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Childrens Medical Office
of North Andover, P.C. |
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Introduction
A baby who spits up too
much
a toddler or child with chronic cough
a child with frequent belly pain and poor appetite
a teenager or adult with heartburn
or excessive appetite...
It may seem strange, but all
these things and more can be caused by the same problem: Gastroesophageal Reflux Disease
(GER or GERD). GER is also sometimes referred to as Acid Reflux, Reflux Esophagitis, or
Hiatal Hernia (although the last term is inaccurate for reasons which will be explained
below). GER is fairly easy to treat/control, but it is sometimes very difficult to
diagnose. In this article, I will explain what GER is, when and how it occurs, how it can
be treated, and many of the difficulties involved in its diagnosis.
GER is a very
common disorder in all age groups. It results from a loose or incompetent lower esophageal
sphincter allowing acid contents of the stomach to splash upwards into the esophagus.
This
causes pain, inflammation, spitting up, or even aspiration into the lungs.
These effects
can, in turn, lead to further complications such as esophagitis, growth failure, or
chronic lung disease. GER occurs in two general forms - an infant form which is usually
benign and outgrown, and an acquired form which can start at any time later in life that
is usually not so benign. There are many approaches to treatment, and these must be
individualized for each patient. Diagnostic tests are not always necessary and no one test
is "best". They all have pros and cons. Thus, diagnostic work-up must also be
individualized. Symptoms of GER should not be ignored except in young babies who are
growing well, developing normally, and seem otherwise healthy. Symptoms of GER should
always be brought to the attention of your physician.
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What is GER?
GER is a loose and/or leaky
lower esophageal sphincter (LES).
A sphincter is a ring of
muscle. There are many sphincters in your body, most of which you are unaware of because
they are deep inside and not under voluntary control. The sphincter you are most likely to
be familiar with is the anal sphincter, which controls defecation, because it is under
(partial) voluntary control.
Sphincters are special, not
just because they are rings, but also because, unlike virtually all other muscles, they
remain contracted all the time until relaxed for a purpose (in contrast, your biceps or
hamstrings remain relaxed until contracted for a purpose). This makes sphincters function
like "doors" in the passageways of your body. They stay closed until they open
to let something pass, then close again.
One such sphincter
"lives" at the lower end of the esophagus, the tube leading from the mouth to
the stomach. It controls the passage of food & drink from the esophagus into the
stomach. It's opening is the involuntary final step in the swallowing reflex which began
under conscious control a second or two earlier in the mouth as a movement of the tongue
and palate. It continues as an involuntary wave of contraction through the esophagus
pushing the food forward, and finishes as a relaxing of the LES to allow the food to pass
into the stomach. Once the food has passed, the LES is supposed to snap shut again.
The LES can be thought of as
either the exit from the esophagus or the entrance to
the stomach. It's both. Normally, a
closed LES prevents stomach contents from flowing backwards into the esophagus. This is
important because the contents of the stomach are usually quite acid. The lining of the
stomach is designed to withstand such acidity, but the lining of the esophagus is not. If
acid gets into the esophagus, it burns. This is immediately painful, can cause tissue
breakdown and inflammation over time, and eventually lead to scarring, narrowing, and even
cancer of the esophagus (although the latter is something that virtually never happens in
childhood because it takes so long to develop).
In persons with GER, the LES
doesn't work right. Either it is too weak (or loose) to hold the stomach contents in
(remaining partially open all the time), or it intermittently spasms and relaxes when it
is not supposed to. This allows the acid contents of the stomach to move upwards into the
esophagus. Sometimes the reflux goes only a little way up, and sometimes it comes all the
way up and out the mouth. The latter is more likely in a small baby. Beyond spitting up,
the symptoms of GER vary by age, degree of acid production, height of the reflux,
frequency of the reflux events, and what other medical predispositions or illnesses
the individual may have.
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Symptoms of GER
There are many symptoms of
GER, and all of them can occur (in slight variations) at all ages. Unfortunately, many
other diseases can also cause all the possible symptoms, so no one symptom tells you with
certainty that GER is what you are dealing with. The most common symptoms include:
- Regurgitation
-
this is the obvious one, "spitting up" or a sour taste in the back of the
throat. Unfortunately, not everyone with GER has it because it only happens when the
refluxed material is coming "all the way up".
- Pain -
the
"classic" pain of GER is "heartburn" but this is by no means the only
kind of pain people experience, and children younger than about 8-9 years are not able to
describe their pain well enough to be sure what they are experiencing is heartburn or not.
- Cough -
people
cough with GER for two reasons - one is a "reflex" which exists between the
nerve endings of the lower esophagus and the lungs, and the other can be if they are
directly aspirating (refluxed material getting into the windpipe itself). See below for a
discussion of the relationship between asthma and GER.
- Poor Appetite/Poor growth -
it's easy to
understand how having abdominal discomfort all the time might suppress your appetite, but
that's not the only reason people with GER don't eat. They also may "learn" that
keeping their stomach less full results in less pain. Unfortunately in a child, this can
effect growth. In a baby poor growth may also come from direct loss of nutrients if the
spitting is severe.
- Excessive
Appetite -
this may seem paradoxical, but it happens. The reason seems to be that
food itself often has an acid neutralizing effect, and eating can temporarily relieve the
discomfort.
- Bleeding
-
if GER becomes severe enough to cause esophagitis, blood can appear in the stool. Most
often it is microscopic and cannot be seen with the naked eye, but sometimes the bleeding
is severe enough that visible blood is present. In a baby it may be bright red, as you
expect. In an older child or adult it will more likely show up as "melena", a
black colored stool which comes from "digested" blood.
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Two Types of GER
There are generally two types of GER,
"congenital" and "acquired".
Congenital GER
is something a baby is born with and,
in fact, it is probably normal. We say this because only a minority of babies have
a fully "competent" LES at birth. The LES tends to be not fully developed by
birth, and allows some degree of reflux in more than 80% of newborns.
The amount of initial GER
seen in any particular infant can vary from mild to severe, but because the LES
grows/matures steadily throughout the first year of life, congenital GER is usually
outgrown by 12 months of age. Unfortunately, this is not always the case. About 2% of
children with congenital GER never outgrow the problem. Those who have not outgrown it by
one year of age are unlikely to ever do so. When congenital GER isn't outgrown by one year
it becomes very similar to acquired GER in it's symptoms, course, and treatment.
Because of the above, it
would be ludicrous to say that all spitty babies have a "disease" called GER. In
infancy, therefore, the challenge is defining the "border" between what
constitutes "normal" vs. "abnormal" GER. Defining that boundary is
difficult and controversial. There are no universally agreed upon standards. Generally,
however, there are two practical ways of approaching the issue:
One approach is to call "abnormal" (and therefore treat) whatever degree of GER causes distress for the family and results in visits to
the doctor. Two babies with the exact same amount of spitting might be treated differently depending on the perceptions of their parents. This is not very sensible or satisfying from a scientific standpoint, and
has the downside of labeling as "abnormal" a child who may in fact be normal, but it is an easy & practical way to practice medicine because
it usually satisfies families and does no harm.
A second approach, more
scientifically rigorous & intellectually correct, is to define objective criteria for when GER becomes a problem for a baby.
Such criteria might include poor growth, bloody stools, more forceful
vomiting, pneumonia, wheezing, or other evidence of aspiration (stomach contents spilling into the windpipe, thus effecting the lungs). It should also
include failure to outgrow the problem by 12 months of age. The problem with this approach is that it leaves out pain. Pain is very hard to assess in
the child under one year of age. In order to do so, we usually depend on parental perceptions. When pain is added to the list, however, the two
approaches start to look functionally equivalent. Hence, the controversy.
Acquired GER
is simply an LES which becomes loose
(incompetent) after having previously been tight (competent). This can start at any age
from childhood on into adulthood, and indeed is most common among adults middle aged and
beyond. When a child appears to "acquire" GER at an early age (toddlerhood or
early elementary school) one always suspects they really had congenital GER that was never
"fully" outgrown but is only now being recognized. This may be particularly
likely if the congenital GER was mild and therefore did not result in a lot of spitting up
at the time. In any case, because they are treated similarly, the distinction does not
really matter much.
The reasons why a previously
competent LES becomes incompetent at an older age are not fully understood, although there
are many contributing "risk factors" we know about. These include:
- Obesity
- Asthma (especially if poorly
controlled)
- Smoking or Drinking
- Neurologic problems (especially
those that decrease muscle tone or activity level)
- Stress/Emotional upset.
When several of these risk
factors combine, it can "tip you over the edge" into GER. Any of them alone can
make GER worse in someone who already has it.
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Establishing the Diagnosis
There is no single test that
easily and unambiguously proves whether or not you have GER. Often the diagnosis can be
correctly suspected just based on one's history of symptoms, however. When the symptoms
are highly suggestive of GER, and other disorders (see below) seem unlikely, it is not
unreasonable to begin treatment (and continue it if effective), without doing any tests
at all.
Tests may be necessary when
symptoms are subtle, atypical, or when other diagnoses are being considered as
possibilities along with GER. The available tests include the following:
- pH probe - This is the best test, but it is rather
invasive and unpleasant. A tube is placed down the nose into the esophagus. It has a
sensor on the end that measures acidity. An x-ray is taken to make sure the end of the
probe is in the right place (lower esophagus), and then the pH is recorded continuously
for 12 or 24 hours. This is usually done in the hospital, especially in pediatrics, and so
often requires elective hospital admission. We can thus see how often, to what degree, and
for how long the lower esophagus becomes more acidic than it should be. A negative pH
probe "rules out" GER more reliably than any other test, except in very young
babies. Under 3 months of age an infant's stomach contents may not be acid enough to
trigger the probe (or cause pain). A pH probe also allows us to do a better job of rating
the severity of the GER than any other test.
- Endoscopy
- This is the most invasive and
unpleasant of the available procedures, and it is not fool-proof since someone with mild
reflux, or reflux of recent onset, might still have an entirely normal endoscopy.
Nonetheless, endoscopy has numerous advantages, especially in long-standing reflux. During
an endoscopy, a doctor looks through a sort of "telescope" into the esophagus
and stomach. This allows us to see the degree of inflammation in the lower esophagus as
well as directly look at the LES to see if it is open or closed at rest. It also allows us
to take biopsies (small specimens) of the lining of the stomach and esophagus looking for
inflammation on a microscopic level and other abnormal cells. This can be important in
judging the long term consequences of GER.
- Upper GI Series
("Barium swallow") -
This
is the oldest, simplest, least invasive, but also least accurate test. Unlike pH probe
& endoscopy, which both require a GI specialist, the UGI can be ordered by any primary
care physician. During this test, a child swallows a liquid which can be seen on x-ray.
X-rays are then taken over several hours to see where the material goes. In particular, it
can be seen whether, once in the stomach, it refluxes back up into the esophagus or not.
The reason an UGI is not very accurate is that "false negative" and "false
positive" results are both common. In other words, someone with a negative UGI might
still have GER, and reflux seen during an UGI is not necessarily abnormal (especially in a
baby) or the cause of the symptoms which led to the study. The major advantage of an UGI
series is that, unlike a pH probe, it is able to diagnose other problems beyond GER. In
particular, it is quite good at identifying anatomic problems like strictures, abnormal
passageways, or an unusual intestinal "roadmap". While these things are rare,
their symptoms can mimic GER and it is good to rule them out.
The bottom line is that there
is no one diagnostic work-up or protocol that is necessary in all patients for the
diagnosis of GER. The approach needs to be individualized for each patient by a physician
who understands the disorder. In some cases, the diagnosis can be made clinically with no
tests whatsoever. In other cases, all three of the above tests will be needed, or perhaps
any subset thereof.
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Natural (Non-Medical) Treatments
There are several very simple non-medical
things which can be done to help GER.
- Trigger
Reduction:
The most
straightforward way to deal with GER is to remove the things which exacerbate it. This is
particularly true in the older child or adult with the disorder. Bringing asthma under
better control is a good idea. Attempts at reducing the stress in ones life or
dealing with psychological problems are always useful. Attempts to lose weight may be in
order. Giving up alcohol, caffeine,
or nicotine can also be helpful if these things exacerbate the
disorder. Getting more sleep and exercise can also help.
- Thickened
Feeds:
In small babies,
thickening the feeds is often a useful strategy to lessen GER. This is usually done by
mixing rice cereal with formula - the typical amounts are 1-2 tsp. per four ounces of
formula. Sometimes this requires enlarging the hole in the nipple to allow the formula to
flow afterwards, but the thickened formula seems to stay in the stomach better with a
slightly loose LES, especially when the GER is mild. Thickening feeds is more difficult to
accomplish in a breast-fed baby. Sometimes an early introduction of spoon-fed cereal given
just after a nursing can have the same effect.
- Anti-Reflux
positioning:
Pay
attention to the position of the body, especially in the first 30-60 minutes after a meal.
Pressure is more important than gravity. One wants to avoid positions that place undue
pressure on the stomach. The worst position possible is an upright, sitting, hunched
forward one (e.g. car seat, infant swing). Even though gravity would seem to be in the
right orientation in that position, the flexed spine involved puts a great deal of
pressure on the abdomen, squeezing it and making reflux quite likely. The best position is
prone (face down) on a slight incline. Prone is better than supine (face up) because the
back is more extended and, therefore, the abdomen is stretched and has less pressure. The
incline provides a slight assistance with gravity. Sometime this position can be achieved
lying on a parent's chest, but it is important to make sure the babies knees are not
flexed up underneath them, which defeats the goal of extending the spine. Indeed, the
"ultimate" anti-reflux position is the so-called "reflux hammock"
(used more commonly in the days before medications were available). In this, the child was
literally placed in a hammock in a prone position, producing hyperextension of the spine
and taking virtually all pressure off the abdomen.
- Don't Rock-the-Boat:
It may seem obvious, but is worth
stating, that bouncing and jostling a baby with GER just after a feed is not a good
idea.
- Burping:
Many parents of babies with GER find
that adhering to a particular burping routine seems to minimize the degree of spitting up.
There is no science behind this and every baby is different. Indeed, some babies seem to
spit up more if they are burped, rather than less. Trial and error will help a parent
discover what sort of burping routine works best for their child, however.
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Medical & Surgical Treatments for GER
There are now numerous
medications available to control GER. The same medications are used (in different dosages)
for both adults and children. There are two broad categories of medication: those that
work by reducing stomach acidity; and those that actually reduce the refluxing itself. The
latter work directly by increasing LES tone, and also indirectly by speeding up the
process of food moving beyond the stomach into the intestines, so that there are less
stomach contents to be refluxed to begin with. The latter category is theoretically
preferable to the first because it gets to the "root of the problem". However,
this group of medications also tends to have more risks and side effects than the first
group does. In practice, because they work by different mechanisms and because neither
medicine is a "complete cure", many patients require treatment with both types
of medications simultaneously to achieve optimal control.
Antacids:
- Acid Neutralizers:
The oldest kind of antacids are acid neutralizers. These
drugs react chemically with the acid in the stomach to remove it's acidity. Most of these
are available over-the-counter and include things like Tums, Rolaids, Maalox, Mylanta,
AlkaSeltzer, Riopan, and many others. The active ingredients in these medicines usually
include some combination of calcium carbonate, magnesium hydroxide, and aluminum
hydroxide. Although they are good for short-term use, and are very effective with a rapid
onset of action (usually within minutes), they are not ideal for long-term chronic
treatment for several reasons. First, their effects tend to wear off rapidly so frequent
dosing is necessary. Second, the calcium containing versions can lead to calcium over
dosage and predispose to kidney stones. In contrast, the aluminum and magnesium hydroxide
containing versions of these medications can actually leach calcium out of the bones,
causing Osteoporosis, when used over the long term. Also, these medications can often
cause constipation. Therefore, we generally recommend using acid neutralizers when only
occasional treatment is needed. We avoid them for long-term chronic use. The other
situation in which acid neutralizers can be helpful is as a "test". Because the
onset of action is so rapid, it is quite useful to see if they are effective in treating
abdominal pain when it is not clear what the cause of the abdominal pain is. A rapid
response to an acid neutralizer is our tip-off that the pain has something to do with
acid.
- Acid Blockers:
In contrast to an acid neutralizer, acid
blockers work by preventing acid from being produced in the first place. Most acid
blockers work by blocking the histamine-2 "H2" receptor in the stomach. These
are "antihistamines", but different than anti-allergy medicines (which block the
H1 receptor). A few acid blockers work by a different mechanism - blocking the uptake of
hydrogen into stomach lining cells (a necessary first step in acid formation).
H2 blockers
include such things as Zantac, Tagamet, and Pepcid. Many of these are now available in
over-the counter forms, although liquid forms in pediatric doses are still prescription
only. The only hydrogen uptake blocker commonly used in children is Prilosec, a prescription
medicine (adult medicines in this class include also Prevacid, Protonix, and
Nexium - which may sometimes be used in teenagers). All of the acid blockers tend to be well-tolerated, with very few side-effects.
None of them have any particular medical advantage over another, although Zantac is the
one given to children the most commonly over the years. These are generally considered to
be the acid-treatment of choice if long-term chronic therapy is needed.
Pro-motility
Agents: Pro-motility agents act by helping things move through the stomach more
quickly. They stimulate the stomach to do its work faster. Some also affect the LES,
increasing it's tone, thus helping reflux directly. There is are really only one
of these
available - Reglan (Metaclopromide). Not long ago another pro-motility
drug, Propulsid (Cisapride) was removed from the market because of it's tendency
to interact with many
other commonly prescribed medicines. Reglan is a much older medicine than
Propulsid, and does not share it's drug interactions. Unfortunately Reglan
can have many side effects and does not work as well as Propulsid did. The
worst side effect of Reglan can be a tendency to produce severe muscle spasms that can come on quite suddenly. This can be quite
frightening and really necessitates stopping the medication. Fortunately, however, this
side effect can be acutely treated using Benadryl. Because of these problems we tend to use pro-motility agents as a second line intervention,
only after acid controlling drugs alone have failed. This
may change in the future, however, if a pro-motility agent as effective
as Cisapride was but without it's drug-interactions or the side effects of Reglan can be found.
SURGICAL TREATMENT:
When all else fails, there is
an operation to correct GER. The decision to take this step is never taken lightly. It is
major surgery with significant risks, and it is not always 100% effective. It is usually
helpful to some degree, however, in cases unresponsive to medications. The surgical
procedure is called a fundoplication or sometimes a "Nissen" - after the surgeon
who originally designed the procedure. It involves making an incision in the abdomen and
taking the upper part of the stomach and essentially wrapping it around itself to tighten
the area.
One of the biggest problems
with a Nissen is that the LES can end up so tight that food cannot pass through from above
in normal swallowing. The child may therefore be unable to eat by mouth and require a tube
through the abdomen straight into the stomach. Sometimes this result is actually desired
(e.g. a neurologically impaired child who does not swallow properly to begin with, and
therefore chokes and gets recurrent pneumonias while eating). A surgeon experienced in
this procedure can try to control exactly how tight he makes it during the operation -
allowing for oral feeding when that is desired and not allowing for it when it is not
desired. This is an inexact science, however, and things do not always turn out as
planned.
Another unfortunate
consequence of fundoplication is retching. The child cannot vomit. Thus, if they get a
stomach flu that would normally cause vomiting and diarrhea, after a fundoplication you
may have retching and diarrhea instead.
It is possible to reverse a
fundoplication, although this is another difficult operation. Overall, fundoplication
should be considered a last resort. It should be done only when all other treatments have
failed, and only when the GER is severe enough that it cannot be tolerated - for instance
if a child is not gaining weight, or is having recurrent aspiration pneumonias. Children
whose GER is associated with neurologic damage meet the above criteria much more often
than normal children do.
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Diseases Which May Mimic or be Confused with GER
Newborn Diseases:
In infancy, many things can cause a spitty baby
other than GER. Most are rare and fall into the category of anatomic abnormalities
(i.e. the plumbing either isn't laid out right or it has blockages). Two other problems
can also masquerade as GER, however, but are distinguished from it by the fact that they
get worse over time and progress into full-fledged vomiting rather than just spitting up.
The first of these is hydrocephalus (water-on-the-brain). If hydrocephalus is
present usually the head will be growing too rapidly, the "soft spot" will
bulge, the eyes may seem to be looking downward all of the time, and the baby will fail to
achieve developmental milestones on time. None of those things happen with GER. The second
thing is pyloric stenosis. This is another "sphincter disorder", but
instead of a stomach entrance which is too loose, pyloric stenosis occurs when the stomach
exit is too tight. Children with pyloric stenosis will have increasingly severe vomiting
which may begin as spitting up, but eventually progresses into projectile vomiting which
literally "shoots across the room". Pyloric stenosis can be diagnosed with an
ultrasound or an UGI series and requires surgery to correct.
Asthma:
The relationship between Asthma & GER can be
maddening - to parents, patients, and doctors alike. That's because it's a two-way street
- both diseases exacerbate each other. It can be very hard to know what came first, the
chicken or the egg (the GER or the Asthma). Here's how it works: the lower esophagus has
nerve endings which, when irritated, send a signal to the brain which in turn reflexively
signals the lungs. The lungs respond by constricting airways and coughing. This reflex
probably evolved as protection against choking & aspiration, but coughing and
constricted airways are the hallmarks of asthma. An asthmatic lung (one with constricted
airways) expands. Air gets trapped inside and it hyper-inflates to a bigger size. This
pushes down on the diaphragm, increases pressure in the abdomen, and makes any tendency
towards GER worse. Thus, one question which "haunts" the care of any asthmatic
is whether "silent" GER could be a contributing factor, and whenever cough
accompanies other symptoms of GER the question of whether it is "just" the GER
or whether there is a separate, independent component of asthma must also be considered.
The only sure thing is that when both are known to coexist in the same patient, it is
important to treat both simultaneously in order to control either one.
Hiatal Hernia:
It used to be thought that GER and Hiatal Hernia
were the same. We now know this is false. Hiatal Hernia is the term we use when a part of
the stomach is in the chest cavity, rather than the abdomen, and what actually passes
through the diaphragm is the upper stomach rather than the lower esophagus. This can be
seen on x-ray. It was once thought that everyone with a Hiatal Hernia must have GER and
vice-versa. We now know that the two findings are totally separate and neither one causes
the other. It is possible to have both, but lots of people with Hiatal Hernias at all ages
do not have symptoms of GER, and lots of people with GER do not have Hiatal Hernias.
Hiatal Hernia in the absence of GER, however, is probably a variant of normal and does not
need treatment.
Peptic Ulcer Disease (PUD):
Ulcers are discrete "sores" on the
stomach or intestinal lining. They are painful and can become progressively deeper. When
deep enough, they can bleed severely. Ulcers usually happen in the stomach or in the first
segment of the small intestine, just beyond the stomach. They are thought to occur as a
result of excess stomach acid. In that way, they are related to GER, but in GER you have
an incompetent LES allowing the acid to into the esophagus, which isn't built to handle
it. In contrast, in PUD the LES works fine, but the stomach & intestinal lining (which
should be able to) can't handle the amount or strength of acid being produced.
Fortunately, PUD rarely happens in childhood. When it does, it tends to be in late
adolescence and in families with a very strong history of the same. Therefore, most of the
time, this is a disease we do not have to worry about as pediatricians.
Esophagitis
is inflammation in the esophagus. GER is the
most common cause, but not the only one. Esophagitis happens in children and adults of all
ages, and can come from various infections, food allergies, chemical irritants, foreign
bodies, and sometimes just appears for no reason at all. A very inflamed esophagus,
regardless of the cause, can bleed, develop strictures (narrowing), or eventually lead to
cancer. Blood in the stool is a sign of esophagitis, but in an adult or older child this
needs to be differentiated from ulcers & other causes of intestinal bleeding. If
esophagitis is due to GER, this should make treatment more urgent, and at times itself
might be a reason to consider surgical options if medications are not working.
Angina: Finally, much later in life GER must also be
distinguished from heart disease. Sometimes the chest pain of cardiac angina (inadequate
blood flow of the heart or blocked coronary arteries which can lead to heart attack) can
be misinterpreted as heartburn as well. Luckily, this is not a concern where children are
concerned because children dont get angina or heart attacks.
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