Tests Used To Diagnose Reflux or GERD

RMacLean
August 2002

Much of the time reflux is diagnosed purely from parental reports of the child's symptoms.  Many times this information is more than sufficient in determining whether or not the child is refluxing and no further testing is required.  In cases where more information is needed the following are some of the tests that may be conducted to diagnose reflux, as well as other digestive conditions or problems.

Barium Swallow (aka Upper GI)

The upper gastrointestinal (GI) series uses x rays to diagnose problems in the esophagus, stomach, and duodenum (first part of the small intestine). It may also be used to examine the small intestine. The upper GI series can show a blockage, abnormal growth, ulcer, or a problem with the way an organ is working.

During the procedure, the child will drink barium, a thick, white, milkshake-like liquid. Barium coats the inside lining of the esophagus, stomach, and duodenum, and makes them show up more clearly on x rays. The radiologist can also see ulcers, scar tissue, abnormal growths, hernias, or areas where something is blocking the normal path of food through the digestive system. Using a machine called a fluoroscope, the radiologist is also able to watch your digestive system work as the barium moves through it. This part of the procedure shows any problems in how the digestive system functions, for example, whether the muscles that control swallowing are working properly. As the barium moves into the small intestine, the radiologist can take x rays of it as well.

The barium may cause constipation and white-colored stool for a few days after the procedure.

Typically the first test done to diagnose reflux it's not always the most reliable, negative results are common with children who actually have reflux.  This is because the child has to actually reflux during the test to provide a positive result.  This test is more valuable at determining anatomic abnormalities within the digestive system.

Reflux Scan

Similar to the Upper GI.  The child swallows a small amount of a radioactive solution, is laid flat on a table which has an x-ray under it.  The x-ray takes constant pictures for one hour to measure the frequency of reflux episodes over the hour.

Upper Endoscopy (aka Scope)

Upper endoscopy enables the physician to look inside the esophagus, stomach, and duodenum (first part of the small intestine). The procedure might be used to discover the reason for swallowing difficulties, nausea, vomiting, reflux, bleeding, indigestion, abdominal pain, or chest pain. Upper endoscopy is also called EGD, which stands for esophagogastroduodenoscopy (eh-SAH-fuh-goh-GAS-troh-doo-AH-duh-NAH-skuh-pee).

The endoscope transmits an image of the inside of the esophagus, stomach, and duodenum, so the physician can carefully examine the lining of these organs. The scope also blows air into the stomach; this expands the folds of tissue and makes it easier for the physician to examine the stomach.

Possible complications of upper endoscopy include bleeding and puncture of the stomach lining. However, such complications are rare. Most people will probably have nothing more than a mild sore throat after the procedure.

WHY IS THIS NEEDED?

The physician can see abnormalities, like inflammation or bleeding, through the endoscope that don't show up well on x rays. The physician can also insert instruments into the scope to treat bleeding abnormalities or remove samples of tissue (biopsy) for further tests.

During the test, small pieces from the lining of the esophagus, stomach, and or duodenum (biopsies) are often taken. The biopsies are then examined by another doctor (pathologist) under a microscope to help in diagnosing your child's illness. Taking the biopsies cannot be felt by your child either during or after the procedure.

IS THERE ANY PREPARATION?
You're child will likely require a period a fasting time before the procedure. This usually involves no solid food twelve hours before, only clear liquids up to six hours prior and then nothing up to four hours prior. This may vary slightly from hospital to hospital.


WHAT HAPPENS THE DAY OF THE PROCEDURE?

• Your child will likely need to arrive in Day Surgery two hours before the procedure.
• When the procedure room and doctors are ready, family and the patient will be taken to the front door of the Operating Room where you will have the chance to meet the anesthetist. Family is not usually allowed into the OR although some hospitals will allow one parent to accompany the child until they are sedated.
• Once the child goes for the procedure, the family will go to the OR waiting room and remain there until the doctor speaks to them.
• An intravenous (I.V.) will be started in the OR, then the anesthetist will inject drugs through the IV before the test. The drugs will make your child sleep. The anesthetist may also put in a tube into the wind pipe and give other drugs through this tube to keep your child asleep. Sometimes, the child will receive a mask to put them to sleep instead of the IV. Some hospitals prefer doing it this way to eliminate the child feeling the needle of the IV going in. Many hospitals will not give children with reflux the mask; however, because of the increased risk of aspiration.
• Your child will not be able to remember anything about the procedure.
• Once the procedure is completed, your child will go to the Recovery Room and the doctor will meet with you to discuss what was seen during the procedure.
• Once awake, they will be taken to the Day Care Surgery Unit and usually a parent is called in to see the child here. They will still be quite groggy and sleepy.
• In the Recovery Room and Day Care Surgery Unit, the nurse will check vital signs.
• After the endoscopy there may be a feeling of fullness in the stomach the first few hours afterwards, and there may be some burping. The throat may also feel scratchy after the procedure and they may be a little hoarse. It's not uncommon for a small amount of dried blood to be noticeable for about a day afterward if your child is a spitter or throws up.
• The I.V. will be removed when your child is drinking well. Usually the hospital will suggest a lighter meal for the first meal after the procedure.
• If your child was intubated by the anesthetist for the procedure, there may be a sore throat for a day or two.
• Usually it's suggested that activities be limited after the procedure to things that do not require a lot of exertion or coordination only because of the drugs they were given for sedation.
• The child will go home when the vital signs are good and they appear awake and alert.
• The child should be able to participate in regular activities the following day.

WHEN ARE THE RESULTS AVAILABLE? 
This will depend on the hospital. But generally, the results of biopsies are usually back within 7 to 14 days and will either be called to you or discussed with you at your clinic visit.

Esophageal manometry measures pressure within the esophagus. This test may also be referred to as an esophageal motility or function study. Your doctor may recommend this test to determine if a swallowing problem is due to improperly working muscles in your esophagus.

When you swallow, muscles in your esophagus normally contract and relax in rolling waves (peristalsis). This action propels food and liquids toward your stomach. Muscular valves (sphincters) at the top and bottom of your esophagus open to let food and liquids in. Then, they close to keep stomach acid from backing up into your esophagus. When these muscles don't work properly, you may have:

* Difficulty swallowing
* Heartburn from reflux
* Esophageal spasms
* Pneumonia due to inhalation (aspiration) of stomach contents

During esophageal manometry, a tiny, pressure-sensitive tube is inserted through your nose — or sometimes your mouth — and into your esophagus. There, it measures the effects of muscle contractions as you swallow. The test takes less than one hour.

Manometry may also be used to measure pressures in your stomach (gastric motility), small intestine (small intestine manometry) and rectum (anorectal function).

Colonscopy/Lower Endoscopy (With Biopsy)

During this procedure the inside of your child's large bowel (colon) may be looked at. A long, flexible tube called a colonoscope is passed into the rectum and then moved into the rest of the colon. The end of the colonoscope has a miniature video camera and a light to see the inside of the bowel. An anesthetist will be there for the procedure to put your child asleep (general anesthesia) and to monitor your child during the procedure.

During the test, small pieces (biopsies) of the lining of the colon are taken. The biopsies are then examined by another doctor (pathologist) under a microscope to help in diagnosing your child's illness. Taking the biopsies cannot be felt by your child either during or after the procedure.

IS THERE ANY PREPARATION?
Your child will need to take medication that will encourage bowel movements (bowel clean protocol). This information will be provided to you by your physician.  Also, the last twelve hours prior to testing, fasting similar to the upper endoscopy will likely be required. Again, your physician will provide this information to you before you go in.

WHAT HAPPENS THE DAY OF THE PROCEDURE?

• Your child will likely need to arrive in Day Surgery two hours before the procedure.
• When the procedure room and doctors are ready, family and the patient will be taken to the front door of the Operating Room where you will have the chance to meet the anesthetist. Family is not usually allowed into the OR although some hospitals will allow one parent to accompany the child until they are sedated.
• Once the child goes for the procedure, the family will go to the OR waiting room and remain there until the doctor speaks to them.
• An intravenous (I.V.) will be started in the OR, then the anesthetist will inject drugs through the IV before the test. The drugs will make your child sleep. The anesthetist may also put in a tube into the wind pipe and give other drugs through this tube to keep your child asleep. Sometimes, the child will receive a mask to put them to sleep instead of the IV. Some hospitals prefer doing it this way to eliminate the child feeling the needle of the IV going in. Many hospitals will not give children with reflux the mask; however, because of the increased risk of aspiration.
• Your child will not be able to remember anything about the procedure.
• Once the procedure is completed, your child will go to the Recovery Room and the doctor will meet with you to discuss what was seen during the procedure.
• Once awake, they will be taken to the Day Care Surgery Unit and usually a parent is called in to see the child here. They will still be quite groggy and sleepy.
• In the Recovery Room and Day Care Surgery Unit, the nurse will check vital signs.
• After endoscopy, there may be some gas pains, and a large amount of gas may be passed after the procedure. Small amounts of blood may be seen in the next few stools. After the test, we suggest a lighter first meal.
• The I.V. will be removed when your child is drinking well. Usually the hospital will suggest a lighter meal for the first meal after the procedure.
• If your child was intubated by the anesthetist for the procedure, there may be a sore throat for a day or two.
• Usually it's suggested that activities be limited after the procedure to things that do not require a lot of exertion or coordination only because of the drugs they were given for sedation.
• The child will go home when the vital signs are good and they appear awake and alert.
• The child should be able to participate in regular activities the following day.

WHEN ARE THE RESULTS AVAILABLE? 
The results of biopsies are usually back within 7 to 14 days and will either be called to you or discussed with you at your clinic visit.

pH Monitoring

Esophageal pH monitoring is a test that measures how often and for how long stomach acid enters the esophagus (the tube that leads from the mouth to the stomach).

Reviewed By Dave Olson, MD
Fellow, American Academy of Pediatrics
Graduate University of Michigan School of Medicine