In this episode of PEM Currents: The Pediatric Emergency Medicine Podcast, I explore the complexities of gastroesophageal reflux (GER) and gastritis in children and adolescents. I’ll make the important distinction between gastritis – which is diagnosed only via endoscopy – and dyspepsia, the term best used to describe the symptoms many patients experience. I’ll dive into the latest clinical practice guidelines and discuss evidence-based approaches to diagnosis and treatment.

Topics covered include:

The pathophysiology of GER and GERD in the pediatric population.
Understanding dyspepsia and its clinical presentation.
Diagnostic strategies and when to consider further evaluation.
The role of lifestyle and dietary modifications in management.
Pharmacological interventions, including the use of proton pump inhibitors (PPIs), H2 blockers, and antacids.
Current controversies and updates in pharmacological treatments.
Management of gastritis and the consideration of Helicobacter pylori infection.

Join me as I scope out the nuances of gastroesophageal reflux and gastritis and provide practical insights for clinicians in the emergency setting.

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References

Rosen R, Vandenplas Y, Singendonk M, et al. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2018;66(3):516-554. doi: 10.1097/MPG.0000000000001889

Lightdale JR, Gremse DA; Section on Gastroenterology, Hepatology, and Nutrition. Gastroesophageal Reflux: Management Guidance for the Pediatrician. Pediatrics. 2013;131(5):e1684-1695. doi: 10.1542/peds.2013-0421

Tighe M, Afzal NA, Bevan A, et al. Pharmacological Treatment of Children with Gastro-oesophageal Reflux. Cochrane Database Syst Rev. 2014;2014(11):CD008550. doi: 10.1002/14651858.CD008550.pub2

Sintusek P, Mutalib M, Thapar N. Gastroesophageal Reflux Disease in Children: What’s New Right Now? World J Gastrointest Endosc. 2023;15(3):84-102. doi: 10.4253/wjge.v15.i3.84

Transcript

Note: This transcript was partially completed with the use of the Descript AI

Welcome to PEMCurrents, the pediatric emergency medicine podcast. As always, I’m your host, Brad Sobolewski, and today’s episode will focus on gastro esophageal reflux and gastritis in children and adolescents. Both conditions can present with similar symptoms. They do, though, have distinct pathophysiologies and management strategies.

So we’re going to discuss the evidence based approaches to diagnosis and treatment, and I will talk about why it is presumptive to call things gastritis before definitive diagnosis, even though I put it in the title of the episode. Alright, let’s scope things out. I’m going to begin by making a brief distinction between gastroesophageal reflux and gastroesophageal reflux disease.

So, reflux itself is a common physiologic process, especially in infants, that usually resolves by 12 to 18 months, when the gastroesophageal sphincter gets tighter, and kids spend more of their life on it. upright. Gastroesophageal reflux disease is when the patients have severe symptoms that persist and cause long term issues.

Now, either way, this is due to reflux of the stomach contents into the esophagus. Now, gastroesophageal reflux is incredibly common in infants with up to 50 percent of b cells. babies under three months regurgitating daily. This typically peaks at about four months of age and improves as the infant grows.

Gastroesophageal reflux disease is less common, but still affects about 10 percent of children and up to 10 to 20 percent of adolescents. Adolescents with GERD often present similarly to adults with heartburn and regurgitation as the primary complaints. Now there are some risk factors for GERD.

Gastroesophageal reflux and reflux disease in children. A main one is neurological impairment. So kids with cerebral palsy or other neurologic disorders have delayed gastric emptying and poor esophageal motility, increasing the risk of GERD. Children with respiratory conditions and chronic lung disease like asthma are more prone to GERD as well.

And reflux itself can exacerbate the existing respiratory symptoms either through microaspiration or vagal mediated bronchospasm. Prematurity and congenital conditions like esophageal atresia also obviously increase the risk. So gastroesophageal reflux and reflux disease result from transient relaxation of the lower esophageal sphincter.

That allows acidic gastric contents to flow back into the esophagus. Now, the lower esophageal sphincter is supposed to prevent this reflux from happening. In GERD, the sphincter relaxes too frequently or incompletely, which can lead to symptoms building up over time. Other factors like delayed gastric emptying and abnormal esophageal motility can worsen problems in general.

And the presentation for GERD varies by age. Infants will have frequent spitting up or vomiting after feeds, irritability during or after feeds, especially in the more significant cases where the esophagus is irritated. Uh, infants may start to refuse to feed due to the discomfort. They can have poor weight gain or even failure to thrive in more severe cases.

And they can have Sandefur syndrome, which is the arching of the back and dystonic posturing that occurs during or after feeds as a response to discomfort from acid reflux. This is sometimes misidentified as seizures. In older children and adolescents, heartburn is the most common symptom. It’s a burning sensation in the chest or epigastrium, and that is the classic symptom in this age group.

You can also see regurgitation, acid or food regurgitating into the mouth, leading to a sour taste. uh, ill defined epigastric or chest pain, and it’s often worse by eating or lying down after meals. And some other symptoms that you gotta think about in reflux, chronic cough, hoarseness, or even asthma like symptoms.

These extra esophageal manifestations can occur due to irritation of the upper airways by the gastric contents. Now, in the pediatric emergency department, the diagnosis of reflux is primarily clinical. You just got to take a good history and do a physical examination, especially when the symptoms are typical, like regurgitation, heartburn, or epigastric pain in an older child or adolescent.

You want to take a good history on feeding or dietary habits. In infants, you want to know the amount and frequency of feeding, especially because baby stomachs are small and no newborn stomach can hold six ounces. So, the parents may say, well, he Doesn’t ever seem full. Well, baby doesn’t know how to be full.

So really, you need to learn how much a baby can take and follow weight gain appropriately. Overfeeding a baby will lead to increased spitting up and reflux. You should also ask about older children and adolescents eating trigger foods like spicy things, caffeinated beverages, and acidic beverages like pop.

These can all exacerbate reflux. You want to ask about nocturnal symptoms. So if the kid has symptoms that are worse at night or immediately upon waking up, this may indicate reflux exacerbated by lying down, especially after meals. Red flags that you should always ask about include hematemesis, melana, dysphagia, and Unintentional weight loss, these all need further investigation for complications like esophagitis or another diagnosis such as EOE or peptic ulcer disease.

If any of those red flags are present, you should definitely consider a further diagnostic workup. Again, otherwise the diagnosis is based on history and physical examination. So if you see failure to thrive or poor weight gain, again, vomiting blood or passing black tori stools, signs of esophagitis such as painful swallowing or difficulty swallowing.

They need more workup often via GI. So diagnostic testing centers around endoscopy. That’s the gold standard and ultimately getting a camera in there. Taking a look for strictures or ulcers and taking a biopsy of the esophageal and gastric mucosa will make the diagnosis and evaluate for other things like eosinophilic esophagitis or helicobacter pylori infection.

Also get a pH monitoring and impedance probe. This measures both acid and non acid reflux events. It’s kind of like a Holter monitor for reflux. This is obviously ordered by a gastroenterologist, but But the probe itself measures reflux, and then the patient can press a button for an event monitor. And this is particularly useful in children with atypical symptoms or extra esophageal manifestations like cough or asthma, and especially in those that have had a norma...