jurnal baret esofagus

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35 3

R ad iog raph ic F ind ings in

C h ild ren and Y oung A du lts

w ith B a rre tt’s E sophagus

B a r ry S . Y ulis h1

The uppe r-g as tro in te s tin a l e xam ina tio n s o f 3 2 pat ie n ts m ean age , 1 1 years w ith

F re d

C .

23

histo logical ly

p roven B a rre tt ’s e sophagus w e re re v iew ed to eva lua te th e rad io log ic

T ho m as C . H a lp in Jr.3 fin d ings in ch ild ren . A ll p a tie n ts had sym p tom s o f ch ron ic g as tro esophagea l re flu x and /

,

o r esophag itis , in c lud ing atyp ica l f in d ings such as asp ira tio n pneum on ia , s e izu re s , and

fa ilu re to th riv e . Fou rteen patie n ts had o th er d ise ases th a t m igh t p red ispose th em to

a b n o rm a l e s o p h a ge a l m o til ity a n d g a s tro e so p h a g e a l re flu x . T w e n ty -five p a tien ts h a d

s ing le -con tra s t and seven pa tie n ts had doub le -con tra s t exam ina tio n s . Fou r p at ie n ts had

no rm a l s ing le -con tras t s tud ie s ; 24 had gas tro esophagea l re flu x ; 12 had s tric tu re s ; 10

had esophagea l u lce rs ; and on ly fou r h ad h ia ta l h e rn ia s . The m os t no tab le d iffe ren ce

be tw een th e re su lts o f endoscopy and th e uppe r-g as tro in te s tin a l s tud ies w as the ra te

o f d e te c tio n o f e sophagea l u lc ers . T en o f th e patie n ts w ith s ing le -con tra s t s tud ie s had

u lce rs seen at endoscopy bu t no t show n rad io log ic a lly . N o spec ific rad io log ic s igns o f

Barret t ’s

esophagus w ere found , a lth ough m ost o f ou r p atie n ts had abno rm a l uppe r

g astro in tes tin al s tu die s.

C h ro n ic g a s tro e so p h a g e a l re flu x in in fa n ts a n d c h ild re n c a n le a d to se r io u s

se q u e la e , s uc h a s e s o ph a g itis , s tric tu re , g a s tro in te s tin a l b le e d in g , fa ilu re to th riv e ,

se izu re -like a c tiv ity , a sp ira tio n p n e u m o n ia , a n d p o ss ib ly a p n e a an d su d d e n -in fan t-

d ea th synd rom e [1 - 7 ]. T h e de ve lop m en t o f B a rre tt’s e sop hag us in ch ild re n as a

re su lt o f ch ro n ic g a s tro e so p h a g e a l re fiu x h a s n o t b e e n

prop e rly ap p rec ia te d un til

recen tly [6 ]. It occu rs w hen the squa m ou s ep ithe lia l lin ing o f the lo w er esoph agu s

is in ju re d b y ch ro n ic re flu x o f a c id a n d p e p s in a n d th e n re p la ce d b y h e te ro to p ic

co lu m na r e p ith e lium [6 , 7 ]. T h is rep o rt p re sen ts rad iog raph ic find ings in 32 ch ild ren

an d yo ung adu lts w ith h is to lo g ica lly p roven B arre tt’s e sop hag us.

M ate ria ls and M e thods

W e re tro sp e c tive ly re v ie w e d th e u p p e r-g a s tro in te s tin a l se r ie s o f 3 0 ch ild re n a n d y o un g

a du lts re fe rre d to th e p ed ia tric ga s tro en te ro lo g y se rv ice a t R a in bo w B ab ie s an d C h ild ren s

H os p ita l be tw e e n 1 9 78 a n d 1 9 86 , a ll o f w h om h ad sy m p to m a tic g as tro e sop h ag ea l re flu x an d

h is to lo g ic e v id en ce o f es op ha g itis an d B a rre tt’s es op hag us . T h ese pa tie n ts rep res en ted 9%

R ece ive d Jun e 1 0, 1 9 86 ; ac cep te d a fte r rev is io n o f tho se w ith e n do sco p ica lly p ro ve n re flu x e so ph ag itis . T w o ad d itio n a l p a tien ts ha d u pp er-

S e p te m ber 4 , 1 98 6 . g as tro in tes t ina l s tu d ie s a t ou r in s ti tu tion , w ith e nd os cop y a nd b iop sy pe rfo rm ed

e ls e w h e re .

D e pa rtm en t o f R a d io lo gy , U n iv e rs ity H osp ita ls G en de r d is tr ibu tio n w a s e qua l, a n d th e a g e s ra n g e d fro m 6 m o n th s to 2 1 ye a rs o ld (m e a n ,

o f C le ve la nd , 2 07 4 A b in g to n R d ., C lev e lan d , O H yea rs ) .

4 41 06 . A d dre ss re p rin t re qu es ts to B . S . Y u h sh . M os t p a tien ts ha d ch ron ic co m p la in ts (a t lea s t 3 m o n th s ’ du ra tion a nd a s lo ng as se ve ra l

2 D ep a rtm e n t o f P ed ia trics , R a inb o w B a b ies an d ye a rs ). T w e n ty -tw o pa tie n ts p re se n te d w ith co m p la in ts su g ge s tive o f e so ph a g itis , in c lu d in g

C h ic iren sH os p ita l, 2 10 1 A d e lb e rt A d ., C le ve lan d , e p igas tric p a in , d ys pha g ia fo r so lid s , a nd che st d is co m fo rt. E ig h te en pa tien ts h ad ch ron ic

.

v o m itin g ; n in e h a d p ro tra c ted vo m itin g d u rin g in fa n cy . N in e h a d g a stro in te s tina l b le e d in g

3

D ep artm e n t o f

{ 149 }

e d ia trics , T h e M ou n t S in a i (usu a lly o ccu lt b loo d in s to o l), se ven ha d h ea rtbu rn , an d se ven ha d w a te r b ras h . F ive p a tien ts

M ed ica l C en te r, U nive rs ity C irc le , C le ve la nd , O H

. . . . . .

4 41 06 . h ad fa ilu re to th riv e , irr ita b ility , o r po s tu r in g es pe c ia lly w ith fe e d ing . E ig h t pa tie n ts ha d

AJ R 148:3 53 -35 7 , Feb rua ry 1 987 p u lm o na ry p rob lem s , inc lud in g n igh t co ug h , pn eum o n ia , o r ch ron ic a s th m a. F ou rte en pa t ien ts

0 3 61 -8 03 X /8 7 /1 4 8 2-0 3 53 h ad d ise a se s tha t can p re d ispo se to ga s tro es op ha g ea l re flu x . T h ese p a tie n ts in c lud e d fiv e

0 A m er ican R o en tgen R ay Soc ie t y w h o h ad re p a ired e so ph ag e a l a tre s ia , five w ith p sych o m o to r re ta rda tio n , th ree w ith a s th m a



I 2

3 54 Y U LIS H E T A L. A J A :1 48 , F eb ru a ry 1 98 7

b ein g t re at ed

w ith th eo ph y lline , a n d o n e w ith fam ilia l d ysa u to no m ia .

O ne ch ild w ith p re v io u s e s o p h ag e a l a tre s ia a nd o n e w ith p syc h o m oto r

re ta rd a tion a lso ha d a s thm a. P a tien ts w ith o th e r u nd er ly ing d ise a ses

in c lu de d tw o pa tien ts w ith c ys tic fib ros is , o ne w ith D ow n sy nd rom e

a nd du od e na l a tres ia , o ne w ith a cu te ly m p ho b las tic leu ke m ia in

re la p se , o n e w ith iso la te d co n g e n ita l h ea rt d ise a s e , a n d o n e w ith

re p a ired om ph a loc e le a nd m alro ta tion .

E a ch p a tie n t h a d fle x ib le fib e ro p tic e so p h a g o g a stro sco p y a n d

b io ps y p e rfo rm e d b y a p ed ia tric g as tro e n te ro log is t. A ll b io ps ie s w e re

ta ken u n de r d ire c t e nd o sco p ic v isu a liz a tio n a t lea s t 2 cm p ro x im a l to

th e lo w e r e so p ha ge a l sp h inc te r. B io ps ie s w e re co ns ide re d po s itive

fo r B a rre tt’s es op ha g us if ab n o rm al co lu m n ar ep ith e liu m w as sh o w n :

1 g as tric fu nd ic typ e m uco sa , 2 ju nc tio na l ep ithe liu m re min is ce nt

o f g as tric ca rd ia , a nd /o r

(3 ) sp e c ia lize d co lu m na r e p ith e liu m w ith

v illifo rm su rfac e a n d g o b le t ce lls (6 1 . J u nc tio n a l e p ith e liu m w as in s u f-

fic ien t b y its e lf un les s m ac ros co p ic ev ide nc e o f B a rre tt’s m uc os a w a s

a lso p re se n t 1 6 1 . C olu m na r e p ith e liu m a t e n d o sc o p y w as n o t a lw ays

a pp a re n t; its s a lm on -p in k c o lo r in c h ild re n is d iffic u lt to d is ting u ish

fro m the a p pe aran ce o f in fla m e d sq ua m o us ep ith e liu m [6 , 7 ]. E so ph -

ag itis w as s us pec te d a t e ndo sc op y (e dem a , e ry th em a, friab ility , u l-

ce rs , e xu d a te ) a n d co n firm ed b y b io p sy .

C on tras t s tu d ie s w e re p e rfo rm e d by p ed ia tric rad io lo g is ts a n d by

rad io lo gy re s id en ts w ith va ry in g d eg ree s o f ex pe rie nce . A ll s tud ie s

do n e b y res id en ts w ere su pe rv ised b y s ta ff ra d io log is ts w h o re v iew ed

a ll fi lm s a nd w h o w e re e ithe r p re se n t du rin g flu o rosc op y o r h ad

a cce s s to th e v id e o ta pe for re v iew o f flu o ro sco p y . S e v e n p a tie n ts

h a d d o u b le -co n tra s t e x a m in a tio n s , w h ile 25 in fa n ts a n d c h ild re n

un ab le to co op era te w e re e xa m ine d b y s in g le -c on tras t te chn iq u e .

B a rium w a s g ive n by c up , b ab y bo ttle , fee d in g tube , o r o cc as ion a lly

th ro u gh g as tro s tom y tub e . A ll pa tie n ts ha d ev a lua tio n o f the s tom ac h

an d du o de nu m to ru le o u t ob s tru c tin g g as tric les io ns a n d m alro ta tion .

G astroe so ph ag ea l re flu x w as eva lu a te d by de live rin g a v o lu m e o f

ba riu m app ro ach in g a no rm a l fee d in g , re m o v in g a fe ed ing tub e if

p re s e n t, b u rp in g th e ch ild w h e re a p p ro p r ia te , a n d o b se rv in g th e

pa tie n t, us ua lly in th e su p in e rig h t pos te rio r ob liqu e po s it ion , fo r

sp o n ta n e o u s g a s tro e so p h a g e a l re flu x . If it w as n o t re a d ily a p p a ren t,

the ch ild w a s g ive n w a te r to d rin k ( if h e /sh e w ou ld ) a n d ob se rve d

w hile d r in k in g w ate r (w ater-s ip h o n te s t) . T h e w ate r-s ip h o n te s t w as

c on s id e red p os itiv e if b a riu m re ac he d th e c a rina w ith e sop h ag ea l

d is te n s io n [8 ]. W e m a de n o

e ffo rt to indu ce re flux ex cep t fo r p os ition a l

c h a n g e .

E va lua tio n fo r e so ph ag itis inc lud e d ass ess m e n t o f p e r is ta ls is a nd

a se a rch fo r o th e r e so p h a g e a l a b n o rm a litie s su ch a s u lc e rs a n d

s tr ic tu re s . A bn orm al p e n s ta ls is in c lu d e s a b se n t p e r is ta ls is a n d u n -

c oo rd ina ted n on pro pu ls iv e co n trac tion s w ith to -an d - fro m o tio n o f

b arium in the eso p ha gu s , freq u en tly w ith in co m p le te e m p ty in g o f th e

e s o p h a gu s . A ll s tu d ie s w ere re v ie w ed re tro sp e c tive ly b y a ra d io lo g is t

w ho kn e w th a t e a ch p a tie n t h a d B a rre tt’s e so p h a g u s.

Resu l t s

Thir ty - two

u pper-g as tro in tes tina l s tud ies w ere rev iew ed .

S e v e n pa tien ts h ad dou b le -con tras t exa m in a tio ns , w h ile 2 5

in fa n ts a n d ch ild re n u na b le to co o p e ra te w e re e xa m in e d b y

s ing le -co n tra s t te ch n iqu e . N o pa tien t h ad gas tric -ou tle t ob -

s tru c tion ; h o w e v e r, tw o ch ild re n h a d h a d s u rg ica lly co rre c te d

m alro ta tio n in in fa n cy .

T w en ty -fou r p a tie n ts h ad gas troe sop hag ea l re flux . T w elve

o f th ese pa tien ts h ad u lce rs an d /o r s tric tu res , an d n ine had

ab no rm a l p e r is ta ls is (F ig s . 1 an d 2 ). E igh t p a tien ts h a d n o

g a stro e s o p h ag e a l re flu x , b u t tw o o f

the se d id h av e rad io lo gic

s ign s o f seve re esoph ag it is w ith seve ra l u lce rs and s tric tu res

F ig . 1 . -E s o p ha g ra m

in 1 -ye a r-o ld g irl w ith

repa ire d es op hag ea l a tres ia ,

s ho w ing an anasto m otic s tr ic tu re an d u lc er a r row . C olu m na r e pith eliu m

w as d is tan t fro m s tric tu re , in d is ta l 3 c m o f e s op h ag u s.

F ig . 2 .- E so p h ag r am in 10 -ye ar -o ld bo y sh ow in g m ild co n to u r d efo rm ity

o f d is ta l e so ph ag us b roa d c lo se d a rrow , ulcers th in a rrow ,

a nd fix ed

tra nsv e rse fo lds open

arrow

po in t s to b ar ium trap ped b etw een tra nsve rse

fo ld s) . C o lu m n ar e p ith e lium line d

d is ta l 3 cm o f e so ph ag us .

a n d tw o h a d a b n o rm a l p e r is ta ls is . F o u r p a tie n ts h a d n o rm a l

s in g le -co n tra s t u p p e r-g a s tro in te s tin a l s tu d ie s . T w o o f the s e

p a tien ts ha d e so pha gea l u lce rs v is ib le a t end oscop y.

T en pa tien ts h ad rad io log ica lly de m on strab le e sop hag ea l

u lce rs , u su a lly tw o o r m o re u lce rs th a t w e re sm a ll a n d in th e

d is ta l es o p h a g u s (F ig s . 3 a nd 4 ). T h re e o f th e se p a tie n ts h a d

s in g le -c on tras t s tu d ie s , an d se ve n h a d do u b le -c on tras t u p pe r-

g a stro in te s tin a l s tu d ie s . O n e p a tie n t h a d a d e e p u lce r in

co lu m n a r e p ith e liu m w ith h ia ta l h e rn ia a n d re flu x . T e n m o re

p a tien ts ha d e ndo scop ica lly v is ib le u lce rs n o t app re c ia ted on

s in g le -co n tra s t s tu d y . T h re e p a tie n ts w ith ra d io lo g ica lly d e m -

ons tra te d esopha gea l u lce ra tion s h ad a dd it ion a l u lce rs de -

te c te d en d o s co p ic a lly . O n e o f th e se p a tie n ts h a d h a d a s in g le -

co n tra s t u pp e r-g a s tro in te s tin a l s tu d y , w h ile tw o h a d h a d d o u -

b le -c o n tra s t s tu d ie s . F o r th e d e te c tio n o f e so p h a g e a l u lce rs ,

do ub le -co n tras t e xam ina tio ns p red ic te d end oscop ic f ind ing s

be tte r tha n s in g le -con tras t e xa m in a tio ns d id .

T w e lve pa tie n ts h ad s tric tu res ; seven o f these w e re in the

m id e so p h a g u s, a n d five w e re in th e d is ta l es o p h a g u s. O f th e

se ven m ide sop hag ea l s tric tu re s, th ree w e re a t the s ite o f

an asto m o sis o f p rev ious esoph agea l a tres ia repa irs , and tw o

o f th e s e p a tie n ts h a d a s in g le u lce r a t th e s ite o f th e a n a s to -

m o tic s tric tu re . T w o p a tie n ts d id n o t h a ve s tr ic tu re s co n firm e d

a t en dosco py, a nd tw o o the rs ha d stric tu re s suspec ted a t

en doscop y bu t n o t de m on stra ted o n upp er-gas tro in tes tin a l

s tud ies .

H ia ta l h e rn ia s w e re d e te c te d in fo u r p a tie n ts , w h o w e re 12 ,



A JA :14 8 , F e bru a ry 1 98 7

B A R R E T T ’S E S O P H A G U S IN C H IL D R E N

35 5

1 5 , 1 9, a nd 2 1

ye a rs o ld , re sp ective ly . E le ven pa tien ts ha d

a b n o rm a l es o p h a g e a l p e ris ta ls is w ith d e la y e d e s o p h a g e a l

e m p ty in g ; fo u r o f th e se h a d h a d e so p h a g e a l a tre s ia . O n e

a d d itio n a l pa tie n t w ith p re v io u s e so p h a g e a l a tre s ia h a d n o

n o ta tio n o f p e r is ta ltic a c tiv ity in h e r ra d io g ra p h ic re p o rt. A d -

F ig . 3 .-E so ph ag ram in 1 6 -y ea r-o ld

bo y sho w in g d is ta l esop hagea l

s tr ic tu re , u lc er s t h in a r row , an d in tram ura l p seud od ive rtic u lae o f e so ph -

a gu s o pe n

arrow . co lum na r ep ith e lium in vo lved en tire le ng th o f s tric tu re .

F ig . 4 -E so ph ag ram in 19 -ye ar -o ld

m an sh ow s d iffu se eso ph ag ea l u lc e rs

th in a rro w , h igh

e so p ha g ea l s tr ic tu re

b road a rro w s ,

an d p atu lo us low er

esophagus .

A t esop hag osco py , a c ir-

cu la r u lce r w as seen at s tr ic tu re s ite ,

n o t v is ib le o n rad lo g raph s . C o lum na r

ep lth e lium lined esop hag us d is ta l to

stricture

d itio n a l p a tie n ts w ith a b n o rm a l e so p h a g e a l p e r is ta ls is in -

c lud ed tw o w ith p sycho m oto r re ta rda tion , on e w ith D ow n

sy n d ro m e a n d d u o d e na l a tre s ia , a n d o n e w ith fa m ilia l d ysa u -

to n o m ia . L e ss co m m o n m a n ifes ta tio n s o f re flu x e so p h a g itis

in c lu d e d o n e ca se e a c h o f in tra m u ra l p s e u d o d ive rticu la e o f

th e esoph agu s [9 ] a ssoc ia te d w ith s tric tu re a nd u lce rs , fixed

tra nsve rse d is ta l e sop hag ea l fo ld s [1 0 ], an d a n in flam ma to ry

e sop hag oga stric po lyp a nd fo ld [1 1

,

1 2]. E s o p ha g itis w a s

p re se n t u n d e r e n d o sc o p ic v isu a liza tion in a ll p a tie n ts , b u t

co lu m na r ep ithe lium co u ld n o t a lw ays b e a ppre c ia ted m a c-

roscopically

Discuss ion

B arre tt [1 3 ] de sc ribe d the firs t cases o f co lum n ar-lined

low er esoph agu s in 1 950 . In 1 953 , A llison a nd John sto ne

[14 ] co in ed the te rm “B arre tt ’s u lce r” to de sc ribe a d eep

u lce ra tio n o cc u rr in g in th e co lu m n a r e p ith e liu m . T h e y w e re

th e firs t to re p o rt th e a ssoc ia tion o f a m idesoph age a l s tric tu re

w ith u lc e r in th e p res e n ce o f a h ia ta l h e rn ia a n d g a stro -

e sop hag ea l re flu x . L ike B arre tt, they th oug h t th a t the co lum -

n a r lin in g w a s co n g e n ita l, a lth o u g h th e y q u e s tio n e d th e p o s-

s ib le s ig n ifica nce o f ch ro n ic ga stro eso pha gea l re flux in the

de ve lo pm en t o f the les io n . M o re rec en tly , re po rts [6 , 7 , 15 ,

1 6 ] h a ve a p p e a re d s up p o rtin g th e re la tio n sh ip b e tw e e n

ch ro n ic ga stro eso pha gea l re flu x a nd the deve lopm en t o f B a r-

re tt’s esoph agu s. T he re a lso ap pea rs to be an in crea se d

p reva len ce o f ad eno ca rc ino m a o f the e so phag us in pa tien ts

w ith B a rre tt’s e so p h a g u s. C h ro n ic g a s tro e s o p h a ge a l re flu x

o f a c id , p e p s in , a n d p o ss ib ly b ile m a y c a u se sp e c ific h is to lo g ic

ch a n g e s th a t le a d e ve n tu a lly to a d e n o ca rc in o m a th ro u g h a

s p e c tru m o f m ultifo ca l dysp las ia a nd ca rc inom a in s itu [15 -

26]

B ecause o f th e p rem a ligna n t na tu re o f B arre tt’s m ucosa ,



35 6

Y U L IS H E T A L.

AJ A:148 , F eb ru ary 1 98 7

m an y au th o rs [9 , 2 7 -29 ] ha ve a ttem p te d to de fine crite ria fo r

its ra d io lo g ic d ia g n o s is . In a d u lts , th e co m p le x o f m id e so p h a -

gea l s tric tu re , u lce r, h ia ta l h e rn ia , a nd gas troesop hag ea l re flu x

once thou gh t sp ec ific fo r B a rre tt’s esoph agus w a s fo und to

b e ra re [9 , 2 7 -2 9 ]. In s te a d , th e se a u th o rs fo u n d th a t the

ra d io lo g ic fe a tu re s a re n o n sp e c ific . H ia tu s h e rn ia , g a s tro -

esoph agea l re flux , and esoph ag itis , inc lud ing stric tu re , m ay

b e p re se n t in d iv id u a lly o r in co m b in a tio n in p e rs o n s w ith

B arre tt’s esoph agu s. Le v ine e t a l. [2 8 ] thoug h t tha t a re ticu la r

m ucosa l pa tte rn on do ub le -co n tra s t u ppe r-gas tro in tes tina l

s tu d ie s m ig h t be m ore spec i f ic fo r B a rre tt ’s eso pha gus , bu t

m os t o f the ir pa tien ts d id no t h ave th is find ing , a nd V ince n t

e t a l. [29 ] th oug h t th a t th is p a tte rn w as no t sp ec ific .

G a s tro e so p h a g e a l re flu x o cc u rs co m m o n ly in in fa n cy a n d

is a re s u lt o f im m a tu r ity o f es o p h a g e a l fu n c tion . M o st ch ild re n

de ve lop no rm a l fu nction w ith in the firs t ye a r o f life [7 ]. In

th o se w ith p e rs is te n t sym p to m a tic re flu x , e so p h a g itis , s tr ic -

tu re , a n d B a rre tt’s e so p h a g u s m a y d e ve lo p [6 , 7 ].

T h e ra d io g ra p h ic fe a tu re s o f B a rre tt’s e so p h a g u s in in fa n ts ,

ch ild ren , a nd youn g ad u lts a re in m a ny respec ts s im ila r to

th o se in th e o ld e r a d u lt, b u t th e re a re im p o rta n t d iffe re n ce s .

F or e xam p le , o n ly fou r o f o u r p a tie n ts had h ia ta l he rn ias , a nd

the you nge st w as 1 2 years o ld . T en pa tien ts ha d eso pha gea l

u lce rs sh o w n ra d io lo g ic a lly , b u t a n a d d itio n a l 1 0 p a tie n ts w ith

s in g le -co n tra s t s tu d ie s h ad u lc ers se e n o n ly a t e so p h a g o s-

co py . T w o pa tien ts w ith do ub le -co n tras t s tud ies had add i-

tio n a l o r d iffe re n t u lce rs d e te c te d a t e n d o sco p y . O f th es e ,

o n e co u ld n o t co o p e ra te b e ca u s e o f s e ve re cys tic fib ro s is ,

a n d a go o d e xa m in atio n co u ld n o t b e o b ta in ed . A d e q u a te

do ub le -co n tras t e xam ina tion s in ou r pa tien ts ag re ed b e tte r

w ith en d o s co p y fo r d e te c tio n o f e so p h a g e a l u lc e rs th a n s in -

g le -co n tras t s tud ies d id . U n like adu lts , in fa n ts and yo ung

ch ild re n d o n o t c oo pe ra te fo r d ou b le -con tra s t ex am in a tio n s .

B e c a u s e

on ly s ing le -con tra s t s tud ies a re do ne in th is a ge

g ro u p , u lc e rs m a y n o t be d e te c te d .

T w e lve o f the 32 pa tien ts h ad rad iog raph ica lly de m o n-

s tra te d s tric tu re s , a lo w e r p e rce n ta g e th a n th a t p re v io us ly

rep o rted in ad u lts and ch ild ren [9 , 27 -30 ], an d a n eve n lo w e r

pe rcen tag e w he n o ne co ns ide rs tha t th ree o f th e m ide so pha -

gea l s tric tu re s w ere a t the s ite s o f e sop hag ea l a tres ia repa irs .

T h e low er ra te p ro bab ly resu lts fro m the tim e it take s to

d eve lop th is type o f in ju ry . If ch ild ren ’s ga stro eso pha gea l

re flux is le ft un tre a ted , th ey cou ld de ve lop m ore s ign ifican t

n a rro w in g a s th e y p ro g res s in to a d u lth o o d .

E igh t o f 1 1 pa tie n ts w ith a bno rm a l p ens ta ls is a nd

p o o r

e sop hag ea l e m pty in g ha d und erly ing d isea ses a ssoc ia te d

w ith a bno rm al esoph age a l m otility . In these pa tien ts , re fluxe d

g astric co n ten ts a re p oorly c le a red , p ro lo ng ing con ta ct tim e

w ith th e eso pha gea l m u cosa . A bno rm a l pe ris ta ls is and

a peris ta ls is ha ve b e e n describ ed in co n ju nction w ith re flu x

e sop hag itis [3 1

,

32]. T h e p resence o f abno rm a l e sophagea l

p e ris ta is is a n d p o o r

es op ha g ea l e m p ty in g m a y b e a s ig n if ic an t

find ing and sho u ld a le rt th e rad io log is t to

lo o k fo r o th e r

ra d io g ra p h ic e v id e n c e o f

esophag i t i s .

T he m ost co m m on ra d io g raph ic f ind ing in ou r pa tien ts w ith

B arre tt’s e so pha gu s w as g as tro esop hag ea l re flux , a n on spe -

c ific find ing th a t m a y b e a ssoc ia ted w ith re flu x esoph ag itis o r

B a rre tt’s esoph agu s. H o w eve r, its d em o ns tra tio n m ay be

fo rtu ito u s ; it o ccu rs in te rm itte n tly [8 ]. If g a s troe s o p h a g e a l

re flu x is n o t re a d ily a p p a re n t, th e w a te r-s ip h o n te s t m a y b e

used to pe rm it red uc tion in fluo rosco py tim e a nd , he nce ,

redu ce ra d ia tion e xp osu re . T h is tes t h as a lo w fa lse -ne ga tive

ra te , w h ich m ean s tha t a neg a tive te s t is ev ide nce aga ins t

th e p re se n c e o f g a s tro e so p h a g e a l re flu x , b u t its h ig h fa lse -

p o s itive ra te m e a n s th a t th e p re se n ce o f g a s tro e so p h a g e a l

re flux m u st be de te rm ine d by co rre la tion w ith c lin ica l s ym p-

to m s [8 ].

O ur pa tie n ts d id n o t sh ow a ny spec ific rad iog ra ph ic s ign s

fo r spec ific d iag nos is o f B a rre tt’s e sop hag us. B ecause th e

ra d io lo g ic d e m o n stra tio n o f re flu x e s op h a g itis c a n b e m o re

d ifficu lt in in fa n ts , c h ild re n , an d a d o le sc en ts , th e p re se n ce o f

B a rre tt’s e s o p h ag u s m a y be s u sp e c te d le ss o fte n . T h e re fo re ,

o n e m u st m a in ta in a h ig h in d e x o f su s p ic io n fo r B a rre tt’s

e s o p h a g us if th e re is ra d io g ra p h ic e v id e n c e o f s tric tu re s ,

u lc e rs , o r o th e r s ig n s o f re flu x e so p h a g itis (F ig s . 1 -4 ).

A C K N O W L E D G M E N T

W e th an k B e ve rly B arre tt D a hm s fo r h e r a ss is tan ce .

R E F E R E N C E S

1

.

B ray P F , H e rb s t JJ , Jo hn so n D G , B oo k L S , Z ite r F A , C ond o n V A . C h ild -

ho od ga stroe sop ha ge a l re fiux . N e uro log ic an d ps yc h ia tric sy nd rom es m im -

ic k ed . J AMA 1977 ;237 :1342- 1345

2.

A ras u T S , W yll ie A , F itzg e ra ld JF , e t a l. G as tro es oph ag ea l re fiux in in fan ts

an d ch ild ren -co m p ara tiv e a cc u ra cy o f d ia gn ost ic m e th ods . J P ed ia tr

1980 ;96 :798 -803

3 . A oth ste in F C, H alp in T C. H igh in cid ence o f p ulm ona ry s ym ptom s in in fa nts

ev a lu ated fo r es op ha gea l d ise ase . A n n O t ol R h in o lL a ry n go l 1 9 8 0 ;8 9 :4 5 0 -

45 3

4.

Ber qu is t

W E, A ac he le fsky G S, K add en M , e t a l. G as troe so ph age al re fiu x-

as so c ia ted rec u rren t p ne um on ia a nd ch ron ic as thm a in c h ild re n . Pediatr ics

1981;68:29 35

5 . A lle n C J, N ew hou se M T. G as tro es op ha gea l re fiu x a nd ch ro nic resp ira to ry

d is eas e . Am R e v R esp ir D is 1984 ;129 :645 - 647

6. D a hm s B B , A o th s te in F C . B a rre tt’s e so pha gu s in ch ild ren : a co ns eq ue nce

o f c hr on ic g a st ro e so p ha g ea l ref iux . Gas t r oen te r o logy 1 98 4;8 6: 3 18 -3 23

7 . A oth s te in F C, D ah rns B B. B arre tt’s e sop h ag us in ch ild ren . In :

S pec h le r S J

an d G oya l A K, ed s . B arre tt ’s esop hag us : pa th op hys io logy , d iag no s is a nd

ma n a g e me n t . A mste rd am : E ls ev ie r, 1 98 5:1 29 -1 41

8 . B lu mh ag en J D, C hris tie D L. G as tr oe so ph ag ea l re flu x in c hild re n: e va lu atio n

o f the w a te r s ip hon te s t. Rad io logy 19 79 ; 1 3 1 : 345 - 349

9 . C h en Y M , G elfa nd D W, O tt D J, W u W C . B arre tt e so ph ag us a s a n e xte ns ion

o f se ve re e so pha g itis : ana lys is o f ra d io log ic s ig ns in 2 9 ca se s. A JR

1985;145:275 281

1 0 . Le v in e M S. G old s te in H M. F ixe d tran sve rse fo lds in the eso p ha gu s : a s ig n

of r ef lu x e so p ha gi ti s. A JR 1984 ;143 :275 - 278

1 1 . B le sh m an M H, B a nn e r M P, Jo hn so n A C , D eF ord JW . T he in fla m ma to ry

e so pha go ga str ic p o lyp an d fo ld . Rad io logy 1978 ;128 :589 -593

1 2 . S ty le s A A, G ibe S P, T ars h is A , S ilve rm an M L, Sc ho lz F J . E s o p h ag o g a st ri c

p oly ps : ra dio gra ph ic a nd e nd os co pic fin din gs .

Rad io logy 1985 ;154 :307 -

31 1

1 3. B arre tt N A. C hro n ic p ep tic u lce r o f the o eso p ha gu s a nd “o e sop h ag itis .’

B r J Su rg 1950 ;38 :175 - 182

1 4 . A llison P R , J oh ns ton e A S. T h e oe so ph ag u s line d w ith g a s tric m uco u s

m e m b r a n e . Thorax

1 9 5 3 ;8 :8 7 -1 0 1

1 5. A d le r R H. T h e lo w e r eso ph ag us line d by co lu mn ar e pithe lium . Its a sso ci-

a tio n w ith

h ia ta l h e rn ia ,

u lc e r, s tr ic tu r e,

a nd tu mo r.

J T ho ra c C ard io va sc

Sur c 1963 ;45 :13 - 34

1 6 . B u rge ss J N , P ayn e W S, A n derse n H A , W e ila nd L H , C ar iso n H C . B a rre t t

eso ph ag us . T he c o lu mnar-ep ith elia l-l ine d low er eso ph ag us . M ayo C lin P roc

1 9 71 ; 46 : 7 2 8 7 3 4



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