Pediatric emergency medicine trisk 1020

Following repair of esophageal atresia or fistula, patients may present at any point in life with an anastomotic stricture and/or an impacted food bolus with the site of retention typically at the site of anastomosis These patients also tend to have poor or disordered esophageal motility and a propensity to have gastroesophageal reflux, which may contribute to stricture formation Patients who present to the ED with dysphagia or intolerance of solids and/or liquids in the setting of a prior history of esophageal atresia repair should undergo contrast esophagography Typically, these patients not have respiratory symptoms, but if they do, a chest radiograph should be obtained The patient should be made nil per os , and if a stricture or obstruction from impacted food or foreign body is demonstrated on the contrast study (Fig 124.3 ), intravenous access and a surgical consultation should be obtained Patients who present with a stricture following fistula or esophageal atresia repair are typically managed with esophagoscopy under general anesthesia with removal of any impacted foreign material and bougie or balloon dilation of the stricture Most such patients are discharged home after these interventions Some patients require multiple dilations over the course of their childhoods FIGURE 124.3 A: Swallow study demonstrating a recurrent esophageal stricture in a patient with a history of TEF repair B: Swallow study in the same patient demonstrating a recurrent stricture in the setting of swallowing a broccoli floret Esophageal Web Rarely, a patient presents with symptoms caused by an esophageal web (Fig 124.4 ) The membranous, congenital narrowing of unclear origin usually allows the passage of liquids, and symptoms often not arise until the child begins to eat solid food Patients may present with feeding intolerance or respiratory symptoms after drinking and eating Recurrent aspiration pneumonia may also develop Rarely, an esophageal web can present with associated anemia, in the form of Plummer–Vinson syndrome An esophagram is usually diagnostic In patients who are minimally symptomatic and who can tolerate sufficient oral intake, definitive management may occur as an outpatient or return procedure Symptomatic patients who have respiratory symptoms or who are unable to achieve adequate oral intake should be admitted for observation and definitive management Often, a thin membranous web may be split by esophageal dilators, cautery, or a hydraulic balloon placed endoscopically across the stenosis If this approach is unsuccessful because the lumen is too small to accommodate the dilator or the tissue is unyielding, segmental esophageal resection may be necessary via thoracotomy or thoracoscopy Caustic Ingestion Caustic ingestion is the leading toxic exposure in children, and can cause devastating injury to the esophagus and stomach with dire consequences The most frequent exposures in children are to mild alkali agents such as household bleach and detergents, some of which can be relatively benign Button battery ingestions in children are increasingly common and can be extremely dangerous (see Chapters 91 Gastrointestinal Emergencies and 118 ENT Emergencies for a full discussion ) The age distribution of pediatric ingestions is bimodal, with accidental ingestions common in children younger than years and suicide attempts more common in teenagers and young adults The extent and severity of injury depends on the type, concentration, and quantity of the ingested agent, as well as the duration of exposure Liquid agents typically cause more injury than solids, with strong alkalis being associated with very severe damage Following the initial ingestion of an acid or alkali, a significant inflammatory response with edema, hemorrhage, and thrombosis can occur within 24 hours Local tissue damage continues for some time after the initial exposure, causing necrosis, edema, potential perforation, and eventual fibrosis and stricture FIGURE 124.4 A child with chronic partial obstruction of the esophagus caused by a congenital web Similar bulbous enlargement of the proximal esophagus can occur with any type of stricture and results in pressure on the trachea and recurrent regurgitation with aspiration T4, 4th thoracic vertebrae Clinical Recognition Clinical findings range from a normal physical examination to respiratory distress and hemodynamic instability Most patients will complain of oropharyngeal discomfort, odynophagia, dysphagia, and chest pain Stridor may indicate laryngeal and epiglottic edema, and if accompanied by drooling should raise suspicion for esophageal injury Other signs of esophageal injury include dysphagia, retrosternal pain, epigastric pain, and hematemesis However, clinical symptoms may be poor predictors of the extent of injury Ominous signs include hemodynamic instability, fever, tachycardia, and mental status changes; such findings raise concern for esophageal perforation and developing mediastinitis Management Initial management includes the assessment of the severity of injury and the prevention of further injury If possible, the type and amount of corrosive agent ... Gastrointestinal Emergencies and 118 ENT Emergencies for a full discussion ) The age distribution of pediatric ingestions is bimodal, with accidental ingestions common in children younger than years