Are reflux-related strictures in children different from those in adults?

N. Meadows (London)

Over the last 5 years, the presence of stricture formation in the esophagus attributable solely to reflux esophagitis has declined in children. This is undoubtedly due to the more aggressive therapeutic approach and the increased application of endoscopy and pH study in the management of gastroesophageal reflux in infancy. Indeed a 20-year study from Navarro in France has identified the incidence of stricture formation in 89 patients of 232 infants diagnosed as having reflux [1].

Any consideration of esophageal stricture in children has to take into account the contribution of other congenital defects that may be present (Table 1). These are all associated with reflux, but in addition may have combined esophageal dysmotility. The best examples of such associations would be Down's Syndrome, Hirschprung's and tracheoesophageal fistulae and atresias. In these situations, delayed acid clearance resulting from both reflux and disordered motility predispose the child more readily to stricture formation.

In adults the situation is slightly clearer, with a higher number of reflux patients progressing to stricture formation (approximately 10%). Of perhaps more significance is that 25% of the patients are entirely asymptomatic [2]. Recently, much interest has arisen in the association of Barrett's epithelium and strictures. It has been estimated that approximately 60-80% of strictures show evidence of Barrett's changes, the stricture occurring at the squamo-columnar junction. Certainly this association is increased in the presence of strictures found in patients with hiatus hernia [3].

Table 1..

	Associations with congenital stenosis	Acquired strictures
	Tracheoesophageal fistula	Caustic ingestion
	Duodenal atresia	Peptic esophagitis
	Anorectal anomalies	Severe infections
	Cardiac anomalies Down's syndrome	Epidermolysis Bullosa

Table 2. .Esophageal stricture Queen Elizabeth Hospital (5-year experience)

4 caustic ingestion

3 tracheoesophageal atresia

2 gastroesophageal reflux

In children it is now believed that the association between Barrett's epithelium and stricture formation is equally strong. Initially it was felt that Barrett's epithelium may represent a congenital change, but it is now clear that this is not the case and does indeed represent change associated with reflux. However, care must be taken in the diagnosis and several of the early studies in which Barrett's epithelium was described may represent single gastric metaplasia. The site from which the biopsy was taken has also to be considered, particularly in the case of hiatus hernia, as exemplified in the recent review of the available pediatric studies by Hassall [4,5].

So what are the major differences between adult strictures and those in children? This is probably best illustrated from experience of esophageal strictures obtained at the Queen Elizabeth Hospital for Children in London. In a 5-year period, we have seen a total of 10 children with esophageal strictures. Four of these were associated with caustic ingestion and were in no way related to gastroesophageal reflux. Of the remainder, five were associated with tracheoesophageal atresia or fistula and in four of these gastroesophageal reflux was thought to play an important contributory role. The remaining two patients had pure gastroesophageal reflux-related strictures, both associated with Barrett's epithelium. This change was also present in three of the patients with tracheoesophageal atresia. The most significant finding was that both patients with gastroesophageal strictures were severely cerebrally palsied.

In conclusion, in children, pure reflux strictures are much more likely to be associated with disorders where esophageal dysmotility is also present. The more aggressive diagnostic work-up and management of reflux has resulted in a reduced risk in children with simple reflux. However, in children with handicap, because of the often silent nature of their reflux, consideration of surgical correction has been suggested as an early therapeutic option. The role of treatment in Barrett's epithelium changes remains a matter for debate, although it is the feeling of many clinicians that consideration should be given to early surgery to prevent complications in childhood, particularly stricture formation.

References

1. Navarro J, Cargill G, Foucaud P. Gastro-oesophageal reflux in pediatric gastroenterology. In: Navarro J, Schmitz J (eds) Gastro-oesophageal Reflux in Paediatric Gastroenterology. Oxford: Oxford Medical Publications, 1992;105-123.

2. Katzka DA. Barrett's oesophagus: introduction and management. Gastroenterol Clin North Am 1989;18:339-357.

3. Cameron AJ, Zinsmeister AR, Mallard DJ, Carry JA. Prevalence of columnar-lined (Barrett's) oesophagus. Gastroenterology 1990;99:918-922.

4. Hassall E, Weinstein WM, Ament ME Barrett's oesophagus in childhood. Gastroenterology 1985;89:1331-1337.

5. Hassall E. New definitions and approaches in children. J Fed Gastroenterol Nutr 1993;16:345-364.