How is Barrett's esophagus treated in children?

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.

Non-drug treatment of Barrett's esophagus. The list of non-pharmacological activities in the treatment of Barrett's esophagus is standardized and includes traditional dietary and dietary recommendations. It should be remembered that the most important for the patient is therapy by position, especially at night. This simplest measure prevents reflux of gastric (or gastrointestinal) contents into the esophagus in a horizontal position. In this regard, raising the head end of the baby's bed becomes an obligatory recommendation. Trying to do this by increasing the number or size of the pillows is an error. Optimum to put under the legs of the bed bruski height of 15 cm.

It is necessary to comply with other specific antireflux measures: do not eat before bed, do not lie down after eating, avoid tight belts, do not smoke. The diet should be depleted in fats and enriched in proteins; It is necessary to avoid taking irritating foods, carbonated drinks, hot and temperature-contrast foods, etc.

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

Drug treatment for Barrett's esophagus. Drug therapy for GERD and Barrett's esophagus in children is not fully developed at the moment. There is no unity on these issues and with therapists.

Most researchers recommend the appointment of H ₂ -gistaminoblockers (H ₂ -GB) or proton pump inhibitors (PPI) in doses exceeding the standard by 1.5-2 times and courses up to 3 months. The purpose 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 the Barrett segments when omeprazole is administered 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, can not promote the regeneration of the barrett's epithelium and reduce the risk of developing adenocarcinoma of the esophagus. 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 therapeutic tactics for Barrett's esophagus primarily depend on the fact and the degree of dysplasia. In other words, medication correction in patients with Barrett's esophagus can be effective only at low degrees of dysplasia of the esophageal epithelium. With a high degree of dysplasia, medication is more palliative in nature, reducing the degree of inflammation, normalizing motor skills, etc. The method of choice in such cases is surgical correction.

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

It should be noted that the recommendations relate mainly to the adult contingent and do not fundamentally differ from each other.

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

1. antisecretory drugs - H ₂ -gistaminoblockers or proton pump inhibitors (in children over 12 years old) -l 4 weeks in the system of step down;
2. antacids - preferably preparations of alginic acid (topalpan, topal) - 3 weeks; in some cases, the use of combined antacids (phosphalugel, maalox);
3. prokinetics - motilium, domperidone - 3-4 weeks with the desired repetition of the course in 3-4 weeks (along with antacids);
4. reparants (with erosive and ulcerative lesions of the esophagus) - preparations of sucralfate, solcoseryl;
5. drugs that indirectly normalize the activity of the autonomic nervous system - vasoactive drugs, nootropics, preparations of belladonna.

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

There is an opinion that an esophagectomy followed by coloplasty should be carried out at a high degree of dysplasia, because according to the results of even multiple biopsies, it is not always possible to distinguish between early adenocarcinoma and a high degree of dysplasia. It is envisaged to use and fundoplication. According to other data, antireflux surgery does not affect the regression of the Barrett's esophagus and is not a prevention of the development of metaplasia in the cylindrical cell epithelium, but only eliminate gastroesophageal reflux for a while.

Along with the opinion on 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 area of the esophagus and adenocarcinoma of the esophagus may develop even after the intervention about the Barrett's esophagus.

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

1. high degree of dysplasia
2. deep penetration;
3. convincing suspicions of malignancy;
4. multiple unsuccessful previous antireflux procedures.

There are also relative indications:

1. strictures that are not amenable to bougie;
2. young patients who refuse to observe for a long time.

A number of publications present an even more radical point of view, according to which the operative treatment of the Barrett's esophagus is necessary, regardless of the absence or presence of dysplasia by the method of esophagogastectomy, in connection with the high risk of development of adenocarcinoma of the esophagus in the cylindrical cell epithelium. According to H.Othersen et al. A radical operation (resection of the Barrett's esophagus) should be performed in the absence of the effect of conservative treatment for 4 months.

In the domestic literature, there are recommendations on the performance of extirpation of the esophagus with one-stage coloesophagoplasty in children with Barrett's esophagus under metaplasia of the esophagus by a small intestine type with a long stricture of the esophagus. In the absence of extensive strictures, it is possible to carry out fundoplication along with drug treatment.

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

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

Alternative methods for treating Barrett's esophagus, including so-called experimental therapy, are aimed at eliminating the ectopic epithelium. One of its varieties is thermal therapy, which uses a laser beam that destroys the superficial epithelium by ablation or coagulation. Early attempts to remove the dysplastic epithelium using a neodymium YAG laser or an electrocauter were not successful because of a subsequent relapse of the disease. Transendoscopic destruction by argon laser meta plastic mucosa in combination with acid suppression can lead to the restoration of the epithelium. 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 into normal epithelium in almost 80% of cases. However, one should also remember the complications of this procedure such as loneliness and perforation of the esophagus.

Another type of laser treatment is photodynamic therapy. Clinical use of it began in the eighties. The patient is preselected a photosensitive porphyrin, which is unselectively accumulated in the dysplastic epithelium. A light beam with a special wavelength acts on the mucous membrane, interacting with porphyrin, and as a result of the photochemical reaction, the barrett's epithelium of the light exposure region is destroyed.

In some clinics in the US and France, this therapy has been tested with varying degrees of success.

Single approaches to the use of photodynamic therapy do not exist. Some scientists believe that this therapy should be used only with a high degree of dysplasia or adenocarcinoma of the esophagus in patients who have contraindications to surgical treatment. The use of photodynamic therapy for low-grade dysplasia produces better results. However, at the present time it can not be said with certainty that the use of both these forms of laser therapy reduces the risk of developing adenocarcinoma of the esophagus. One should also remember the consequences of laser therapy, since it is known that corrosion 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 - 375 thousand dollars. This, of course, limits the wide 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 adenocarcinoma of the esophagus. Only dynamic endoscopic observation with multiple biopsy allows timely diagnosing dysplastic changes in metaplastic epithelium and determining the tactics of treatment.

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

If a short segment without dysplasia is detected, the frequency of endoscopic examination should be no more than 1 time in 2 years; The detection of a long segment suggests an endoscopic study with a biopsy once a year.

With low-grade dysplasia, PHAGS is performed once every 6-12 months. On the background of actively conducted therapy. High-grade dysplasia in the Barrett's esophagus suggests an endoscopic examination with a biopsy once every 3-6 months. If it is impossible or unwilling to carry out surgical treatment.

It should also lead the opinion of pessimists who argue that there are no significant differences in the average life expectancy of patients regardless of the regularity of endoscopic control.

[1], [2], [3], [4], [5]