Complicated GERD

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The important esophageal complications of chronic reflux are strictures, Barrett's esophagus, and adenocarcinoma. Aggressive medical management, preferably with proton pump inhibitors, and close follow-up, using tests to assess symptoms and severity of reflux, are warranted in complicated GERD. Surgical management is contemplated in patients who remain unresponsive to medical therapy.


Exposure of the esophagus to acid and perhaps to pepsin is crucial to the pathogenesis of reflux strictures; hiatal hernia and esophageal dysmotility are other risk factors [80]. Reflux strictures are typically located in the distal third of the esophagus, and should be distinguished from congenital esophageal stenosis and other types of strictures: caustic (generally more proximal), eosinophilic, postoperative/ anastomotic, following radiation therapy or sclero-therapy, or (rarely in children) malignant. Esoph-ageal mucosal biopsies obtained below the stricture help to confirm the diagnosis of reflux esophagitis and exclude eosinophilic esophagitis, Barrett's esophagus, or malignancy. Reflux strictures are treated with a series of dilations in conjunction with potent antireflux therapy [81]. Surgical resection or strictureplasty are reserved for recalcitrant strictures [82].

Barrett's esophagus

Barrett's esophagus, a rare diagnosis in children, is known to occur with long-standing acid exposure, and in association with cystic fibrosis, severe mental retardation, and repaired esophageal atresia [83], [84]. Genetic predispositions, prolonged duration of esoph-ageal acid exposure, more severe nocturnal symptoms, and a reduced sensitivity to acid are implicated in the causation of Barrett's esophagus. Normal esophageal squamous epithelium is replaced by intestinal columnar metaplasia with goblet cells; the metaplasia is recognized in the distal esophagus as salmon-colored tongues of tissue projecting proximally into the paler pink esophagus. Guidelines for screening and surveillance have been proposed to help identify patients with Barrett's esophagus who may progress to develop dysplasia and adenocarcinoma [85].


Adenocarcinoma is extremely rare in childhood, but it does occur and should be sought in those with Barrett's esophagus. In an 11 year-old patient, the diagnosis of Barrett's esophagus was reported to progress to adeno-carcinoma [86]. The risk of developing esophageal ade-nocarcinoma increases with hiatal hernia size, Barrett's esophagus length, and acid reflux severity.

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