Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal problems among children or adults. It is defined as the movement of solid or liquid contents from the stomach into the esophagus. Gastrointestinal reflux imaging encompasses methods used to visualize and diagnose GERD.
Purpose
The purpose of gastroesophageal reflux scanning is to visualize the interior of the upper stomach and lower esophagus. Such inspections assist in making an accurate diagnosis and in planning appropriate treatment.
Precautions
For all tests used to evaluate GERD, persons must not have other medical complications such as high blood pressure, asthma, or esophageal varices. They should not be experiencing other acute medical conditions.
Description
A brief description of gastroesophageal reflux disease assists in understanding the scanning methods used. Gastroesophageal reflux disease is the term used to describe the symptoms and damage caused by the back-flow (reflux) of the contents of the stomach into the esophagus. Stomach contents are usually acidic. Because of their acidity, they have the potential to cause chemical burns in unprotected tissues such as those lining the esophagus.
Gastrointestinal reflux is common in the American population. Approximately one adult in three reports experiencing some occasional reflux, commonly referred to as heartburn. Approximately 10% of these persons experience reflux on a daily basis. Most persons have very mild disease. Occasionally, persons experience burning as a result of reflux. This is described as reflux esophagitis when it occurs in the esophagus.
There are several causes of gastroesophageal reflux. These include the following:
Incompetent lower esophageal sphincter. When the muscular sphincter that is the boundary of the esophagus and stomach relaxes, reflux can occur. This is the most common cause for gastroesophageal reflux. Reflux usually occurs when persons bend, lift a weight, or strain. Persons with esophageal strictures or Barrett's esophagus are more likely to experience gastroesophageal reflux than are others.
Acidic irritation. Gastric contents are acidic, with a pH less than 3.9. Such acid is very caustic to the lining of the esophagus. Repeated exposure to acidic gastric contents leads to scarring. If the exposure is sufficiently severe or prolonged, strictures can develop. Occasionally, pancreatic enzymes or bile reflux into the stomach and lower esophagus. These contents are extremely acidic (with a pH less than 2.0).
Abnormal esophageal clearance. Acid reflux is washed away by saliva that is swallowed over the course of a day. During the night, swallowing is decreased. This results in a longer contact time between acidic stomach contents and the esophagus. The net result is a chemical injury. Sjögren's syndrome, radiation to the oral cavity, and some medications (anticholinergics) also decrease the flow of saliva and can result in chemical injury. Saliva also contains bicarbonate, which neutralizes some acid content. This, too, is diminished at night, contributing to nocturnal exposure and irritation over a period of time. Other medical conditions such as Raynaud's disease and scleroderma are often associated with abnormal esophageal clearance. Hiatal hernia is present in more than 90% or persons with erosive disease.
Delayed gastric emptying. When gastric outflow is obstructed or gastric motility is impaired, gastric contents do not leave the stomach in a timely manner. This enhances the opportunity for gastric reflux.
Heartburn associated with gastroesophageal reflux occurs 30 to 60 minutes after eating. It also occurs when a person reclines. Most persons who experience gastroesophageal reflux can obtain relief with baking soda (Alka-Seltzer) or antacid tablets. This pattern is often sufficient for diagnostic purposes. Under these conditions, physical examination and laboratory findings are usually within normal limits.
Persons with complicated GERD, or those who do not respond to the usual remedies (baking soda or antacid tablets), require special examinations. There are several imaging methods used in the diagnosis of GERD. Details concerning each of the procedures follow.
Upper endoscopy
Endoscopy documents the condition of mucosa in the lower esophagus and upper stomach, evaluating the extent of GERD progression.
Ambulatory esophageal pH monitoring
Measurements of pH are used to evaluate the degree of GERD.
Barium esophagography
Barium esophagography can detect many abnormalities. including reflux.
Esophageal manometry
This documents the ability of the esophageal sphincter to close and keep stomach contents from refluxing.
Health care team roles
A family physician, pediatrician, internist, or cardiologist usually makes the initial diagnosis of GERD. A gastroenterologist usually performs the tests required for diagnosis. A radiology technologist performs the barium esophagography and a radiologist interprets it.
KEY TERMS
Barrett's esophagus—An abnormal condition of the (usually) lower esophagus in which normal mucous cells are replaced by changed cells. The condition is often a prelude to cancer.
Dysphagia—Difficulty in swallowing.
Erythema—Redness.
Esophageal varices—Varicose veins at the lower-most portion of the esophagus. These are easily injured. Bleeding from esophageal varices is often difficult to stop.
Esophagus—The tube that connects the mouth to the stomach.
Hematemesis—Vomit that contains blood, usually seen as black specks in the vomitus.
pH—A measure of acidity; technically, a measure of hydrogen ion concentration.
Raynaud's disease—A disease of the arteries in hands or feet.
Reflux—Backflow, also called regurgitation.
Sjögren's syndrome—An autoimmune disorder characterized by dryness of the eyes, nose, mouth, and other areas covered by mucous membranes.
Sphincter—A physiologic valve comprised of muscle.
BOOKS
Bentley D., M. Lawson, and C. Lifschitz. Pediatric Gastroenterology and Clinical Nutrition. New York, NY: Oxford University Press, 2001.
Davis M., and J. D. Houston. Fundamentals of Gastroenterology. Philadelphia, PA: Saunders, 2001.
Herbst, J.J. "Gastroesophageal reflux (chalasia)." In Nelson Textbook of Pediatrics, 16th ed., edited by Richard E. Behrman et al., Philadelphia, PA: Saunders, 2000, pp.1125-1126.
Isselbacher K. J., and D.K. Podolsky. "Approach to the patient with gastrointestinal disease." In Harrison's Principles of Internal Medicine. 14th ed., edited by A. S. Fauci, et al. New York, NY: McGraw-Hill, 1998, pp.1579-1583.
Murry T., and R. L. Carrau. Clinical Manual for Swallowing Disorders. Albany, NY: Delmar, 2001.
Orlando, R. Gastroesophageal Reflux Disease. New York, NY: Marcel Dekker, 2000.
Owen W.J., A. Adam, and R.C. Mason. Practical Management of Oesophageal Disease. Oxford, UK: Isis Medical Media, 2000.
Richter, J.E. Gastroesophageal Reflux Disease: Current Issues and Controversies. Basel, SWI: Karger Publishing, 2000.
Wuittich, G. R. "Diagnostic imaging procedures in gastroenterology." In Cecil Textbook of Medicine, 21st ed,, edited by Lee Goldman and J. Claude Bennett, Philadelphia, PA: W.B. Saunders, 2000, pp.645-649.
PERIODICALS
Carr M.M., M.L. Nagy, M.P. Pizzuto, C.P. Poje, and L.S.Brodsky. "Correlation of findings at direct laryngoscopy and bronchoscopy with gastroesophageal reflux disease in children: a prospective study." Archives of Otolaryngology, Head and Neck Surgery 127, no. 4(2001): 369-374.
Carr M.M., A. Nguyen, C. Poje, M. Pizzuto, M. Nagy, and L. Brodsky. "Correlation of findings on direct laryngoscopy and bronchoscopy with presence of extraesophageal reflux disease." International Journal of Pediatric Otorhinolaryngology 54, no. (2000): 27-32.
Mercado-Deane M.G., E.M. Burton, S.A. Harlow, A.S. Glover, D.A. Deane, M.F. Guill, and V. Hudson. "Swallowing dysfunction in infants less than 1 year of age." Pediatric Radiology 31, no. 6 (2001): 423-428.
Stordal K., E.A. Nygaard, and B. Bentsen. "Organic abnormalities in recurrent abdominal pain in children." Acta Paediatrica 90, no. 5 (2001): 638-642.
ORGANIZATIONS
American College of Gastroenterology, 4900 B South 31st Street, Arlington, VA, 22206. (703) 820-7400. <http://www.acg.gi.org>.
American College of Radiology. 1891 Preston White Drive, Reston, VA, 20191. (703) 648-8900. <http://www.acr.org>.
American Osteopathic College of Radiology. 119 East Second St., Milan, MO 63556. (660) 265-4011. <http://www.aocr.org>.
