Barrett's esophagus in children

The problem of Barrett's esophagus has attracted the attention of clinicians around the world for half a century. This topic has been studied in sufficient detail and described in no less detail in the "adult" literature. The number of pediatric publications concerning Barrett's esophagus is small. This is largely explained by the prevailing (and still extant) point of view that Barrett's esophagus is a purely "adult" pathology, the fatal implementation of which occurs far beyond childhood. As a result, serious study of this disease in children began only in the last two decades, and the first publications date back to the early 80s.

It is no secret that such a high interest in the problem of Barrett's esophagus is primarily due to the high risk of development of esophageal adenocarcinoma (ECA) on metaplastic (true Barrett's) epithelium, the incidence of which in the presence of Barrett's esophagus is 40 times higher than in the population. The above allows us to rightfully classify Barrett's esophagus as a precancerous disease.

The casuistically low frequency of detection of esophageal adenocarcinoma in children creates 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 regard, the search for possible early markers of Barrett's esophagus acquires special meaning in childhood, at the early stages of the disease, when it is possible to competently organize dispensary observation and control the course of the process.

Historical aspect

The history of the discussed issue dates back to 1950, when the 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 "short esophagus and sliding hernia of the esophageal opening of the diaphragm with developed esophageal stricture in a patient. Of this tetrad of signs, the "short" esophagus, i.e. partial replacement of the normal flat non-keratinizing epithelium of the esophagus with the columnar epithelium of the stomach or intestine, turned out to be the most viable. It was this sign that the followers of Imperra used as the basis for the syndrome named after him.

The chronology of subsequent events illustrates the difficult and thorny path from Barrett's initial premise to the modern interpretation of Barrett's esophagus.

In 1953, PR Allison and AS Johnston specified that the esophageal ulcers they had identified were formed on the columnar epithelium and called them "Barrett's ulcers". In 1957, NR Barrett revised his initial hypothesis of the occurrence of esophageal ulcers, admitting the acquired nature of the latter (as a result of gastroesophageal reflux). BR Cohen et al. in 1963 published the results of a study in which they discovered columnar epithelium in the esophagus without ulcer formation and were the first to introduce the term "Barrett's syndrome". In 1975, AR Naef et al proved the high risk of developing esophageal adenocarcinoma in Barrett's esophagus.

One of the first studies devoted to Barrett's esophagus in children was the study by BBDahms et al., who found Barrett's esophagus in 13% of children who underwent endoscopic examination for symptoms of esophagitis. Cooper JMetal. in 1987 described 11 cases of Barrett's esophagus in children with strong 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 esophageal adenocarcinoma in a child with Barrett's esophagus.

In the 90s of the 20th century, periodically appeared works concerning the problem of Barrett's esophagus in children. It is worth mentioning several world centers where this problem is studied: the University of British Columbia (Canada), the University of Cam Sebastian (Spain), a number of universities in the USA, Great Britain, Northern Ireland.

These publications admit that Barrett's esophagus in children can be both congenital and acquired, but the main role, as most authors assume, belongs to reflux - acid and alkaline. In this regard, however, it is unclear why pathological gastroesophageal reflux in some cases is complicated by esophagitis, and in others, with a relatively milder course of the process - Barrett's esophagus.

The number of modern equivalents of the term Barrett's esophagus is surprising. It is enough to name the main ones: Barrett's syndrome, "lower part of the epithelium lined with columnar epithelium", Barrett's epithelium, Barrett's metaplasia, specialized intestinal metaplasia, endobrachioesophagus, etc. But they are very far from the basic description of Barrett himself and imply, basically, only one thing: the presence of columnar epithelium of the stomach and/or small intestine in the lower third of the esophagus, which, in the presence of dysplasia, can predispose to the development of esophageal adenocarcinoma.

In relation to childhood, we believe it is appropriate to use the term "Barrett's transformation" in cases where the child does not have obvious signs of "classic" Barrett's esophagus, but already has focal or "semi-segmental" areas of metaplasia of the esophageal epithelium. Having a solid eponymous basis, the term reflects the essence of the changes occurring in the esophagus at stages preceding the formation of true Barrett's esophagus. At the same time, it should not be used as a diagnosis, being rather a pre-diagnosis (pre-disease) in relation to Barrett's esophagus.

Epidemiology of Barrett's esophagus

The incidence of Barrett's esophagus is usually determined among patients with symptoms of gastroesophageal reflux disease (GERD). In adults, this figure ranges from 8-20% and has significant geographic and demographic variations.

Thus, in the USA, Barrett's esophagus is detected in 5-10% of patients with GERD symptoms, with a significant predominance of patients with a short segment of Barrett's esophagus. In Europe, Barrett's esophagus is found in 1-4% of patients undergoing endoscopic examination. In Japan, this figure does not exceed 0.3-0.6%. There are no exact data for African countries, but it is known that the black population suffers from GERD, Barrett's esophagus and esophageal adenocarcinoma approximately 20 times less often than the white population.

It is extremely important to note that the true incidence of Barrett's esophagus is much higher because the most commonly used endoscopic examination for GERD is not sensitive enough to detect Barrett's metaplasia. There is an "iceberg" of undiagnosed cases of Barrett's esophagus.

There are data on significant gender differences in the incidence of Barrett's esophagus: men predominate in the ratio. The true incidence rates of Barrett's esophagus in children are unknown. The figures of 7-13% available in the literature seem clearly overestimated.

Symptoms of Barrett's Esophagus

Barrett's esophagus does not have a specific picture. As a rule, the diagnosis is established based on the results of endoscopic screening and histological findings. However, most children with Barrett's esophagus present complaints typical of GERD: heartburn, belching, regurgitation, odynophagia, and less often dysphagia. Some children have a "wet pillow symptom".

Symptoms of Barrett's Esophagus

Methods of diagnosing Barrett's esophagus in children

One of the main diagnostic methods that helps to suspect Barrett's esophagus is fibroesophagogastroduodenoscopy (FEGDS). This method allows for a visual assessment of the esophagus and the esophagogastric junction and for taking biopsy material for histological and, if necessary, immunohistochemical examination.

Diagnosis of Barrett's Esophagus

Treatment of Barrett's Esophagus

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.

How is Barrett's esophagus treated in children?

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