Esophagitis in Pediatric Esophageal Atresia

Abstract

Objective: Esophagitis is highly prevalent in patients with esophageal atresia (EA). Peptic esophagitis has long been assumed to be the primary cause of esophagitis in this population, and prolonged acid suppressive medication usage is common; such treatment is of unknown benefit and carries potential risk. Methods: To better understand the role of commonly used antireflux treatments in EA, we analyzed all patients with repaired EA who underwent endoscopy with biopsies at our institution between January 2016 and August 2018. Macroscopic erosive and histologic esophagitis on biopsy was graded per predefined criteria. Clinical characteristics including acid suppressive medication usage, type of EA and repair, presence of hiatal hernia, and history of fundoplication were reviewed. Results: There were 310 unique patients (33.5% long gap EA) who underwent 576 endoscopies with biopsies during the study period. Median age at endoscopy was 3.7 years (interquartile range 21–78 months). Erosive esophagitis was found in 8.7% of patients (6.1% of endoscopies); any degree of histologic eosinophilia (≥1 eosinophil/high power field [HPF]) was seen in 56.8% of patients (48.8% of endoscopies), with >15 eosinophils/HPF seen in 15.2% of patients (12.3% of endoscopies). Acid suppression was common; 86.9% of endoscopies were preceded by acid suppressive medication use. Fundoplication had been performed in 78 patients (25.2%). Proton pump inhibitor (PPI) and/or H2 receptor antagonist (H2RA) use were the only significant predictors of reduced odds for abnormal esophageal biopsy (P = 0.011 for PPI, P = 0.048 for H2RA, and P = 0.001 for PPI combined with H2RA therapy). However, change in intensity of acid suppressive therapy by either dosage or frequency was not significantly associated with change in macroscopic erosive or histologic esophagitis (P > 0.437 and P > 0.13, respectively). Presence or integrity of a fundoplication was not significantly associated with esophagitis (P = 0.236). Conclusions: In EA patients, acid suppressive medication therapy is associated with reduced odds of abnormal esophageal biopsy, though histologic esophagitis is highly prevalent even with high rates of acid suppressive medication use. Esophagitis is likely multifactorial in EA patients, with peptic esophagitis as only one of multiple possible etiologies for esophageal inflammation. The clinical significance of histologic eosinophilia in this population warrants further investigation.

Eosinophilic esophagitis in esophageal atresia: Tertiary care experience of a “selective” approach for biopsy sampling

“…During the study period, clinical charts of 370 patients with EA and 118 patients with EoE were reviewed. Among these, 15 The prevalence of EoE in our cohort of EA survivors (4.0%) was much greater than the 0.1-0.57% estimated in general population, 5 but lower than previously reported (9.5-30%). [11][12][13][14][15][16] Characteristics and main results of previous series are summarized in Table 3.…”

“…Among these, 15 The prevalence of EoE in our cohort of EA survivors (4.0%) was much greater than the 0.1-0.57% estimated in general population, 5 but lower than previously reported (9.5-30%). [11][12][13][14][15][16] Characteristics and main results of previous series are summarized in Table 3. Beside possible regional variability, the main factor accounting for this difference is the approach to esophageal biopsy sampling: "routine" versus "selective".…”

“…30 Gastric acid-inhibiting effect is likely to have a significant role in resolving EE in EA children because of their considerably higher risk of developing severe GERD with prolonged esophageal acid exposure time. 3,15,16,31 PPIs have been shown to also exert anti-inflammatory effects, 17 by inhibiting the production of proinflammatory cytokines and adhesion molecules that act as ligands on the eosinophil cell surface. [32][33][34] Of course, as for EoE from general population, these anti-inflammatory properties of PPIs can also explain PPI-REE observed in EA patients without evidence of GERD.…”

Eosinophilic Esophagitis in Esophageal Atresia

“…Other case series of EoE in EA patients include Yasuda et al (15.2%), Gorter et al (1.25%), Pedersen et al (10%), Batres et al (3%), Oliveira et al (4%), Yamada et al (6%), Kassabian et al (5%), and Lardenois et al (9.5%) (3, 6–13). These figures are significantly higher than the reported incidence of 8–10% EoE in children with suspected GERD not responding to standard anti-reflux treatment (14, 15).…”

“…In the study by Yasuda et al which also looked at treatment outcomes in 31 EA patients with EoE, 10 (32%) were PPI responders, 5 responded only when H2 receptor antagonists was added to PPI, 6 responded only to viscous budesonide and 1 to elimination diet, 1 to the addition of erythromycin as a prokinetic and 3 spontaneously improved over time. Five of the remaining non-responders are being followed up on high dose PPI therapy alone (13). This study was limited by incomplete follow up data as only 66% of EA patients diagnosed with EoE were followed up.…”