Barrett's esophagus in children

The problem of Barrett's esophagus attracts the attention of clinicians around the world for half a century. This topic has been studied in sufficient detail and is described in no less detail in the "adult" literature. The number of pediatric publications relating to Barrett's esophagus is small. This is largely due to the prevailing (and extant to our days) point of view, according to which Barrett's esophagus is a purely "adult" pathology, the fatal realization of which occurs far beyond the child's age. As a result, a serious study of this disease in children began only in the last two decades, and the first publications date from the early 80's.

It is no secret that such a high interest in the problem of Barrett's esophagus is due, first of all, to the high risk of development on the metaplastic (truly barretian) epithelium of adenocarcinoma of the esophagus (ACP), whose incidence in the presence of Barrett's esophagus is 40 times greater than that in the population. The above allows us to rightfully refer Barrett's esophagus to precancerous diseases.

The casually low incidence of adenocarcinoma of the esophagus in children gives rise to the illusion that this problem is the prerogative of therapists and surgeons. At the same time, it is well known that many acquired "adult" diseases "come from childhood". In this case, the search for possible early markers of the Barrett's esophagus acquires a special meaning precisely in childhood, in the early stages of the development of the disease, when it is possible, by correctly constructing a dispensary observation, to monitor the course of the process.

The Architectural Aspect

The history of the issue under discussion has its origins since 1950, when British surgeon Norman R. Barrett published his famous work "Chronic peptic ulcer of the oesophagus and" oesophagitis ", in which he described a combination of peptic ulcer of the esophagus, congenital "A short esophagus and a sliding hernia of the esophageal opening of the diaphragm with a developed stricture of the esophagus. From this tetrad of signs, the "short" esophagus was historically the most viable; a partial replacement of the normal flat nonkeratinized epithelium of the esophagus by the cylindrical epithelium of the stomach or intestine. It was this sign that was put by the followers of Impperra in the basis of the syndrome, named after him.

The chronology of further events illustrates the difficult and thorny path from the initial premise of Barrett to the treatment of Barrett's esophagus in our time.

In 1953 PRAllison and ASJohnston clarified that the ulcers of the esophagus revealed by them are formed on the cylindrical epithelium and called them "Barrett's ulcers". In 1957, NR Barrett reconsidered his original hypothesis of the occurrence of ulcers of the esophagus, allowing the acquired character of the latter (following gastroesophageal reflux). BR Cohen et al. In 1963 published the results of a study in which a cylindrical epithelium was found in the esophagus without ulceration and the term "Barrett's syndrome" was first introduced. In 1975, AR, Naef etaL proved a high risk of developing adenocarcinoma of the esophagus in the Barrett's esophagus.

One of the first studies on Barrett's esophagus in children was the study of BBDahms et al., Who found Barrett's esophagus in 13% of children who underwent an endoscopic examination for symptoms of esophagitis. Cooper JMetal. In 1987 described 11 cases of Barrett's esophagus in children with severe histological and histochemical confirmation. Later, in 1988, RBTudor et al. Described more than 170 cases of Barrett's esophagus in children, and in 1989 JCHoeffel et al. Found adenocarcinoma of the esophagus in a child with Barrett's esophagus.

In the 90s of the 20th century, work was periodically published on the problem of Barrett's esophagus in children. There are several world centers where this problem is being studied: University of British Columbia (Canada), Cam Cam Sebastian University (Spain), a number of universities in the USA, Great Britain, Northern Ireland.

In these publications, it is allowed that Barrett's esophagus in children can be both congenital and acquired, but the main role, as most authors suggest, belongs to reflux - acid and alkaline. In this connection, however, it is not clear why pathological gastro-esophageal reflux in some cases is complicated by esophagitis, and in others, with a relatively easier process, by Barrett's esophagus.

The number of modern equivalents of Barrett's esophagus is surprising. Suffice it to say the main ones: Barrett's syndrome, "the lower part of the epithelium lined with a cylindrical epithelium", Barrett's epithelium, Barret's metaplasia, specialized intestinal metaplasia, endobrachiasophagus, etc. Bet they are quite far from the basic description of Barrett himself and imply basically only one: cylindrical epithelium of the stomach and / or small intestine in the lower third of the esophagus, which in the presence of dysplasia may predispose to the development of adenocarcinoma of the esophagus.

With regard to childhood, we consider it appropriate to use the term "barrett transformation" in cases where the child does not have obvious signs of the "classical" Barrett's esophagus, but there are focal or "semi-segmental" areas of metaplasia of the esophageal epithelium. Having a solid eponymic basis, the term reflects the essence of the changes occurring in the esophagus at the stages preceding the formation of the true esophagus of Barrett. However, it should not be used as a diagnosis, being rather pre-diagnosis (pre-illness) in relation to Barrett's esophagus.

Epidemiology of Barrett's esophagus

The incidence of Barrett's esophagus is usually determined among patients who have symptomatic gastroesophageal reflux disease (GERD). In adults this indicator varies between 8-20% and has significant geographical and demographic fluctuations.

For example, in the US, Barrett's esophagus is defined in 5-10% of patients with GERD symptoms, and patients with a short segment of the barrett's esophagus are markedly prevalent. In Europe, Barrett's esophagus occurs in 1-4% of patients subjected to endoscopic examination. In Japan, this figure does not exceed 0.3-0.6%. There is no precise data on African countries, but it is known that the black population is about 20 times less likely to suffer from GERD, Barrett's esophagus and adenocarcinoma of the esophagus, rather than white.

Of particular importance is the fact that the true frequency of Barrett's esophagus is much higher, since the endoscopic test that is most often used to diagnose GERD is not sensitive enough to assess barrett's metaplasia. There is a kind of "iceberg", the underwater part of which is the undiagnosed cases of Barrett's esophagus.

There is evidence of significant gender differences in the incidence of Barrett's esophagus: men predominate in the ratio. The true incidence of Barrett's esophagus in children is unknown. Available and literature figures of 7-13% seem to be overstated.

Symptoms of Barrett's esophagus

Barrett's esophagus does not have a specific pattern. As a rule, the diagnosis is established by the results of endoscopic screening and histological findings. At the same time, most children with Barrett's esophagus present complaints typical of GERD: heartburn, belching, regurgitation, loneliness, less often dysphagia. Some children have a "symptom of a wet pillow".

Symptoms of Barrett's esophagus

Barrett's esophagitis diagnosis in children

One of the main diagnostic methods that helps to suspect Barrett's esophagus is fibroesophagogastroduodenoscopy (FEGDS). This method allows us to give a visual assessment of the esophagus and the zone of the esophageal-gastric transition and to take a biopsy material for carrying out a histological and, if necessary, immunohistochemical study.

Diagnosis of Barrett's esophagus

Barrett's esophagus treatment

Programs for treating children with Barrett's esophagus usually combine the use of non-drug, medicamentous and, in some cases, surgical methods of treatment. The logic of such programs consists in understanding the most important pathogenetic role of gastroesophageal reflux in such patients. In other words, the basic therapy of Barrett's esophagus and GERD is practically identical.

How is Barrett's esophagus treated in children?

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