Medical Management Considerations
Gastroesophageal reflux disease (GERD) is a chronic, progressive disorder involving the backward flow of gastroduodenal contents into the esophagus. GERD is the most common serious condition of the gastrointestinal (GI) tract. It is caused by (1) a defective lower esophageal sphincter, (2) a gastric emptying disorder, or (3) failed esophageal peristalsis.
Note: These considerations are in addition to the normal medical care provided to an individual without GERD. All recommendations can be addressed through clinical examination by the primary care provider, unless otherwise noted.
Many treatments relieve symptoms of heartburn but fail to stop reflux. Because the patient does not experience pain, it is possible for the epithileal lining of the esophagus to be slowly destroyed without the physician’s knowledge, which may lead to overt cancer of the esophagus. Thus, it is very important to address symptoms of regurgitation in addition to symptoms of heartburn.
Esophagitis heals in up to 90% of cases treated with intensive medical therapy. However, these treatments do not address the underlying mechanical cause of GERD; thus, symptoms recur in more than 80% of cases within one year of medication withdrawal. In these cases, surgical therapy may be beneficial.
Perform the following test(s) until diagnosis can be made. The choice of which specific test(s) to perform may depend upon the availability of the test, the qualifications and willingness of the examiner, and the ability of the patient to cooperate with the procedure.
Note: Consider only if lifestyle and diet modifications do not generate marked improvement.
Note: Consider only when no significant response to lifestyle changes or long-term drug therapy.
Surgery has been found to be more effective than medical therapy in improving symptoms and endoscopic signs of esophagitis. However, it should only be considered for individuals who:
The primary goals of surgical intervention for GERD are to:
Below is a list of possible surgical procedures, although there is no clear consensus in regard to which types are superior to others for persons with developmental disabilities.
Note: It has recently been suggested that there may exist a relationship between Helicobacter pylori infection and gastrointestinal disorders. Although this relationship has not been fully established, it may be possible that eradication of H. pylori can exacerbate gastroesophageal reflux in the general population and possibly in patients with developmental disabilities.
Bohmer, C.J. et al. (1997). Gastroesophageal Reflux Disease in Intellectually Disabled Individuals: Leads for Diagnosis and the Effect of Omeprazole Therapy. American Journal of Gastroenterology, 92(9) 1475-1479.
Projansky, R. et al. (1994). Symptomatic H. Pylori Infection in Young Patients With Severe Neurologic Impairment. Journal of Pediatrics,125, 750-752.
Rogers, B., Lock, T., (1996). Pediatric Dysphagia, In Developmental Disabilities in Infancy and Childhood (2nd Edition. Volume II) (Eds). A.J. Caputo., P.J. Accardo. Paul H. Brookes Publishing. Baltimore. pp 163-178.
Eicher, P.S. (1997). Feeding. In M. L. Batshaw (Ed.), Children with Disabilities (4th ed., pp. 621-641). Baltimore: Paul H. Brookes.
Schwarz, S.M. et al. (2001). Diagnosis and Treatment of Feeding Disorders in Children with Developmental Disabilities. Pediatrics, 108, 671 – 676.
Ritter, M.P. et al. (Ed.) Organ, C.H. Jr. (1998). Treatment of Advanced Gastroesophageal Reflux Disease With Collis Gastroplasty and Belsey Partial Fundoplication. Archives of Surgery, 133(5), 523-529.
Society of American Gastrointestinal Endoscopic Surgeons, Committee on Standards of Practice. (1996). Guidelines for Surgical Treatment of Gastroesophageal Reflux Disease. Retrieved on June 14, 2006 from http://www.lapsurgery.com/sagegerd.htm
Kastner, T. (1997). Helicobacter Pylori Infection in Institutional Settings. Exceptional Health Care, (November).
Lewis, J.H. (1999). Gastroesophageal Reflux Disease. In (Ed.) M.R. Dambro, Griffith’s 5 Minute Clinical Consult.(pp. 422-423). Baltimore: Lippincott Williams & Wilkins.
Smith Consultant Group and McGowan Consultants. (1998). (Ed.) M.L. Snyder, Gastroesophageal Reflux Disease. Health and Wellness Reference Guide (pp. 215-220). Neri Productions, State of Tennessee Commission on Compliance..
Starrett, A.L. (1991). In: Developmental Disabilities in Infancy and Childhood. Eds: Capute, Arnold J. and Pasquale J. Accardo. Baltimore: Paul H. Brookes Publishing Co., Inc., pp. 184-185.
American Gastroenterological Association (AGA), 301-654-2055,
California Department of Developmental Services, 916-654-1690,
California Regional Centers, 916-654-1958,
Digestive Disease Week, 609-848-1000,
International Foundation for Functional Gastrointestinal Disorders, 888-964-2001,
National Digestive Diseases Clearinghouse, 212-685-3440
National Institute of Diabetes, Digestive and Kidney Diseases,
Pediatric/Adolescent Gastroesophageal Reflux Association (PAGER), 301-601-9541,
Society of American Gastrointestinal Endoscopic Surgeons (SAGES), 310-314-2404
Theodore A. Kastner, M.D., M.S.
Felice Weber Parisi, M.D., M.P.H.
Terrance D. Wardinsky, M.D.
Larry Yin, M.D., M.S.P.H., F.A.A.P.
Funded by a grant from the California Department of Developmental Services
For more information, contact:
Center for Health Improvement
1330 21st Street, Suite 100
Sacramento, CA 95814
This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services and the Center for Health Improvement.