Consultation with the Specialist: Gastroesophageal Reflux

Thirty years ago, gastroesophageal reflux disease was virtually unknown; today, it seems necessary to consider it a potential cause of an enormous range of symptoms. Not long ago, reflux was diagnosed simply by ordering an upper gastrointestinal barium study; now the complexity of differentiating between gastroesophageal reflux (GER) episodes and gastroesophageal reflux disease (GERD) mandates an understanding of the strengths and weaknesses of a variety of tests. Several decades ago, few options for therapy of reflux existed, and those that did were not very effective or even frankly detrimental; currently, the range of proven therapeutic options is greater, and the pediatrician must exercise finesse in prescribing these options.

It has been useful to consider the symptoms, diagnostic complexity, and therapy of reflux as an“ iceberg” (Figure⇓ ). The largest section at the bottom represents common, easily diagnosed, and easily treated cases; the tip of the iceberg represents those cases that occur less frequently, provide considerable diagnostic and therapeutic challenges, and require subspecialist consultation. Exactly where the demarcation occurs between these sections of the iceberg depends on the individual pediatrician’s expertise and the local availability of subspecialty expertise. Each section that follows will consider both infantile GERD (which is more common) and childhood GERD.