Diagnosis of gastroesophageal reflux disease in children

By combining the clinical picture and endoscopic features, the following forms of gastroesophageal reflux disease in children are distinguished.

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

A 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 extraepithelial symptoms is possible, but not necessary.

[8], [9], [10]

Endoscopically negative form

In practice, the pediatrician is relatively rare. Diagnosis is established with 2 cardinal symptoms: esophageal complaints and extra-oesophageal symptoms. At endoscopic examination the picture of esophagitis is absent, however at daily рН-metry it is possible to define a 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 - an accidental finding with fibroesophagogastroduodenoscopy for pain abdominal syndrome. The daily pH-metry confirms pathological gastroesophageal reflux.

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

Metaplastic form of gastroesophageal reflux disease in children

With this form, a histological examination reveals gastric metaplasia. Clinical symptoms of esophagitis, sliding hernia of the esophageal opening of the diaphragm, extra-esophageal signs of the disease are possible, but not necessary. 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 mucosal inflammation.

X-ray examination

After a survey of the thoracic and abdominal cavities, the esophagus and stomach with barium in the straight and lateral projections, in the Trendelenburg position with a slight compression of the abdominal cavity, are examined standing. Assess the patency and diameter of the esophagus, the relief of the mucous membrane, the nature of peristalsis. Gastoesophageal reflux disease is characterized by a reverse cast of contrast from the stomach into the esophagus.

Endoscopy

Endoscopy allows to assess the condition of the mucosa of the esophagus, as well as the severity of motor disorders in the lower esophageal sphincter. For an objective evaluation, it is convenient to use the endoscopic criteria of T. Titman (1990) in the modification.

Endoscopic criteria of gastroesophageal reflux disease in children (according to G. Tytgat in the modification of VF Privorotsky)

• Morphological changes:
  • I degree - moderately expressed focal erythema and / or friability of the mucosa of the abdominal esophagus;
  • II degree - total hyperemia of abdominal esophagus with focal fibrinous plaque, single superficial erosions of predominantly linear form on the apices of the folds of the mucous membrane;
  • III degree - the spread of inflammation on the thoracic esophagus. Multiple (merging) erosions, located non-circularly. Increased contact sensitivity of the mucosa is possible;
  • IV degree - ulcer of the esophagus. The Barrett Syndrome. Stenosis of the esophagus.
• Motor disorders:
  • moderate motor disorders in the lower esophageal sphincter (Z-line up to 1 cm), short-term induced subtotal (one of the walls) prolapse to a height of 1-2 cm, a decrease in the tone of the lower esophageal sphincter;
  • distinct endoscopic signs of cardia deficiency, total or subtotal provoked prolapse to a height of more than 3 cm with possible partial fixation in the esophagus;
  • marked spontaneous or provoked prolapse above the legs of the diaphragm with possible partial fixation.

[27], [28]

Histological examination

The histological picture of reflux-esophagitis is characterized by hyperplasia of the epithelium in the form of a thickening of the basal cell layer and lengthening of the papillae. Also, infiltration with lymphocytes and plasma cells, plethora of vessels of submucosal layer is detected. Less commonly, dystrophic changes are detected, and metaplastic changes and epithelial dysplasia are significantly less common.

Viurethrisophageal pH-metry (daily pH-ionitration)

This method is the "gold standard" for determining pathological gastro-esophageal reflux, which allows not only to detect reflux, but also to clarify the degree of its manifestation, to elucidate the effect of various provoking moments on its occurrence, to select an adequate treatment. Gastroesophageal reflux in adults and children over 12 years should be considered pathological if the time for which the pH reaches 4.0 and below is 4.2% of the total recording time, and the total number of refluxes exceeds 50. Characteristic is the increase in the De Meester index , normal not exceeding 14.5.

Intraesophageal impedance measurement

The technique is based on a change in intra-esophageal resistance as a result of gastroesophageal reflux and restoration of the initial level as the esophagus clears. The method can be used to diagnose gastroesophageal reflux, to study esophageal clearance, to determine the average volume of reflux, to diagnose a sliding hernia of the esophageal aperture of the diaphragm, dyskinesia of the esophagus, and cardia deficiency. The study also assesses the acidity of gastric juice in the basal phase of secretion.

Manometry of the esophagus

Manometry of the esophagus is one of the most accurate methods of examining the function of the lower esophageal sphincter. The technique does not allow directly diagnosing reflux, but with its help it is possible to examine the boundaries of the lower esophageal sphincter, to assess its consistency and its ability to relax when swallowing. Gastoesophageal reflux disease is characterized by a decrease in the tone of this sphincter.

Ultrasonography

Ultrasound is not considered to be a highly sensitive diagnostic method for gastroesophageal reflux disease, but it is possible to suspect a disease. The diameter of the lower third of the esophagus is more than 11 mm (during the pharynx - 13 mm) may indicate a severe cardia deficiency and the 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 assessing the esophageal clearance and evacuation from the stomach; The sensitivity of the method varies from 10 to 80%.

Differential diagnosis of gastroesophageal reflux disease in children

In children of early age, the clinical picture of gastroesophageal reflux disease with persistent regurgitation and vomiting, which is not suppressed by traditional diet therapy, requires the elimination of the developmental abnormalities of the digestive tract (achalasia of cardia, congenital esophagus stenosis, congenital short esophagus, hernia of the esophageal aperture of the diaphragm, pyloric stenosis), myopathies, allergic and infectious inflammatory diseases of the digestive tract. In the older age, gastroesophageal reflux disease should be differentiated with achalasia, hernia of the esophageal aperture of the diaphragm. Especially valuable data endoscopic and radiographic methods of investigation; The detection of esophagitis during esophagoscopy does not exclude another etiology of the condition. Among the esophagitis several forms are distinguished.

• Chemical esophagitis is the result of ingestion of liquids containing acids or alkalis and causing a chemical burn of the esophagus. More often the disease is provoked by accidental use of household chemicals by young children. The disease develops sharply, accompanied by severe pain, drooling. When endoscopic examination in the first hours you can see a pronounced edema, signs of mucosal necrosis usually expressed more strongly in the upper and middle third of the esophagus. The further course depends on the depth of the burn.
• Allergic (eosinophilic) esophagitis is the result of a specific immune response to food allergens (cow's milk protein, chicken egg, etc.). The disease can have a clinical picture similar to that of gastroesophageal reflux disease, endoscopic findings show signs of esophagitis (usually I degree). In contrast to gastroesophageal reflux disease, the daily pH-metry does not show signs of pathological gastroesophageal reflux, and histologically, mixed infiltration with a significant number of eosinophils (> 20 in the field of vision) is detected.
• Infectious esophagitis is one of the symptoms of infections caused by the herpes simplex virus, cytomegalovirus, cryptosporidia and Candida fungi . Candidiasis of the esophagus is characterized by white focal deposits on the mucosa of the esophagus, which are poorly removed and contain the mycelium of the fungus. Esophagitis associated with herpes or cytomegalovirus infection does not have a specific clinical picture or endoscopic features. The diagnosis can be established only with immunohistochemical examination. Along with inflammatory changes in the esophagus, motor disorders are possible, therefore, differential diagnosis with gastroesophageal reflux disease is difficult. Most children combine the infectious and reflux mechanisms of esophagitis.
• Traumatic esophagitis is a consequence of mechanical trauma (with prolonged probe feeding, swallowing of sharp objects). Carefully collected anamnesis, the data of radiological and endoscopic studies help to establish the correct diagnosis.
• The specific esophagitis arising from Crohn's disease and certain systemic diseases is usually accompanied by other signs of the disease, which help to correctly interpret the detected endoscopic changes.

In the development of esophagitis, one patient may have several causes, so one should consider each of them, prescribing treatment taking into account the individual features of the etiology of the disease.

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