthma,
recurrent pneumonia, recurrent cough), dental erosions, and Sandifer syndrome.
What are some warning signs in infants with recurrent vomiting that warrant further
investigation? - ANSWER Bile-stained emesis, GI bleeding, onset of vomiting after
6 months, failure to thrive, diarrhea, fever, hepatosplenomegaly, abdominal
tenderness or distension, or neurologic changes.
What is an upper GI series used for? - ANSWER To investigate anatomic
etiologies of recurrent vomiting, not for diagnosing GERD.
What is the purpose of acid-suppressant therapy in older children with heartburn or
frequent regurgitation? - ANSWER Diagnostic and therapeutic
When should a child be referred to a pediatric gastroenterologist for evaluation of
GERD? - ANSWER If symptoms require ongoing acid suppressant therapy or if
symptoms fail to improve with empiric therapy
What are some nonreflux diagnoses that can present with reflux-like symptoms? -
ANSWER Eosinophilic esophagitis (EoE)
What is the purpose of esophagoscopy and mucosal biopsies in evaluating GERD? -
ANSWER To evaluate for mucosal injury secondary to GERD or nonreflux
diagnoses including EoE
Is endoscopic evaluation necessary for all infants and children with suspected
GERD? - ANSWER No
What are the indications for intraluminal esophageal pH monitoring? - ANSWER
To quantify reflux and evaluate for objective evidence of symptom associations
What is the difference between pH probe and pH impedance probe? - ANSWER
pH impedance probe also measures multiple intraluminal impedance
When may pH impedance studies have a higher diagnostic yield? - ANSWER In
evaluating for respiratory or atypical complications of reflux disease or breakthrough
reflux symptoms while on acid-suppressant therapy
At what age does reflux spontaneously resolve in 85% of affected infants? -
ANSWER 12 months
,What factors coincide with the resolution of reflux in infants? - ANSWER
Assumption of erect posture and initiation of solid feedings
How can regurgitation volume be reduced in infants? - ANSWER Offering small
feedings at frequent intervals and thickening feedings with rice cereal
Is there evidence to support empiric use of acid suppression in infants with
unexplained crying or fussy behavior? - ANSWER No
What is GERD? - ANSWER Gastroesophageal reflux disease, a condition where
stomach acid flows back into the esophagus.
Why may empiric acid suppression not be appropriate in neonates with suspected
GERD? - ANSWER Because careful attention to potential factors leading to
symptoms and/or objective testing is needed.
What are the therapeutic options for treating suspected esophageal or
extraesophageal complications of acid reflux in older infants and children? -
ANSWER Histamine-2 (H2)-receptor antagonists or proton pump inhibitors (PPIs).
What has PPI therapy been shown to do in the treatment of GERD? - ANSWER
Significantly heal both esophageal mucosal injury and symptoms within 8-12 weeks.
What are potential risk factors associated with long-term PPI therapy? - ANSWER
Risk for infection (pneumonia, Clostridium difficile-associated diarrhea) and an
increased risk for osteoporosis in adults.
Are there standardized recommendations for prophylaxis or surveillance for
complications in pediatric patients on long-term PPI therapy? - ANSWER No, but
one should consider weaning or discontinuing treatment if it is no longer required.
Is there sufficient evidence to support the routine use of prokinetic agents for
treatment of pediatric GERD? - ANSWER No.
Is spontaneous resolution likely in older children with GERD and those with
underlying neurodevelopmental disorders? - ANSWER Less likely.
How can episodic symptoms of GERD be controlled? - ANSWER With intermittent
use of acid blockers.
What may be required for those with persistent symptoms of GERD? - ANSWER
Chronic acid suppression.
What are some complications of reflux esophagitis or chronic GERD? - ANSWER
Feeding dysfunction, esophageal stricture, and anemia.
Is Barrett esophagus common in children? - ANSWER No, it is very uncommon.
In which patients may Barrett esophagus occur? - ANSWER Patients with an
underlying primary diagnosis that offers high risk for GERD.
, What does Figure 21-1 show? - ANSWER Esophagitis associated with GERD.
What is the appearance of the mucosa in Figure 21-1? - ANSWER Erythematous
with loss of vascular pattern.
What does the endoscopic view of the esophagus show? - ANSWER Irregular dark
streaks trailing down the inside lining.
Is there a downloadable slide for Figure 21-1? - ANSWER Yes.
Is there a favorite figure for Figure 21-1? - ANSWER Yes.
What is the size of the downloadable slide for Figure 21-1? - ANSWER PPT.
What is antireflux surgery? - ANSWER Surgical procedure to treat GERD.
When is antireflux surgery considered? - ANSWER When medical therapy fails or
has severe complications.
What are potential complications after antireflux surgery? - ANSWER Dumping
syndrome, gas bloat syndrome, retching or gagging, wrap failure.
What are the common symptoms of GERD in infants? - ANSWER Feeding
dysfunction, dysphagia, esophageal food impaction, heartburn.
What should be ruled out before diagnosing Eosinophilic Esophagitis (EoE)? -
ANSWER Other causes for esophageal eosinophilia.
What are the two most common complications of EoE? - ANSWER Esophageal
food impaction and esophageal stricture.
What are the effective treatments for EoE? - ANSWER Elimination of food
allergens or swallowed topical steroids.
What is EoE? - ANSWER Eosinophilic Esophagitis, affects boys, GERD-like
symptoms
What are common initial presentations of EoE in young children? - ANSWER
Feeding dysfunction, abdominal pain, vomiting, regurgitation
What are common symptoms of EoE in adolescents? - ANSWER Solid food
dysphagia, food impactions
When should EoE be considered as a diagnostic possibility? - ANSWER If a child's
symptoms are unresponsive to GERD management
What are some common features of the esophageal mucosa in EoE? - ANSWER
Thickening, mucosal fissures, strictures, rings
