## 4 Discussion

Table 7: _Cont._important source of bias, as not all patients routinely benefit from endoscopy and biopsies to rule out eosinophil esophagitis. As indicated above, there were no statistically significant differences between the GERD group and the control group regarding the thrombocyte values. Similar studies do not quote significant differences between hemoglobin, the mean corpuscular volume and thrombocytes either in GERD children as compared to children who do not have this pathology or in children diagnosed with reflux that may or may be not associated with esophagitis [23]. The erythrocyte sedimentation rate was higher in the GERD patients, being one of the statistically significant modifications. Despite being slightly higher in GERD patients, fibrinogen values were not found to differ with statistical significance. On the other hand, anemia associated with the ESR can also suggest a systemic condition, and it thus becomes essential to exclude such a probability [24]. Comparative studies regarding the fibrinogen level in the middle ear fluid and in the blood of children diagnosed with pharyngo-laryngeal reflux and serous otitis media have been conducted, yet the results of these studies are not conclusive [25]. Regarding the serum iron values, the results seem more categorical, as the values recorded in the GERD patients are lower than the ones recorded in the control group and below the biological limit for serum concentrations, most probably due to anemia. Iron-deficiency anemia in GERD patients has also been described in other studies [26] and seems to be a common systemic manifestation of GERD in pediatric patients. Within the study group, we did not detect any liver function test abnormalities. However, in children diagnosed with reflux, hepatitis and liver failure can occur as a result of the administration of H2 inhibitors [27]. In our study, the total protein values were not modified; nevertheless, albumin displayed slightly lower, yet statistically non-significantly so, values within both groups. However, the electrophoresis of proteins is a recommended test that increases the accuracy of diagnosis in immunodeficiency cases that can also occur in GERD [28]. Immunochemical tests indicated significant increases in all the immunoglobulins in the GERD patients, an aspect that could be interpreted as an increased antigenic stimulation induced by acid exposure in such patients. In particular, the Ig E increase could suggest the association with food allergies or asthma. However, according to some studies, food allergies with mainly gastrointestinal symptoms are non-IgE mediated [29]. The blood glucose levels do not show significant changes, as opposed to the magnesium levels, which tend towards the upper limit of the normal variation range in our study group patients. Recent studies have indicated that there may be statistically significant correlations between the severity of GERD symptoms and the basal blood glucose level, suggesting a genetic factor in the association of GERD with the metabolic syndrome [30]. Not least, GERD can also be associated with other less common manifestations, such as esophageal polyps [31]. Such cases were excluded from our cohort, as it would have been impossible to identify the real cause of the reflux symptoms, given the anatomical abnormalities.