Barrett's esophagus in children. Diagnosis and management

Barrett's oesophagus and oesophageal cancer following oesophageal atresia repair: a systematic review

BACKGROUND

Concern exists that patients born with oesophageal atresia (OA) may be at high risk for Barrett's oesophagus (BO), a known malignant precursor to the development of oesophageal adenocarcinoma. Screening endoscopy has a role in early BO identification but is not universal in this population. This study aimed to determine prevalence of BO after OA repair surgery, to quantify the magnitude of this association and inform the need for screening and surveillance.

METHODS

A systematic review, undertaken according to PRISMA guidelines, was preregistered on PROSPERO (CRD42017081001). PubMed and EMBASE were interrogated using a standardized search strategy on 31 July 2020. Included papers, published in English, reported either: one or more patients with either BO (gastric/intestinal metaplasia) or oesophageal cancer in patients born with OA; or long-term (greater than 2 years) follow-up after OA surgery with or without endoscopic screening or surveillance.

RESULTS

Some 134 studies were identified, including 19 case reports or series and 115 single- or multi-centre cohort studies. There were 13 cases of oesophageal cancer (9 squamous cell carcinoma, 4 adenocarcinoma) with a mean age at diagnosis of 40.5 (range 20-47) years. From 6282 patients under long-term follow-up, 317 patients with BO were reported. Overall prevalence of BO was 5.0 (95 per cent c.i. 4.5 to 5.6) per cent, with a mean age at detection of 13.8 years (range 8 months to 56 years). Prevalence of BO in series reporting endoscopic screening or surveillance was 12.8 (95 per cent c.i. 11.3 to 14.5) per cent.

CONCLUSION

Despite a limited number of cancers, the prevalence of BO in patients born with OA is relatively high. While limited by the quality of available evidence, this review suggests endoscopic screening and surveillance may be warranted, but uncertainties remain over the design and effectiveness of any putative programme.

Barrett's esophagus in children: what is the evidence?

BACKGROUND

This study systematically reviewed etiology, prevalence, treatment and outcome of Barrett's esophagus (BE) in the pediatric population.

METHODS

PubMed^® was searched for terms "Barrett's esophagus" and "children". End points were age of patients, etiology, association with other syndromes, treatment, incidence of carcinoma and outcome. This review was conducted according to the PRISMA guidelines. Data were collected, entered and analyzed into a Microsoft Excel^® spreadsheet database.

RESULTS

Search revealed 278 articles published between 1984 and 2017, of which 18 met the inclusion criteria. There were 130 patients for analysis with a mean age 10.6 years (0.8-17.2 years). BE was diagnosed in 80 patients with confirmed gastroesophageal reflux (GER) only; further 20 patients were neurologically impaired and had GER, 13 after esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) repair with associated GER, 6 post-chemotherapy, 1 after post caustic burns, 1 after esophageal replacement with stomach, 1 after peptic esophageal stricture, 1 with secretory diarrhea, 1 with Fanconi anemia, 1 tetralogy of Fallot, and 5 healthy children. Regarding treatment, 26 were on medical treatment only, 16 had surgeries combined with medical treatment, 80 patients underwent surgery only, 1 was on diet management, 4 were on surveillance only and 2 were never treated for BE as death occurred because of associated conditions. Fundoplication was the most commonly performed surgery (82.2%). Adenocarcinoma was found in one 23-year-old patient. Mean follow-up was 3.45 years (10 months-13 years) and long-term outcome showed recurrences in 8 and esophago-mediastinal fistula and proximal esophagus ulcer in 1. There were 7 lethal outcomes which were not directly associated with BE.

CONCLUSIONS

Although BE is considered a premalignant condition; incidence of carcinoma in pediatric population is low. Long-term follow-up with endoscopies and biopsies seems to be advisable for BE evidence and malignant alterations.

Surgical and Molecular Pathology of Barrett Esophagus

BACKGROUND

Patients with Barrett esophagus (BE) are predisposed to developing dysplasia and cancer. Adenocarcinoma, which is associated with BE, is the most common type of esophageal tumor and, typically, it has an aggressive clinical course and a high rate of mortality.

METHODS

The English-language literature relating to tumor epidemiology, etiology, and the pathogenesis of BE was reviewed and summarized.

RESULTS

The role of pathologists in the diagnosis and pitfalls associated with grading Barrett dysplasia is addressed. Current molecular testing for Barrett neoplasia, as well as testing methods currently in development, is discussed, focusing on relevant tests for diagnosing tumor types, determining prognosis, and assessing therapeutic response.

CONCLUSIONS

Grading is essential for developing appropriate treatment plans, follow-up visits, and therapeutic interventions for each patient. Familiarity with current molecular testing methods will help physicians correctly diagnose the disease and select the most appropriate therapy for each of their patients.

Barrett's esophagus in children: does it need more attention?

BACKGROUND

Few studies have reported on Barrett's esophagus (BE) in children. Moreover, information on the age at diagnosis and the duration between reflux-symptoms and diagnosis is lacking.

METHODS

A review of the literature was performed in PubMed, EMBASE and the Cochrane database.

RESULTS

Fourteen articles were included, of which 4 cohort studies and 10 studies investigating patients already diagnosed with BE. The cohort studies showed 37 patients diagnosed with BE (0.3-4.8%), mean age 12.4 years. Time between onset of reflux-symptoms and BE was 2.8 years. All 14 studies together showed 176 patients with BE (mean age 9.5 years). Time between onset of reflux-symptoms and BE was 5.3 years. During endoscopic follow-up of 45 patients, 26 still had BE, 17 no longer had evidence of BE, and two had developed esophageal-adenocarcinoma.

CONCLUSION

This review shows that BE and esophageal-adenocarcinoma occur in children. However, criteria used to define BE by the included studies were not comparable to the current criteria and data on GERD symptoms may have been inaccurate. Therefore, we recommend performing a long-term prospective study on the relationship between (duration of) GERD and the development of BE in children in order to define screening guidelines.

Barrett's esophagus at a tertiary care center: association of age on incidence and prevalence of dysplasia and adenocarcinoma

OBJECTIVES

Barrett's esophagus (BE) is traditionally thought of as a disease of middle-aged Caucasian men. Little is known about BE in younger patients. We sought to assess the effect of age on features of BE including the prevalence and incidence of dysplasia and carcinoma.

METHODS

All patients enrolled into the Cleveland Clinic BE registry from 1979 to 2002 were studied. Age, ethnicity, number of endoscopies, hiatal hernia size, length of Barrett's segment, prevalence and incidence of dysplasia, and cancer were compared between patients > or = 50 yr old and < 50 yr old.

RESULTS

There were 837 patients in the registry (638 > or = 50 yr, 199 < 50 yr). Hiatal hernia size was larger in patients > or = 50 yr than in those < 50 yr (median 4.0 cm, interquartile range 2.0-5.0 cm vs 3.0, 2.0-4.0 cm; p < 0.01). Otherwise, there were no significant differences among other features in the patient population. There were 225 patients with dysplasia or cancer (195 > or = 50 yr and 30 < 50 yr; p < 0.01). Of this group, 176 were prevalent cases (159 > or = 50 yr and 17 < 50 yr) and 49 were incident cases (36 > or = 50 yr and 13 < 50 yr). The odds of those > or = 50 yr being a prevalent case of high-grade dysplasia or cancer was five times the odds of those < 50 yr (p < 0.01). The incidence of dysplasia or cancer was similar in both age groups.

CONCLUSIONS

Our study supports emerging data that approximately 25% of BE patients are less than 50 yr of age. While older patients had a higher prevalence of dysplasia or adenocarcinoma, the incidence of dysplasia and adenocarcinoma is similar in both age groups. Future screening strategies for BE should recognize these important findings.

Laparoscopic fundoplication and gastrostomy

Minimally invasive surgical approaches to various pediatric surgical disease processes are becoming the standard of care. Laparoscopic Nissen fundoplication is transitioning toward the preferred method for the surgical correction of gastroesophageal reflux (GER) disease in infants and children that do not respond to medical management or have complications from their GER. This approach offers a shorter hospitalization, reduced discomfort, and cosmetic advantages when compared with the open operation. This report discusses the pathophysiology of GER, its clinical manifestations, and the diagnostic evaluation for this disorder. Also, the laparoscopic Nissen fundoplication technique currently utilized at Children's Mercy Hospital is described.

Gastroesophageal reflux disease in children

In the pediatric population, gastroesophageal reflux most often presents in infancy as effortless regurgitation, but pathologic GERD is accompanied by signs of malnutrition, respiratory diseases, and esophagitis or its complications. Because of the distinctive pathophysiology predisposing infants to GERD, the diagnostic approach must begin with a thorough history that determines the extent of further diagnostic tests and the course of management. Empiric therapy assumes importance in infants with GERD because of the limited differential diagnoses in consideration. Conservative therapy is of utmost importance because of the unique provocative factors in the pathophysiology of infantile GERD. Prokinetic pharmacotherapy takes precedence over acid suppression because of the more important role of motility factors compared with acid secretion in infantile GERD.

The prevalence of gastroesophageal reflux disease in institutionalized intellectually disabled individuals

OBJECTIVE

The prevalence of gastroesophageal reflux disease (GERD) was randomly investigated among Dutch and Belgian intellectually disabled individuals.

METHODS

In six institutes including 1607 residents, 435 persons with IQ <50 underwent 24-h esophageal pH-metry and were scored for possible predisposing factors and characteristic reflux symptoms. In 49 (11.2%) cases the test failed because of technical reasons. A pathological pH test was defined as a pH <4 for >4.5% of the measured time. Subjects with a pathological pH test (patients) were compared with those with a normal pH test (controls).

RESULTS

Of the remaining individuals, 51.8% (200/386) showed a normal pH test, whereas 186 showed a pathological pH test (median duration pH <4: 14.2%, range: 4.5-78.4%). As possible predisposing factors scoliosis, cerebral palsy, use of anticonvulsant drugs or other benzodiazepines, and IQ <35 were found, whereas symptoms such as vomiting, hematemesis, rumination, and depressive symptoms were indicative for reflux. At endoscopy reflux esophagitis was diagnosed in 129 of the 186 patients (69.4%). In 61 (47.3%) of 129 patients, grade I, 43 (33.3%) grade II, 25 (19.4%) grade III/IV (Savary-Miller) were found. Barrett's esophagus was found in 18 (14.0%) and peptic strictures in five (3.9%) cases.

CONCLUSIONS

An abnormal 24-h pH-metry and symptoms suggestive for GERD were documented frequently in a large cohort of institutionalized intellectually disabled individuals. Further endoscopical evaluation confirmed the diagnosis of reflux esophagitis in the majority of these individuals.

Barrett's Esophagus and Barrett's Associated Neoplasia: Etiology and Pathologic Features

BACKGROUND: The incidence of Barrett's esophagus (BE) has been increasing in recent years. Patients with BE have 30- to 125-fold increased risk of developing adenocarcinoma. New techniques allowing early diagnosis, in addition to the identification of markers capable of predicting tumor progression, are needed. METHODS: The authors discuss the diagnostic features of BE and BE-associated neoplasia. RESULTS: BE can exhibit different types of metaplastic mucosa, but only the specialized (intestinal) mucosa has the potential to progress to dysplasia and carcinoma. The problems associated with diagnosing BE and with predicting the behavior of this condition are outlined. CONCLUSIONS: Studies are underway to identify molecular markers capable of predicting which BE patient will progress to carcinoma. Brush cytology and flow cytometry may become useful tools in the early detection of this disease.

Gastroesophageal reflux in childhood

Gastroesophageal reflux (GER) is one of the most frequent symptomatic clinical disorders affecting the gastrointestinal tract of infants and children. During the past 2 decades, GER has been recognized more frequently because of an increased awareness of the condition and also because of the more sophisticated diagnostic techniques that have been developed for both identifying and quantifying the disorder. Gastroesophageal fundoplication is currently one of the three most common major operations performed on infants and children by pediatric surgeons in the United States. Normal gastroesophageal function is a complex mechanism that depends on effective esophageal motility, timely relaxation and contractility of the lower esophageal sphincter, the mean intraluminal pressure in the stomach, the effectiveness of contractility in emptying of the stomach, and the ease of gastric outflow. More than one of these factors are often abnormal in the same child with symptomatic GER. In addition, in patients with GER disease, and particularly in those patients with neurologic disorders, there appears to be a high prevalence of autonomic neuropathy in which esophagogastric transit and gastric emptying are frequently delayed, producing a somewhat complex foregut motility disorder. GER has a different course and prognosis depending on the age of onset. The incompetent lower esophageal sphincter mechanism present in most newborn infants combined with the increased intraabdominal pressure from crying or straining commonly becomes much less frequent as a cause of vomiting after the age of 4 months. Chalasia and rumination of infancy are self-limited and should be carefully separated from symptomatic GER, which requires treatment. The most frequent complications of recurrent GER in childhood are failure to thrive as a result of caloric deprivation and recurrent bronchitis or pneumonia caused by repeated pulmonary aspiration of gastric fluid. Children with GER disease commonly have more refluxing episodes when in the supine position, particularly during sleep. The reflux of acid into the mid or upper esophagus may stimulate vagal reflexes and produce reflex laryngospasm, bronchospasm, or both, which may accentuate the symptoms of asthma. Reflux may also be a cause of obstructive apnea in infants and possibly a cause of recurrent stridor, acute hypoxia, and even the sudden infant death syndrome. Premature infants with respiratory distress syndrome have a high incidence of GER. Esophagitis and severe dental carries are common manifestations of GER in childhood. Barrett's columnar mucosal changes in the lower esophagus are not infrequent in adolescent children with chronic GER, particularly when Heliobacter pylori is present in the gastric mucosa. Associated disorders include esophageal dysmotility, which has been recognized in approximately one third of children with severe GER. Symptomatic GER is estimated to occur in 30% to 80% of infants who have undergone repair of esophageal atresia malformations. Neurologically impaired children are at high risk for having symptomatic GER, particularly if nasogastric or gastrostomy feedings are necessary. Delayed gastric emptying (DGE) has been documented with increasing frequency in infants and children who have symptoms of GER, particularly those with neurologic disorders. DGE may also be a cause of gas bloat, gagging, and breakdown or slippage of a well-constructed gastroesophageal fundoplication. The most helpful test for diagnosing and quantifying GER in childhood is the 24-hour esophageal pH monitoring study. Miniaturized probes that are small enough to use easily in the newborn infant are available. This study is 100% accurate in diagnosing reflux when the esophageal pH is less than 4.0 for more than 5% of the total monitored time.