Clinical Presentation of GERD

Clinical Presentation In older children and adolescents, subjective symptomatol-ogy is the most common form of presentation to the physician . However, childhood development and communica-tion renders descriptions of symptoms unreliable in children younger than 8–12 years of age. Furthermore, many of the typical symptoms of GERD are non-specific and can vary greatly with age. In contrast, most adolescents are able to describe their symptoms and to determine how troublesome they are.( Nelson SP, et al ,2009)Consequently, a thorough history and physical examination may be sufficient to make a diagnosis of GERD in the older child and adolescent age group without the use of other investigations. (Gold BD., 2004)

In adults, two symptomatic reflux syndromes have been defined: typical reflux syndrome and reflux chest pain syn-dromeTypical reflux syndrome is defined by the presence of troublesome heartburn and/or regurgitation, but patients may have additional symptoms such as epigastric pain or sleep disturbance. In contrast, reflux chest pain syndrome is defined as episodes of chest pain resembling cardiac ischemic pain without accompanying heartburn or regurgitation. In the pe-diatric population, there is now consensus that a symptom-based diagnosis of typical reflux syndrome can similarly be made in neurologically intact adolescents and children over the age of approximately 8 years who have the cognitive ability to provide a reliable report of their symptoms.( Vakil N,, et al , 2006)

Other reflux syndromes in children include the presence or absence of esophageal mucosal injury and/or extra-esophageal manifes-tations of disease. Diagnosis of these disorders, as well as the ‘functional gastrointestinal disorders’, generally require more specialized investigations, including upper gastrointestinal endoscopy; therefore, referral to a pediatric gastroenterologist should be sought. .( Vandenplas Y,, et al ,2009)

In making a symptom-based diagnosis of GERD, it is im-portant that rumination is considered and excluded Rumi-nation syndrome, according to the Rome III criteria, is the repeated painless regurgitation and re-chewing or expulsion of food in the absence of retching and any inflammatory, meta-bolic, anatomical, or neoplastic process that may otherwise explain the symptoms. A further important distinguishing fea-ture from GERD is the absence of symptoms during sleep. Chronic cough is a symptom that is often listed as an extra-esophageal complication of GERD, although in the pediatric population this remains controversial. A Cochrane review has concluded anti-reflux treatment to be of no efficacy in cough outcomes in infants and insufficient evidence exists to support treatment in older children.( Mosby I., 2009)

Other presenting complaints may suggest alternate diagnoses or complications of GERD and should be investigated further and referred on to specialist services when appropriate . In particular, the sensation of dysphagia or bolus food obstruction should raise the possibility of eosinophilic esophagitis and, if PPI therapy proves non-effective, referral should be made to a pe-diatric gastroenterologist for further evaluation. .( Harnett KM, et al , 2010)

Some children are at particularly high risk of developing GERD and its more severe complications. These include chil-dren with neurological impairment, neuromuscular disease, certain genetic disorders, certain congenital abnormalities, and others.( Harnett KM, et al , 2010)

In particular, many of these children will develop severe and chronic GERD; therefore, early in-volvement of a pediatric gastroenterologist is recommended.