How is Barrett's esophagus in children treated?

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

Non-drug treatment of Barrett's esophagus. The list of non-drug measures for the treatment of Barrett's esophagus is standardized and includes traditional regimen and dietary recommendations. It should be remembered that position therapy is of the utmost importance for the patient, especially at night. This simple measure prevents reflux of gastric (or gastrointestinal) contents into the esophagus in a horizontal position. In this regard, raising the head of the child's bed becomes a mandatory recommendation. Trying to do this by increasing the number or size of pillows is a mistake. It is optimal to place bars up to 15 cm high under the legs of the bed.

It is also necessary to follow other specific anti-reflux measures: do not eat before bed, do not lie down after eating, avoid tight belts, do not smoke. The diet should be low in fats and rich in proteins; it is necessary to avoid irritating foods, carbonated drinks, hot and contrasting food, etc.

When drawing up a diet therapy program for children with GERD, it should be taken into account that in most cases this disease is combined with gastritis, gastroduodenitis, diseases of the biliary system and pancreas, intestines. Therefore, as a "basic" diet, the following dietary tables should be recommended: 1st, 5th, 4th.

Drug treatment of Barrett's esophagus. Drug therapy of GERD and Barrett's esophagus in children is currently not fully developed. There is no unity on these issues among therapists.

Most researchers recommend the use of H2 _- histamine blockers (H2 _- HB) or proton pump inhibitors (PPI) in doses 1.5-2 times higher than standard doses and in courses of up to 3 months. The use of high doses is due to the need for adequate suppression of gastroesophageal reflux, i.e. suppression of the acid "attack" on the esophagus.

There are data indicating the appearance of areas of squamous epithelium in Barrett's segments when using omeprazole at a dose of 20 mg 2 times a day for at least 3 months. At the same time, there is an opinion that this therapy is not effective, cannot promote the regeneration of Barrett's epithelium and reduce the risk of developing esophageal adenocarcinoma. Long-term administration of antisecretory therapy in maintenance doses after the main course is also recommended, which is hardly advisable in pediatrics.

There is an opinion that the treatment tactics for Barrett's esophagus primarily depend on the fact and degree of dysplasia. In other words, drug correction in patients with Barrett's esophagus can be effective only at low degrees of dysplasia of the esophageal epithelium. At a high degree of dysplasia, drug treatment is rather palliative, reducing the degree of inflammation, normalizing motility, etc. The method of choice in such cases is surgical correction.

Along with antisecretory drugs, many authors recommend the use of prokinetics, antacids and relarative agents in various combinations and courses of different durations (in the structure of the GERD treatment algorithm).

It should be noted that the recommendations apply mainly to adults and are not fundamentally different from each other.

Therapy in children with GERD and "Barrett's transformation" does not depend on the morphological form of Barrett's esophagus and the presence of dysplasia. However, neither factor is decisive in determining the plan of medical examination and prognosis in children with this pathology. In practice, the following treatment regimen is used:

1. antisecretory drugs - H2 _- histamine blockers or proton pump inhibitors (in children over 12 years old) -l 4 weeks according to the step down system;
2. antacids - preferably alginic acid preparations (topalpan, topal) - 3 weeks; in some cases, it is possible to use combined antacids (phosphalugel, maalox);
3. prokinetics - motilium, domperidone - 3-4 weeks with the desirable repetition of the course after 3-4 weeks (together with antacids);
4. reparants (for erosive and ulcerative lesions of the esophagus) - sucralfate preparations, solcoseryl;
5. drugs that indirectly normalize the activity of the autonomic nervous system - vasoactive drugs, nootropics, belladonna preparations.

Surgical treatment of Barrett's esophagus. There are no uniform recommendations on the timing and tactics of surgical correction of Barrett's esophagus in children. There is no complete unity of views on this problem among adult surgeons either.

There is an opinion that esophagectomy with subsequent coloplasty should be performed in case of high-grade dysplasia, since even the results of multiple biopsies cannot always differentiate between early adenocarcinoma and high-grade dysplasia. The use of fundoplication is also envisaged. According to other data, antireflux operations do not affect the regression of Barrett's esophagus and do not prevent the development of metaplasia in the cylindrical cell epithelium, but only eliminate gastroesophageal reflux for some time.

Along with the opinion about the need for surgical treatment of patients with a high degree of dysplasia, there is evidence that surgical treatment does not prevent the further development of neoplastic changes in the remaining section of the esophagus and adenocarcinoma of the esophagus can develop even after surgery for Barrett's esophagus.

Given the high risk of malignancy, many authors suggest a more radical method of treatment - esophagogastrectomy. According to the authors, absolute indications for this operation are:

1. high degree dysplasia
2. deep penetration of ulcers;
3. convincing suspicion of malignancy;
4. multiple unsuccessful previous antireflux treatments.

Relative indications are also distinguished:

1. strictures that do not respond to probing;
2. young patients who refuse long-term follow-up.

A number of publications present an even more radical point of view, according to which it is necessary to perform surgical treatment of Barrett's esophagus regardless of the absence or presence of dysplasia by the method of esophagogastrectomy due to the high risk of developing esophageal adenocarcinoma in the cylindrical cell epithelium. According to H.Othersen et al., radical surgery (resection of a section of Barrett's esophagus) is advisable to perform if there is no effect from conservative treatment within 4 months.

In the domestic literature there are recommendations on performing extirpation of the esophagus with one-stage coloesophagoplasty in children with Barrett's esophagus in case of esophageal metaplasia of the small intestinal type with an extended esophageal stricture. In the absence of extended strictures, fundoplication can be performed along with drug treatment.

According to some researchers, the presence of Barrett's esophagus in a child is an absolute indication for surgical treatment, which consists of resection of the altered section of the esophagus followed by plastic surgery or a colon transplant or local tissues with simultaneous antireflux protection (no Nissen or Beisi),

Some doctors believe that neither conservative nor surgical treatment excludes the progression of the disease, and the likelihood of developing esophageal adenocarcinoma does not depend on the size of the affected segment or the degree of dysplasia.

Alternative treatments for Barrett's esophagus, including the so-called experimental therapy, are aimed at eliminating ectopic epithelium. One of its varieties is thermal therapy, which uses a laser beam that destroys the surface epithelium by ablation or coagulation. Early attempts to remove dysplastic epithelium using a neodymium YAG laser or electrocautery were unsuccessful due to subsequent relapse of the disease. Transendoscopic destruction of the metaplastic mucosa with an argon laser in combination with acid suppression can lead to epithelial restoration. Antisecretory therapy in these cases should be performed both before and after thermal ablation, since the absence of hydrochloric acid allows the exposed surface of the esophagus to bend with normal epithelium in almost 80% of cases. However, one should also remember the complications of this procedure, such as odynophagia and esophageal perforation.

Another type of laser treatment is photodynamic therapy. Its clinical use began in the eighties. The patient is pre-treated with a photosensitive porphyrin, which accumulates non-selectively in the dysplastic epithelium. A light beam with a special wavelength affects the mucosa, interacting with the porphyrin, and as a result of a photochemical reaction, Barrett's epithelium in the area of light exposure is destroyed.

This therapy has been tried in some clinics in the United States and France with varying degrees of success.

There are no uniform approaches to the use of photodynamic therapy. Some scientists believe that this therapy should be used only for high-grade dysplasia or adenocarcinoma of the esophagus in patients with contraindications to surgical treatment. The use of photodynamic therapy for low-grade dysplasia gives better results. However, at present, it cannot be said with certainty that the use of both of these forms of laser therapy reduces the risk of developing adenocarcinoma of the esophagus. It is also necessary to remember the consequences of laser therapy, since it is known that corrosive damage is a risk factor for squamous cell carcinoma.

One of the main disadvantages of photodynamic therapy is its high cost. The price of a dose of highly sensitive porphyrin is about 3 thousand dollars, and a specialized laser is 375 thousand dollars. This certainly limits the widespread use of this method.

Clinical examination

One of the main tasks of clinical examination of patients with Barrett's esophagus is the prevention of the development of esophageal adenocarcinoma. Only dynamic endoscopic observation with multiple biopsies allows timely diagnosis of dysplastic changes in the metaplastic epithelium and determination of treatment tactics.

The nature of dynamic observation, in our opinion, should be determined by the following points: the presence of dysplasia, its degree, the length of the metaplastic area (short or long segment).

If a short segment without dysplasia is detected, the frequency of endoscopic examination should be no more than once every 2 years; detection of a long segment requires endoscopic examination with biopsy once a year.

In case of low-grade dysplasia, FEGDS is performed once every 6-12 months against the background of active therapy. High-grade dysplasia in Barrett's esophagus requires endoscopic examination with biopsy once every 3-6 months if surgical treatment is impossible or undesirable.

It is also worth citing the opinion of pessimists who claim that there are no significant differences in the average life expectancy of patients regardless of the regularity of endoscopic monitoring.

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