What is gastroesophageal reflux?
What causes gastroesophageal reflux?
Who gets gastroesophageal reflux?
How does it cause disease?
What are the common findings?
How is gastroesophageal reflux diagnosed?
How is gastroesophageal reflux treated?
How can gastroesophageal reflux be prevented?
Links to other information?
Judith M. Sondheimer, M.D.
Professor of Pediatrics
University of Colorado Health Science Center
Chief of Pediatric Gastroenterology, Hepatology, and Nutrition
University of Colorado Health Science Center and the Children's Hospital
Gastroesophageal reflux (also called "chalasia," GER, or GERD) is the effortless regurgitation of stomach contents back into the esophagus. It may be associated with vomiting and spitting up, especially in young infants.
The cause of this condition is not completely understood. However, from studies in which the esophagus is monitored for the presence of gastric contents, everyone refluxes occasionally, especially in the hour after eating. It is thought that reflux of stomach contents occurs when the sphincter muscle at the lower end of the esophagus relaxes temporarily, removing the barrier that prevents gastric contents from flowing into the esophagus. These temporary relaxations occur more frequently after meals, allowing reflux to occur two to three times in the hour after eating.
In healthy individuals, reflux episodes do not occur during sleep. In patients with abnormal amounts of reflux, episodes not only occur after eating, but also during sleep, and they last longer. As a consequence of more frequent and longer episodes of reflux, the esophagus is exposed to the damaging effects of stomach acid for a longer proportion of the day. Secondary changes in the muscle function of the esophagus as a result of acid damage may allow for yet more reflux to occur. In a small number of reflux episodes, the precipitating event may be straining, sneezing, coughing, or other activities that increase the pressure on the stomach, forcing contents into the esophagus.
It is rare that the sole cause of acid reflux is an "immature sphincter" or a low-pressure sphincter. Even in the youngest infants, the lower esophageal sphincter is well developed and provides a barrier against reflux. Food allergy has been thought to cause reflux, both in infants and in older children, but it is probably a cause in only a minority of cases.
Everybody refluxes a little; therefore, data on incidence are not entirely clear because separating normal from abnormal is not always definite. Infants under six months seem particularly at risk for acid reflux. Some studies have estimated that as many as 40% of healthy, thriving babies who are under 6 months of age have abnormal amounts of acid reflux. The major symptom at this young age is recurrent spitting and vomiting.
By 12 to 16 months of age, there is a dramatic decrease in the number of infants with symptoms of GER. A recent pediatric office survey, however, indicates that up to 15% of healthy children and adolescents may still have symptoms of reflux, including heartburn and regurgitation. Infants and children with serious developmental and physical handicaps, who spend long periods of time in the supine position, appear to be at a high risk for GER.
Children who are unable to swallow normally also are at a higher risk for GER because they are unable to clear the esophagus as efficiently. Children with injury to the brain from infection, inherited metabolic disease, tumors and other causes are at higher risk for reflux.
Most individuals with GER are healthy, and the symptoms are more of an annoyance than a true threat to health. However, the presence of acid material in the esophagus is associated with symptoms that may be more serious:
The most common symptom of GER in young infants is effortless regurgitation. Other symptoms in young children include failure to thrive, food refusal, colicky crying, respiratory disease, and anemia. Young infants with GER also may have constipation. Adults and older children may complain of heartburn, but many pediatric patients just complain of a bellyache.
Stresses, such as intercurrent illness, vigorous laughing or crying, or strenuous physical activities that increase the pressure on the abdomen (e.g., swimming, weight lifting, or long-distance running), will increase the symptoms of GER. Emotional stress makes most chronic diseases less easy to tolerate. GER is no exception. However, emotional stress is not a recognized cause of GER.
There are several tests to diagnose GER. In most cases, especially in healthy infants whose major symptom is frequent spitting, the diagnosis is based upon the typical nature of the symptoms. Sometimes, further testing may be necessary in patients:
In healthy infants, GER is not a major health hazard, and it tends to improve with time. Therefore, physicians try not to use too many diagnostic tests and complicated treatments. Often, some simple changes in feeding technique are helpful. Thickening the baby's bottle with rice cereal (two to three teaspoons per ounce of formula) often helps reduce spitting. Some anti-reflux formulas already have a thickening agent added. Keeping the infant upright for as long as possible after feeding may help.
It is recommended that the infant sleep in the right lateral position, rather than flat on the back to assist in emptying the stomach. In older children, elevating the head of the bed, from four to eight inches by inserting bricks under the head posts, is helpful. Avoiding eating or drinking for two hours prior to bed is recommended for older children. Avoiding large meals, even in young infants, is helpful. Treating constipation, if it is present, often is associated with improvement. Older children should avoid caffeine, carbonated beverages, alcohol, and high fat meals.
In some patients with GER, medications of two types are used:
These side effects are more likely to occur in patients receiving large doses; in very sick, hospitalized children; or in very premature infants. Risk of cardiac side effects is increased by the simultaneous use of other medications, including erythromycin and its related compounds.
Sometimes, medical therapy of GER is disappointing. There may only be partial control of the symptoms. There are no medications that permanently get rid of all symptoms. Many young infants get better spontaneously at about 12 to 14 months of age, often in association with learning how to walk. In children over 12 to 14 months who still have GER, the symptoms tend to recur when the medications are stopped, just as they do in adults.
In a few cases, the complications of GER are severe, and surgical treatment is recommended. The surgical procedure performed in most cases is a "fundoplication." In this procedure, the surgeon takes a tuck in the upper part of the stomach (the fundus) just below the junction of the stomach and the esophagus. This "plication" of the fundus effectively prevents the stomach contents from flowing backward into the esophagus.top
It is not known how to prevent gastroesophageal reflux.
Nelson SP, Chen EH, Syniar GM, Christoffel KK. One-year follow-up of symptoms of gastroesophageal reflux during infancy. Pediatr 1998;102:E67.
Orenstein SR. Gastroesophageal reflux. Pediatri in Rev 1999;20:24.
Zeiter DK, Hyams JS. Gastroesophageal reflux: pathogenesis, diagnosis and treatment. All Asth Proc 1999;20:45.
About the Author
Dr. Sondheimer received her undergraduate degree at Swarthmore College. She completed her medical degree at Columbia College of Physicians and Surgeons, with a pediatric residency at the University of Colorado Health Science Center, followed by a pediatric gastroenterology fellowship at the Hospital for Sick Children in Toronto. For nine years, she served as Chief of Pediatric Gastroenterology at SUNY Syracuse.
Since 1985, she has been Professor of Pediatrics and Chief of Pediatric Gastroenterology, Hepatology and Nutrition at the University of Colorado Health Sciences Center and the Children's Hospital of Denver. Her major clinical and research interest is in gastroesophageal reflux in infancy and its associated causes and therapy; and in problems of infants with short bowel syndrome.
Copyright 2012 Judith M. Sondheimer, M.D., All Rights Reserved
The information contained in these topics is not intended nor implied to be a substitute for professional medical advice, it is provided for educational purposes only. You assume full responsibility for how you choose to use this information.
Always seek the advice of your physician or other qualified healthcare provider before starting any new treatment or discontinuing an existing treatment. Talk with your healthcare provider about any questions you may have regarding a medical condition. Nothing contained in these topics is intended to be used for medical diagnosis or treatment.
If you think that you are having a medical emergency,
call 911 or the number for the local emergency ambulance service NOW!
And when in doubt, call your doctor NOW
or go to the closest emergency department.
By using this website, you accept the information provided herein "AS IS." Neither RemedyConnect nor the providers of the information contained herein will have any liability to you arising out of your use of the information contained herein or make any express or implied warranty regarding the accuracy, content, completeness, reliability, or efficacy of the information contained within this website.
RemedyConnect, Inc. has created this privacy statement in order to demonstrate our firm commitment to your privacy. The following discloses our information gathering and dissemination practices for this website: http://www.remedyconnect.com.
Acquisition of Information through PMD
We do not acquire any more information about website visitors than is required by law or is otherwise necessary to provide a high level of service efficiently and securely. Our site's registration form requires users to give us contact information (e.g., their name and e-mail address) and demographic information (e.g., children's birth months, but not birth dates). We use customer contact information from the registration form to (1) send the user pertinent medical and parenting information and (2) allow your local health provider lists of who is registering on that provider's site as a parent/guardian, staff member, doctor, or visitor. Users may opt-out of receiving future mailings; see the choice/opt-out section below.
We use your IP address to help diagnose problems with our server and to administer our Website. Your IP address is used to help identify you and to gather broad demographic information.
Demographic and profile data is also collected at our site. We may use this data to tailor the visitor's experience at our site, showing them content that we think they might be interested in, and displaying the content according to their preferences.
Our site may use order forms to allow users to request information, products, and services.
Your Doctor's Right to Privacy
We will respect your doctor's right to privacy. A doctor typically does not give his/her e-mail address to the parents/guardians of patients. We will not provide the e-mail addresses of doctor(s) in the local practice to users of their site without the doctor(s)' permission. Their site is restricted to use by whomever they wish, and they may deny access to their site to one or more prior users. In unusual cases, doctors may change their private site's access code and arrange for us to e-mail the new access code to approved users.
This site contains links to other sites. RemedyConnect.com is not responsible for the privacy practices or the content of such Websites. See Disclaimers.
Disclosure to Third Parties
We will provide individually-identifiable information about website users to third parties only if we are compelled to do so by order of a duly-empowered governmental authority, we have the express permission of the visitor, or it is necessary to process transactions and provide you services from our affiliates: Live Agent Answering Service, Digital Answering Service, Medical Answering Service and Pediatric Answering Service.
Privacy and Our Business Partners
This site may make chat rooms, forums, message boards, and/or news groups available to its users. Please remember that any information that is disclosed in these areas becomes public information and you should exercise caution when deciding to disclose your personal information.
This site has security measures in place to protect the loss, misuse and alteration of the information under our control. For further information regarding our security, please contact us at email@example.com. If you have any concerns regarding the security of information, please do not provide any information to RemedyConnect, Inc. until you are comfortable with our security measures.
You may correct or update your User Registration information at any time, by visiting the User Registration section and providing your personal password that you set at registration. If need be, please email us at firstname.lastname@example.org.
Our site provides users the opportunity to opt-out of receiving e-mail communications from our partners or us, except communications approved by your doctor's practice office. To so opt-out, please email us at email@example.com. To be removed as a user, please email us at the same address. If need be, you may mail requests to us at RemedyConnect, Inc., 9200 E. Mineral Avenue, Suite 100, Centennial, CO 80112. Our telephone number is 303-793-0703.
Contacting the Website
If you have any questions about this privacy statement, the practices of this site, or your dealings with this Website, you can contact us by email at firstname.lastname@example.org or by mail at our address above.