Gastroesophageal reflux in children: a clinical review.

The diagnosis of gastroesophageal reflux requires careful consideration of the patient's clinical history and initial evaluation of presenting symptoms. In cases where overt vomiting in noted, the initial evaluation should include a barium esophagram and upper gastrointestinal series. The diagnosis of gastroesophageal reflux may not be established by one test alone, but may require many tests to confirm the presence of significant reflux and to assess its sequellae. It is imperative to demonstrate that the extent and timing of GER is not merely physiologic. Continuous intraesophageal pH monitoring has proven to be the most sensitive test for gastroesophageal reflux and better identifies its frequency, duration, and relationship to other symptoms. Manometry assesses the competence of the lower esophageal sphincter and integrity of esophageal peristalsis. The standard acid reflux test is a provocative test of gastroesophageal reflux. Gastric outlet obstruction, both organic and functional, may be primary causes of gastroesophageal reflux, and may be evaluated with barium contrast studies and scintigraphic stomach-emptying studies. Poor esophageal transit and clearance are contributing factors which promote esophagitis. Treatment of gastroesophageal reflux requires identification of the primary cause, and selection of the therapeutic modality appropriate to the severity of reflux and its associated sequellae. In those patients with severe clinical sequellae, the most effective treatment for gastroesophageal reflux is surgical fundoplication.