EXPERT ANALYSIS FROM AAP 2017
CHICAGO (FRONTLINE MEDICAL NEWS) – “All that vomits is not necessarily GERD,” so distinguishing gastroesophageal reflux disease (GERD) from nonerosive reflux disease (NERD) remains essential when doing a differential diagnosis. Fortunately, five questions backed by increasing evidence can help you make the call.
“Everyone in the room knows babies puke, and babies can puke a lot,” Barry K. Wershil, MD , said at the annual meeting of the American Academy of Pediatrics. The approach to diagnosing GERD is age specific. “Kids who puke tend to outgrow it over time. With development, 95% or more are no longer refluxing at 18 months of age.”
In infants and toddlers, there is no symptom or group of symptoms to reliably diagnose GERD or predict treatment response – that’s key take-home point No. 1, said Dr. Wershil, the head of the division of gastroenterology, hepatology and nutrition at the Ann & Robert H. Lurie Children’s Hospital of Chicago, as well as a professor of pediatrics at Northwestern University, also in Chicago. In older children and adults, a history and/or physical exam are generally sufficient to diagnose GERD reliably and to start treatment.
“So generally there is no reason to initially refer older children and teenagers to a gastroenterologist,” Dr. Wershil said. “One of the essential things [you] do is consider all the causes of vomiting that are not GERD. If your first go-to is GERD, you’re going to miss other issues.”
Dr. Wershil reviewed the definitions: Gastroesophageal reflux is passage of gastric contents into the esophagus. GERD, on the other hand, is defined by the troublesome symptoms or complications associated with reflux of gastric material into the esophagus. In contrast, NERD is the presence of reflux symptoms with no evidence of mucosal erosion or mucosal breaks.
Considerations backed by evidence
Unfortunately, symptoms alone do not always differentiate erosive versus nonerosive esophagitis, Dr. Wershil said, although recurrent vomiting, poor weight gain, anemia, feeding problems, and respiratory problems can be signs of complicated GERD.
He recommended the following five considerations to distinguish GERD from NERD:
“Those five questions in 1983 had little evidence, but in 2017 there is more evidence that these are the questions to focus on,” Dr. Wershil said.
The role of diagnostic testing
Diagnostic testing, such as pH monitoring, impedance testing, and endoscopy, can be useful in specific situations but carry limitations for widespread use, Dr. Wershil said. “Each test has reasons and limitations.”
An upper GI tract series looks only for anatomic anomalies, for example. pH monitoring is still used in many centers, but in general, impedance monitoring has become more common because it can detect both acid and nonacid reflux: “You can get a very detailed analysis of events happening in the esophagus over time.” One caveat Dr. Wershil added is that, “in some instances, we’re unsure how to define this in the pediatric age ranges we treat.”
Endoscopy has a limited role for the rare patients with mucosal changes or erosive esophagitis, he added. Endoscopy is ordered to detect mucosal changes that confirm esophageal erosion. “In all the kids we scope with positive pH, we rarely find erosive esophagitis,” Dr. Wershil said. “What we find more often is NERD. That really represents more of what we see in our patient population.”
“I hope this information is a good starting point to understand the algorithms that get generated,” Dr. Wershil said.
He recommended an algorithm for gastroesophageal reflux prepared by the American Academy of Pediatrics’ Section on Gastroenterology, Hepatology, and Nutrition (Pediatrics. 2013 May. doi: 10.1542/peds.2013-0421 ). “I think this information is really solidly grounded in evidence.”
Dr. Wershil is a consultant for Alexion Pharmaceuticals; is a member of the speakers bureau for Abbott Nutrition, Mead Johnson Nutrition, and Nutricia; and receives funding from the National Institutes of Health Consortium of Eosinophilic Gastrointestinal Disease Researchers.