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Esophagitis in Pediatric Esophageal Atresia

Acid May Not Always Be the Issue

Yasuda, Jessica L.*; Clark, Susannah J.; Staffa, Steven J.; Blansky, Bradley*; Ngo, Peter D.*; Hamilton, Thomas E.; Smithers, Charles Jason; Jennings, Russell; Manfredi, Michael A.*

Journal of Pediatric Gastroenterology and Nutrition: August 2019 - Volume 69 - Issue 2 - p 163–170
doi: 10.1097/MPG.0000000000002336
Original Articles: Gastroenterology

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.

*Division of Gastroenterology, Hepatology and Nutrition

Department of General Surgery

Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA.

Address correspondence and reprint requests to Jessica L. Yasuda, MD, Division of Gastroenterology, Hepatology and Nutrition, 300 Longwood Avenue, Boston Children's Hospital, Boston, MA 02115 (e-mail:

Received 29 October, 2018

Accepted 18 February, 2019

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (

Jessica L. Yasuda and Susannah J. Clark contributed equally to this work.

The authors attest this is their original work and report no conflicts of interest. There are no funding sources to report.

© 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,