Gastroesophageal Reflux Disease (GERD) Concepts

Gastroesophageal Reflux (GERD)

• Refers to the regurgitation of stomach secretions into the esophagus through the lower esophageal sphincter
• Transient lower esophageal sphincter relaxations develop reflux disease
• Dysfunctional lower esophageal sphincter loosens independent of swallowing and has a decreased ability to constrict, allowing stomach contents to regurgitate back into the esophagus due to sphincter insufficiency

Gastroesophageal Reflux (Infant)

• Occurs due to the immaturity of the lower esophageal sphincter, allowing easy regurgitation of gastric contents into the esophagus
• Typically starts within 1 week after birth and may be associated with a hiatal hernia
• Complications of GERD in infants include:
  • Irritability
  • Failure to thrive
  • Esophagitis
  • Aspiration pneumonia
  • Wheezing
  • Apnea

Diagnostic Assessment

• Upper GI series: to look for anatomical abnormalities such as intestinal malrotation
• pH probe: to calculate the amount of acidic reflux into the esophagus in a 24-hour period
• Esophageal manometry: to assess esophageal motility and ensure normal esophageal peristalsis
• Endoscopy: to obtain biopsies and assess the degree of esophagitis

Assessment Findings

• Vomiting
• Irritability
• Periods of apnea
• Difficulty swallowing
• Regurgitation of food or sour liquid

Therapeutic Management (Infant)

• Feed infants a formula thickened with rice cereal
• Hold infants in an upright position and keep them upright for at least 30 minutes post-feeding
• Avoid placing infants in car seats at home
• Avoid tight clothing and diapers
• Avoid exposure to cigarette smoke
• Breastfeeding mothers may need to eliminate dairy from their diet or try a hypoallergenic formula for 2 weeks
• Ranitidine (Zantac) or omeprazole (Prilosec) may be prescribed

Surgical Management

• Laparoscopic or surgical fundoplication: wrapping the upper portion of the stomach (fundus) around the lower esophagus to prevent regurgitation of stomach contents
• Nasogastric tube in place after surgery to assess drainage, color, and patency

Gastroesophageal Reflux (Children and Adolescents)

• Young children may present with vomiting
• Older children and adolescents may have similar symptoms to adults
• Chronic reflux can lead to erosion of the esophagus with perforation or stricture
• Certain conditions, such as cerebral palsy, Down syndrome, cystic fibrosis, and obesity, can increase the risk of GERD

Therapeutic Management (Children and Adolescents)

• Avoid lying down until 3 hours after a meal
• Sleep at night with the upper body elevated on a foam wedge or extra pillow
• Avoid acidic foods, fatty foods, chocolate, or alcohol
• Eat smaller portions
• Lose weight if overweight
• Avoid bending over after meals
• Remove tight belts

Pyloric Stenosis

• A condition in infants that blocks food from entering the small intestine
• Hypertrophy or hyperplasia of the muscle surrounding the sphincter occurs, making it difficult for the stomach to empty
• Normally, a muscular valve (pylorus) between the stomach and small intestine holds food in the stomach until it is ready for the next stage in the digestive process
• In pyloric stenosis, the pylorus muscles thicken and become abnormally large, blocking food from reaching the small intestine
• Incidence: 1:150 in males and 1:750 in females, most frequently in first-born White male infants

Assessment Findings (Pyloric Stenosis)

• Vomiting after feeding
• The baby may vomit forcefully, ejecting breast milk or formula