Diagnosis of gastroesophageal reflux disease in children

Based on the combination of clinical picture and endoscopic signs, the following forms of gastroesophageal reflux disease in children are distinguished.

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ], [ 6 ], [ 7 ]

Typical form of gastroesophageal reflux disease in children

The diagnosis can be made if the patient has esophageal complaints in combination with endoscopically and histologically confirmed esophagitis. In this case, the presence of a sliding hernia of the esophageal opening of the diaphragm and extraesophageal symptoms is possible, but not necessary.

[ 8 ], [ 9 ], [ 10 ]

Endoscopically negative form

In pediatric practice, it is encountered relatively rarely. The diagnosis is established with 2 cardinal signs: esophageal complaints and extraesophageal symptoms. Endoscopic examination does not show the picture of esophagitis, but daily pH-metry can determine pathological gastroesophageal reflux.

[ 11 ], [ 12 ], [ 13 ], [ 14 ], [ 15 ], [ 16 ], [ 17 ], [ 18 ], [ 19 ]

Asymptomatic form

The absence of specific esophageal symptoms is combined with endoscopic signs of esophagitis. Often these signs are an accidental finding during fibroesophagogastroduodenoscopy for abdominal pain syndrome. Daily pH-metry confirms pathological gastroesophageal reflux.

[ 20 ], [ 21 ], [ 22 ], [ 23 ], [ 24 ], [ 25 ], [ 26 ]

Metaplastic form of gastroesophageal reflux disease in children

In this form, histological examination reveals gastric metaplasia. Clinical symptoms of esophagitis, sliding hernia of the esophageal orifice of the diaphragm, extraesophageal signs of the disease are possible, but not obligatory. The metaplastic form should be distinguished from Barrett's esophagus, which is considered a complication of gastroesophageal reflux disease. The cardinal sign is the detection of areas of intestinal metaplasia with possible dysplasia against the background of inflammation of the mucous membrane.

X-ray

After a survey image of the chest and abdominal cavities, the esophagus and stomach are examined standing with barium in direct and lateral projections, in the Trendelenburg position with slight compression of the abdominal cavity. The patency and diameter of the esophagus, the relief of the mucous membrane, and the nature of peristalsis are assessed. Gastroesophageal reflux disease is characterized by a reverse flow of contrast from the stomach into the esophagus.

Endoscopy

Endoscopy allows to evaluate the condition of the esophageal mucosa, as well as the degree of motor disturbances in the lower esophageal sphincter. For an objective assessment, it is convenient to use the endoscopic criteria of G. Titgat (1990) in modification.

Endoscopic criteria for gastroesophageal reflux disease in children (according to G. Titgat as modified by V.F. Privorotsky)

• Morphological changes:
  • Grade I - moderate focal erythema and/or friability of the mucous membrane of the abdominal esophagus;
  • Grade II - total hyperemia of the abdominal esophagus with focal fibrinous plaque, single superficial erosions, predominantly linear in shape, at the tops of the folds of the mucous membrane;
  • Stage III - spread of inflammation to the thoracic esophagus. Multiple (merging) erosions, located non-circularly. Increased contact vulnerability of the mucous membrane is possible;
  • IV degree - esophageal ulcer. Barrett's syndrome. Esophageal stenosis.
• Motor disorders:
  • moderate motor disturbances in the area of the lower esophageal sphincter (elevation of the Z-line up to 1 cm), short-term provoked subtotal (along one of the walls) prolapse to a height of 1-2 cm, decreased tone of the lower esophageal sphincter;
  • clear endoscopic signs of cardiac insufficiency, total or subtotal provoked prolapse to a height of more than 3 cm with possible partial fixation in the esophagus;
  • pronounced spontaneous or provoked prolapse above the crura of the diaphragm with possible partial fixation.

[ 27 ], [ 28 ]

Histological examination

The histological picture of reflux esophagitis is characterized by epithelial hyperplasia in the form of thickening of the basal cell layer and elongation of the papillae. Lymphocyte and plasma cell infiltration and vascular congestion of the submucosal layer are also detected. Dystrophic changes are determined less often, and metaplastic changes and epithelial dysplasia are determined much less often.

Vitroesophageal pH-metry (daily pH-ionization)

This method is the "gold standard" for determining pathological gastroesophageal reflux, allowing not only to detect reflux, but also to clarify the degree of its severity, to find out the influence of various provoking factors on its occurrence, to select adequate treatment. Gastroesophageal reflux in adults and children over 12 years of age should be considered pathological if the time during which the pH reaches 4.0 and below is 4.2% of the total recording time, and the total number of refluxes exceeds 50. An increase in the De index is characteristicMeester, normally not exceeding 14.5.

Intraesophageal impedancemetry

The method is based on the change in intraesophageal resistance as a result of gastroesophageal reflux and restoration of the initial level as the esophagus is cleared. The method can be used to diagnose gastroesophageal reflux, study esophageal clearance, determine the average volume of refluxate, diagnose sliding hernia of the esophageal opening of the diaphragm, esophageal dyskinesia, and cardia insufficiency. The study also evaluates the acidity of gastric juice in the basal phase of secretion.

Esophageal manometry

Esophageal manometry is one of the most accurate methods for studying the function of the lower esophageal sphincter. The technique does not allow for direct diagnosis of reflux, but it can be used to study the boundaries of the lower esophageal sphincter, assess its consistency and ability to relax when swallowing. Gastroesophageal reflux disease is characterized by a decrease in the tone of this sphincter.

Ultrasound examination

Ultrasound is not considered a highly sensitive diagnostic method for gastroesophageal reflux disease, but it is possible to suspect the disease. A diameter of the lower third of the esophagus greater than 11 mm (during swallowing - 13 mm) may indicate severe cardia insufficiency and possible formation of a sliding hernia of the esophageal opening of the diaphragm (the normal diameter of the esophagus in children is 7-10 mm).

Radioisotope scintigraphy

Radioisotope scintigraphy with Tc allows assessment of esophageal clearance and gastric evacuation; the sensitivity of the method ranges from 10 to 80%.

Differential diagnosis of gastroesophageal reflux disease in children

In young children, the clinical picture of gastroesophageal reflux disease with persistent regurgitation and vomiting, not relieved by traditional diet therapy, requires the exclusion of malformations of the gastrointestinal tract (achalasia of the cardia, congenital stenosis of the esophagus, congenital short esophagus, hernia of the esophageal opening of the diaphragm, pyloric stenosis), myopathies, allergic and infectious and inflammatory diseases of the gastrointestinal tract. In older children, gastroesophageal reflux disease should be differentiated from achalasia, hernia of the esophageal opening of the diaphragm. The data of endoscopic and radiological examination methods are especially valuable; the detection of signs of esophagitis during esophagoscopy does not exclude another etiology of the condition. Among esophagitis, several forms are distinguished.

• Chemical esophagitis is a consequence of swallowing liquids containing acids or alkalis and causing a chemical burn of the esophagus. Most often, the disease is provoked by accidental use of household chemicals by young children. The disease develops acutely, accompanied by severe pain, salivation. During an endoscopic examination in the first hours, pronounced edema can be seen, signs of necrosis of the mucous membrane are usually more pronounced in the upper and middle third of the esophagus. The further course depends on the depth of the burn.
• Allergic (eosinophilic) esophagitis is a consequence of a specific immune response to food allergens (cow's milk protein, chicken egg, etc.). The disease may have a clinical picture similar to gastroesophageal reflux disease; endoscopic examination reveals signs of esophagitis (usually grade I). Unlike gastroesophageal reflux disease, daily pH-metry does not reveal signs of pathological gastroesophageal reflux, and histological examination reveals mixed infiltration with a significant number of eosinophils (>20 in the field of view).
• Infectious esophagitis is one of the symptoms of infections caused by the herpes simplex virus, cytomegalovirus, cryptosporidia and Candida fungi. Esophageal candidiasis is characterized by white focal plaques on the esophageal mucosa, which are difficult to remove and contain fungal mycelium. Esophagitis associated with herpes or cytomegalovirus infection does not have a specific clinical picture or endoscopic signs. The diagnosis can only be established by immunohistochemical examination. Along with inflammatory changes in the esophagus, motility disorders are possible, so differential diagnostics with gastroesophageal reflux disease is difficult. Most children have a combination of infectious and reflux mechanisms of esophagitis.
• Traumatic esophagitis is a consequence of mechanical trauma (during prolonged tube feeding, swallowing sharp objects). A carefully collected anamnesis, X-ray and endoscopic examination data help to establish the correct diagnosis.
• Specific esophagitis that occurs with Crohn's disease and some systemic diseases is usually accompanied by other signs of the disease that help to correctly interpret the detected endoscopic changes.

Several reasons may be involved in the development of esophagitis in one patient, so each of them should be considered, prescribing treatment taking into account the individual characteristics of the etiology of the disease.

[ 29 ], [ 30 ], [ 31 ], [ 32 ]