Gastroesophageal Reflux Disease (GERD)

Mitchell Cohen

Every adult, at one time or another, has experienced heartburn and that gnawing mid-chest discomfort after a big meal. Maybe you had one too many hot dogs at the ballpark, or maybe your cousin's chili was a bit too hot for you.
But when these symptoms are frequent or can't be attributed to spicy ingredients, it could be gastroesophageal reflux disease (GERD). And it can be a problem not just for adults, but for children as young as newborns. In fact, it's not uncommon for infants to experience the post-feeding vomiting and fussiness of GERD. Most will outgrow the disease without medication, but there are some who will need more aggressive treatment.

What Is GERD?
The burping, heartburn, and spitting up that are associated with GERD happen when acidic stomach contents move backward into the esophagus (called reflux). If the lower esophageal sphincter (the muscle that connects the esophagus with the stomach) relaxes or is weak, it can allow stomach contents to reflux.
More than 60 million adults experience reflux at least once a month, and it's not usually a cause for alarm. Many times, people aren't even aware that they are experiencing reflux.
With GERD, however, reflux occurs more frequently and causes enough discomfort that the person affected is aware of the condition. About 19 million people have GERD. After nearly all meals, a person with GERD suffers heartburn, also known as acid indigestion, which feels like a burning sensation in the chest, neck, and throat.
It's normal for babies to occasionally spit up small amounts of formula or breast milk following a feeding, particularly when being burped or during periods of movement. For babies with GERD, however, breast milk or formula regularly refluxes into the esophagus and sometimes out of the mouth. Sometimes babies regurgitate forcefully; other times they experience something like a "wet burp." Because stomach acid is part of what's refluxed, the esophagus can become irritated, resulting in esophagitis. In some cases, babies with GERD can have choking episodes or develop aspiration pneumonia when stomach contents are refluxed up to the level of the trachea (windpipe) and then into the lungs. Babies with GERD may also experience extended periods without breathing known as apnea. If prolonged, these apneic episodes can be life-threatening.

Signs and Symptoms
Heartburn is the most common symptom of GERD in adults and children, and it can last up to 2 hours and is worse after meals. Those with reflux also may feel like food is coming back up into the mouth, leaving a bitter aftertaste of stomach acid. The symptoms may be worse if a child or adult lies down or if a baby is held in a face-up position after a meal.
Some foods are thought to make GERD worse. Chocolate, peppermint, fried or fatty foods, caffeine, and alcohol may weaken the lower esophageal sphincter. Studies show that smoking may relax the muscle, as may pregnancy (which may explain why many pregnant women experience heartburn). Here are the most common signs that your infant or young child may have GERD:

• pain, irritability, or constant or sudden crying (signs that may be mistaken for colic) after eating
• frequent spitting up or vomiting after eating
• vomiting more than 1 hour after eating
• regular spitting up that continues after the first year, the age when most children grow out of it
• inability to sleep soundly
• "wet burp" or "wet hiccup" sounds
• poor weight gain or weight loss
  

Other, less common signs include:

• constant eating and drinking
• inability to eat certain foods
• refusing food or accepting only a few bites despite hunger
• swallowing problems (such as gagging or choking)
• hoarse voice
• frequent sore throats
• frequent respiratory problems (such as pneumonia, bronchitis, wheezing, or coughing)
• bad breath
• drooling
  

Diagnosing GERD
GERD is often diagnosed by doctors simply taking a good history of the problem. Sometimes a special X-ray called a barium swallow is performed to exclude other causes of vomiting. A barium swallow can also show the refluxing of liquid into the esophagus, and it may show whether the esophagus is irritated or whether there are any physical abnormalities in the upper digestive tract. If your doctor orders this test, your child will be given a small amount of a chalky liquid (barium) to swallow - this liquid will show up on the X-ray.
A more sensitive test called the 24-hour pH-probe study is considered the most accurate way to diagnose reflux. A thin, flexible tube is placed in the esophagus and the tip rests just above the lower esophageal sphincter. The tube is connected to a device that monitors the acid levels in the esophagus. Consistently high acid levels in the lower esophagus indicate the refluxing of stomach acid, as found in GERD.
Another test called a milk scan involves a series of scans that track the journey of a liquid after it's swallowed. A milk scan can show whether a refluxed liquid is aspirated into the lungs.
Upper endoscopy, which involves the direct visualization of the esophagus, stomach, and a portion of the small intestines using a tiny fiberoptic camera, also can be used to diagnose GERD. Biopsies (small pinches of the lining of the esophagus) can be obtained at the time of endoscopy to determine whether there is inflammation due to GERD or whether there are other problems such as allergic esophagitis (inflammation of the esophagus due to allergies) that are causing the symptoms.

Complications of GERD
Most babies outgrow the condition by the time they are 1 year old, and it's uncommon for a child to have GERD beyond age 2. Children with developmental or neurological disorders like cerebral palsy, however, are more at risk for the condition and can experience more severe symptoms. Some children may develop complications as a result of GERD. Because of constant reflux of stomach acid, the esophagus can become red and irritated (esophagitis) . The constant reflux also can be painful, causing a child to refuse to eat. If severe, GERD also can cause bleeding and result in scar tissue that can make it difficult to swallow.
Because a child with GERD loses nutrients from spitting up and also may have a decreased desire to eat, proper nutrition is sometimes a concern. If your child is not gaining weight as expected or is losing weight, talk to your doctor.
Respiratory problems are another possible complication of GERD. If the stomach contents enter the trachea, lungs, or nose, your child can develop breathing problems or pneumonia.

Treating GERD
Although there's no evidence that breast-fed babies spit up less than formula-fed babies or that soy formula is a solution, some babies may benefit from special formulas. Doctors have had more success in recommending that parents slightly thicken their baby's formula or breast milk with rice cereal so that it may cause less reflux. Your doctor may recommend that you try thickening your child's breast milk or formula or that you try a different brand of formula.
Your doctor may also prescribe a medicine to reduce the amount of acid in your stomach.
If medical treatment alone is not successful and your child is failing to grow or develop complications of reflux, a surgical procedure called fundoplication may be an option. Though the procedure may vary, it basically involves creating a valve at the top of the stomach by wrapping a portion of the stomach around the esophagus. In some patients, the fundoplication can be performed using minimally invasive surgery, or laparoscopy.
After surgery, your child may experience a gagging sensation during meals and may feel full more quickly. Also, your child may not be able to burp or vomit.
[AAFP]