C h a p t e r 2 9
Disorders of Gastrointestinal Function
699
sphincter (e.g., alcohol, chocolate, fatty foods, and heavy
smoking) also cause refluxate, as may central nervous sys-
tem depressants, obesity, pregnancy, hiatal hernia, delayed
gastric emptying, and increased gastric volume. Although
acid damages the esophageal mucosa, the combination of
acid and pepsin many be particularly injurious.
Clinical Manifestations.
The most frequent symptom
of GERD is heartburn. It frequently is severe, occurring
30 to 60 minutes after eating. It often is made worse by
bending at the waist or assumption of the recumbent posi-
tion and usually is relieved by sitting upright. The sever-
ity of heartburn is not indicative of the extent of mucosal
injury; only a small percentage of people who complain
of heartburn have mucosal injury. Often, the heart-
burn occurs during the night. Antacids provide prompt,
although transient, relief. Other symptoms include
belching and chest pain. The pain usually is located in
the epigastric or retrosternal area and often radiates to
the throat, shoulder, or back. Because of its location, the
pain may be confused with angina. The reflux of gastric
contents also may produce respiratory symptoms such as
wheezing, chronic cough, and hoarseness.
8
Diagnosis and Treatment.
Diagnosis of GERDdepends
on a history of reflux symptomatology and selective use
of diagnostic methods, including radiographic studies
using a contrast medium such as barium, esophagos-
copy, and ambulatory esophageal pH monitoring.
8–10
The treatment of GERD usually focuses on conser-
vative measures. These measures include avoidance of
positions and conditions that increase gastric reflux.
8–10
It is recommended that large meals and foods that
reduce lower esophageal sphincter tone (e.g., caffeine,
fats, chocolate) be avoided, that meals be eaten sitting
up, and the recumbent position be avoided for several
hours after a meal. Bending for long periods should be
avoided because it tends to increase intra-abdominal
pressure and cause gastric reflux. Sleeping with the head
elevated helps to prevent reflux during the night. Weight
loss usually is recommended in overweight people.
Pharmacologic treatment includes the use of antac-
ids and inhibitors of gastric acid secretion. Antacids
neutralize gastric acid and are used for rapid relief of
occasional heartburn. Histamine-2 (H
2
)–receptor antag-
onists inhibit gastric acid production. They are available
as over-the-counter drugs and often are recommended
when additional treatment is needed. The proton pump
inhibitors act by inhibiting the gastric proton pump,
which regulates the final pathway for acid secretion (see
Chapter 28, Fig. 28-10). These agents may be used for
persons who continue to have daytime symptoms, recur-
rent strictures, or large esophageal ulcerations. Surgical
treatment may be indicated in some people.
Complications.
Complications of GERD result from
persistent reflux, which produces a cycle of hyper-
emia, edema, and erosion of the mucosal surface of
the esophagus. Esophageal mucosal damage is related
to acidity of the refluxate. These complications include
strictures of the esophagus and a condition called
Barrett
esophagus.
Strictures are caused by a combination of
scar tissue, spasm, and edema. They produce narrowing
of the esophagus and cause dysphagia when the lumen
becomes sufficiently constricted.
Barrett esophagus is characterized by a reparative pro-
cess in which the squamous mucosa that normally lines
the esophagus gradually is replaced by columnar epithe-
lium resembling that in the intestines.
11
The diagnosis
of Barrett esophagus is based on endoscopic evidence of
abnormal mucosa above the level of the gastroesopha-
geal junction and histologically documented intestinal
metaplasia (called
specialized intestinal metaplasia
) that
predisposes to the development of adenocarcinoma.
Gastroesophageal Reflux in Children
Gastroesophageal reflux is a common problem in infants
and children. The small reservoir capacity of an infant’s
stomach coupled with frequent spontaneous reductions
in sphincter pressure contribute to reflux. At least one
episode of regurgitation a day occurs in as many as half
of infants ages 0 to 3 months. By 6 months of age it
becomes less frequent and usually abates as the child
assumes a more upright posture and eats solid foods.
12,13
Although many infants have minor degrees of reflux,
complications such as esophageal damage and second-
ary respiratory disease can occur in children with more
frequent or persistent episodes. The condition occurs
more frequently in children with cerebral palsy, Down
syndrome, and other neurologic disorders.
Clinical Manifestations.
Clinical manifestations of
reflux esophagitis include evidence of pain when swal-
lowing, hematemesis, anemia due to esophageal bleed-
ing, heartburn, irritability, and sudden or inconsolable
crying. Parents often report feeding problems in their
infants.
12,13
These infants often are irritable and demon-
strate early satiety. Sometimes the problems progress to
actual resistance to feeding and failure to thrive. Tilting
of the head to one side and arching of the back may be
noted in children with severe reflux.
12
This head posi-
tioning is thought to represent an attempt to protect the
airway or reduce the pain-associated reflux. Sometimes
regurgitation is associated with recurrent otalgia. The
ear pain is thought to occur through referral from the
vagus nerve in the esophagus to the ear. In some chil-
dren, chronic regurgitation may prompt dental caries.
A variety of respiratory symptoms are caused by dam-
age to the respiratory mucosa when gastric reflux enters
the esophagus. Reflux may cause laryngospasm, apnea,
and bradycardia. Asthma may co-occur with GERD in
about 50% of asthmatic children. Asthmatic children
who are particularly likely to have GERD as a provoca-
tive factor are those with symptoms of reflux, those with
refractory or steroid-dependent asthma, and those with
nocturnal worsening of symptoms.
14
Diagnosis and Treatment.
Diagnosis of gastroesoph-
ageal reflux in infants and children often is based on
parental and clinical observations. The diagnosis may
