Esophagus, Esophageal Atresia, TEF Flashcards

Question

Regarding achalasia cardia, which one is false? A. There is failure of relaxation of the lower oesophagus. B. Histochemistry shows an increase in neuropeptide, VIP and gastrin. C. Nifedipine and calcium channel antagonists are used as medical treatment. D. Pneumatic dilatation is one of the treatments. E. Myotomy over 4–5 cm is the surgical treatment.

Answer 1

B. Histochemistry shows decrease, not increase, in neuropeptide, VIP and gastrin.

Answer 2

D. Barium meal shows narrowing of lower oesophagus. CT is not the investigation of choice, plain x-rays may show air-fluid level in lower oesophagus. Barium meal shows rate tail appearance due to funneling and narrowing of oesophagus. 24-h pH monitoring is required for diagnosis of gastroesophageal reflux.

Answer 3

E. Loose (floppy) fundoplication is part of the procedure.

Answer 4

E. Gastroesophageal reflux incidence is about 15 percent, while residual or recurrence is 25 percent.

Answer 5

Theory of invaginating longitudinal tracheoesophageal folds merging to form a septum (caudally to cranially) 4th week AOG: - Foregut starts to differentiate into a ventral respiratory part, and a dorsal esophageal/digestive tract. - Laryngotracheal diverticulum invaginates ventrally into the mesenchyme. - The ventral respiratory system separates from the esophagus by the formation of lateral tracheoesophageal folds that fuse in the midline and create the tracheoesophageal septum. 6th-7th week AOG: Separation between trachea and esophagus is complete. Incomplete fusion of the folds results in a defective tracheoesophageal septum and an abnormal connection between the trachea and esophagus. However, there is little evidence to support this, hence newer theories have also been proposed.

Answer 6

1) Imbalance in the growth of cranial and caudal folds In chick embryo studies, cranial and caudal folds were found in the region of tracheoesophageal separation. EA/TEF would then be due to an imbalance in the growth of these folds. 2) Foregut occlusion and failure of recanalization. Rat studies suggest that EA/TEF results from disturbances in either epithelial proliferation or apoptosis. 3) EA may be a component of cephalic neurocristopathy. The observation that there is a clear association of neural crest-implicated cardiovascular anomalies (aortic arch, conotruncal and membranous ventricular septal defects), as well as thymic, thyroid, parathyroid, and facial malformations with EA, as seen with the DiGeorge syndrome, suggests that the pathogenesis of EA may be related to defective pharyngeal arch development. 4) The distal fistula tract and esophagus are of possibly of respiratory origin, and defects in lung morphogenesis account for this aspect of the EA-TEF anomaly. 5) Environmental teratogens have also been implicated.

Answer 7

More recent studies show that ectopic expression of sonic hedgehog occurs in the tissues between the notochord and the gut. Knockout mice models have helped elucidate the functions of different genes in the development of foregut aberrations such as EA/TEF. Also, the relationship between BMP4 (bone morphogenic protein) and Nog, the gene encoding noggin (which is a BMP antagonist), may also have an impact on the development of EA/TEF.

Answer 8

EA has occurred in infants born to mothers with: 1) prolonged exposure to contraceptive pills 2) exposure to progesterone and estrogen during a pregnancy 3) hyperthyroidism and diabetes 4) intrauterine exposure to thalidomide and diethylstibestrol 5) use of methimazole in early pregnancy 6) maternal phenylketonuria 7) infant with fetal alcohol syndrome

Answer 9

1 in 2500-3000 live births Slight male preponderance Risk for a 2nd child with EA/TEF among parents of one affected child: 0.5-2%, increasing to 20% when more than one child is affected. Empirical risk of an affected child born to an affected person: 3-4% Relative risk for EA/TEF in twins (vs singletons): 2.56 (high risk among twins of same gender) Lack data but reported: White ethnicity First pregnancy Increasing maternal age (twofold increased risk for women 35-40yo, threefold for >40yo) Rate of multiple births high for each type of EA-TEF anomaly In vitro fertilization patients Chromosomal anomalies in 6-10%

Answer 10

Down syndrome the DiGeorge sequence the polysplenia sequence Holt-Oram syndrome the Pierre Robin sequence Feingold syndrome Fanconi syndrome Townes-Brock syndrome Bartsocas-Papas syndrome McKusick-Kaufman syndrome theCHARGE association (coloboma, heart defects, atresia choanae, developmental retardation, genital hypoplasia, and ear deformities) The schisis association (omphalocele, neural tube defects, cleft lip and palate, and genital hypoplasia) cerebral hypoplasia Potter syndrome (bilateral renal agenesis) Trisomy 18 Chromosomal anomalies are found in 6-10% of patients. Trisomy 18 > 21

Answer 11

Three separate genes have been associated with EA/TEF: 1) MYCN haploinsufficiency in Feingold syndrome 2) CHD7 in CHARGE syndrome, and 3) SOX2 in the anophthalmia–esophageal–genital (AEG) syndrome H&A

Answer 12

Gross type A (7%) Pure esophageal atresia without TEF - If no concomitant proximal fistula, upper esophagus ends at the level of the azygos vein. - Distal esophagus is short and often suspended by a fibrous band. - Long gap. Gross type B (2%) Esophageal atresia with proximal fistula - Fistula located at thoracic aperture or higher in the neck. - Gasless abdomen Gross type C (85%) Esophageal atresia with distal fistula - Proximal esophagus usually at 3rd-4th thoracic vertebrae. Gross type D (<1%) Esophageal atresia with proximal and distal fistulas Gross type E (4%) H-Type Fistula without esophageal atresia - Fistula is usually at the thoracic aperture or higher in the neck. Gross type F Esophageal stenosis

Answer 13

The factors responsible for the early disturbance in organogenesis leading to EA may affect other organs or systems as well. EA can be divided clinically into isolated EA and syndromic EA. Anomalies most frequently encountered in syndromic EA: Cardiac (13-34%) Vertebral (6-21%) Limb (5-19%) Anorectal (10-16%) Renal (5-14%) Nonrandom associations: VACTERL (20%) Vertebral Anorectal Cardiac Tracheoesophageal Renal Limb *Hydrocephalus also recently considered CHARGE Coloboma Heart defects Atresia of the choanae Developmental retardation Genital hypoplasia Ear deformities Complex cardiac deformities may account for most deaths associated with EA malformations (most common are VSDs and ASDs).

Answer 14

Prenatal UTS (20-40%) 1) Polyhydramnios 2) Absent/small gastric bubble 3) Dilated cervical esophagus (pouch sign) MRI may be used as adjunct in the diagnosis of EA anomalies suspected on UTS.

Answer 15

Clinical 1) Pooling of saliva in the proximal esophagus and mouth 2) Regurgitation, choking, coughing on feeding 3) Cyanosis, respiratory distress 4) Inability to pass feeding catheter through the mouth into the stomach 5) Distension of abdomen (if with fistula) Imaging: 1) CXR AP/Lat: Pass OGT, instill air to distend upper esophageal pouch, and do a frontal and lateral chest film with downward pressure on the tube. - (+) Air in stomach: distal TEF - (-) Air in stomach: EA w/o distal fistula (or fistula occluded with mucus) - Tip should curl up in the upper pouch 2) Barium esophagography in the prone position (For TEF without EA) - Repeated choking during feedings and aspiration infiltrates - Bronchoscopy with or without esophagoscopy is required to confirm the diagnosis.

Answer 16

Clinical 1) Examine rib cage for deformity 2) Examine spine for congenital scoliosis 3) Examine upper limbs for radial anomalies 4) Assess anus for patency and position 5) Auscultate heart for any murmurs 6) Palpate abdomen for masses (kidney anomalies) Imaging 1) Echocardiogram (only requirement preop; others can be done as outpatient) - Identify cardiac anomalies - Delineate laterality of aortic arch and descending aorta, to aid in determining surgical approach. —> Right-sided arch (3%): Left thoracotomy preferred —> Left- sided arch: Right thoracotomy 2) Renal ultrasound Other considerations 1) Rigid Bronchoscopy Screen for: - laryngotracheoesophageal cleft - tracheal stenosis - tracheal bronchus to the right upper lobe - proximal fistulas - location of distal fistula (helps predict gap) —> Trifurcation fistula: long gap (closer to carina, longer gap) —> Fistula 2cm above carina: short gap - incidence of simultaneous proximal and distal fistula: <5% - may prolong procedure, infant may decompensate prior to fistula ligation 2) Geneticist

Answer 17

Waterston Risk Groups A (100% Survival) BW >2500g Otherwise healthy. —> Immediate primary repair. B (85% Survival) BW 2000-2500g, well Higher weight with moderate associated anomalies (non cardiac plus PDA, VSD, ASD) —> Delayed repair. C (65% Survival) BW < 2000g or Higher with severe associated cardiac anomalies —> Staged repair. — Spitz (Okamoto modification) Class I (Low risk, 100% survival) - No major cardiac anomaly, BW =/> 2000g Class II (Moderate risk, 81% survival) - No major cardiac anomaly, BW < 2000g Class III (Relatively high risk, 72% survival) - Major cardiac anomaly, BW =/> 2000g Class IV (High risk, 27% survival) - Major cardiac anomaly, BW < 2000g

Answer 18

Patient must be transferred to a level I pediatric surgical center. 1) Insert a F10 tube into the upper esophagus and placed on continuous suction (sump catheter— may use F5 as suction catheter inserted in F10). 2) Position child head-up and on his/her side. 3) If in respiratory distress, consider gentle low-pressure ventilation via endotracheal intubation. Forceful ventilation must be avoided to prevent lung damage, gastric distention, and perforation with insufflation through the distal fistula. 4) Start broad-spectrum antibiotics. 5) Pulmonary physiotherapy. 6) IV therapy with 10% dextrose and hypotonic saline. 7) Administer Vitamin K.

Answer 19

1) Child placed in a left lateral decubitus position. A small axillary roll is placed under the chest to enlarge the right-sided intercostal spaces. 2) Surgeon stands to the right of the patient (infant’s back), with the assistant opposite. (Consider opposite positioning for right-sided aorta) 3) Patient’s arm is positioned over the head. Leave tube in place so it can be advanced during the operation. 4) A slightly curved 4-5cm long incision is made 1cm below the inferior tip of the scapula. 5) Via muscle sparing approach, open the auscultatory triangle and retract the muscles (latissimus dorsi posteriorly and the serratus anterior anteriorly). If the serratus muscle needs to be transected, this should be done as low as possible to preserve the long thoracic nerve. The fourth or fifth intercostal space is then entered. 6) Via extrapleural approach, the pleura is gently pushed away from the endothoracic fascia, first in the middle of the incision so that an infant rib spreader can be inserted and opened. 7) As rib spreader is further opened, gently push away the pleura even more posteriorly until the posterior mediastinum is exposed. 8) The distal fistula may start from the trachea directly underneath the azygos vein, in which case the azygos vein is transected between 3-0 or 4-0 absorbable ligatures or simply cauterized and divided. If the distal fistula originates more cephalad on the trachea, the vein can be left intact. Recently, a relationship between division of the azygos vein and the development of an anastomotic leak has been suggested. 9) The distal esophagus is easily found because it distends with each inspiration and the vagus nerve is intimately attached. Once identified, the distal segment should be followed proximally to locate where the fistula enters the trachea. The fistula should be dissected and mobilized close to the trachea, which will spare as many vagal nerve branches as possible. The fistula can be encircled with a vessel loop or suture to aid in exposure. 10) There are several ways to ligate the fistula on the tracheal side. Ligation without division can result in a higher recanalization rate. We prefer to divide the fistula sharply after placing traction sutures at each end. A series of 5-0 PDS (Ethicon, Inc., Sommerville, NJ) sutures are then used to close the tracheal side, taking care not to compromise the tracheal lumen. Another option is to apply a single 5-mm clip across the fistula where it connects to the membranous trachea. We have found this technique to be simple and efficient and results in a smaller pouch remnant on the posterior tracheal wall. However, there are anecdotal reports of clip migration and recanalization of the fistula using this technique. The tracheal closure can be checked by irrigating with warm water and applying a higher ventilation pressure to assess for an air leak. 11) Identify proximal pouch by asking anesthesiologist to push on the repogle tube. A traction suture is sometimes helpful for traction during blunt dissection. 12) Once mobilized, the tip of the proximal pouch is amputated to expose lumen and mucosa. 13) An end to end anastomosis is done with 5-0 absorbable sutures, starting in the middle of the back wall of each esophageal segment, including both mucosa and muscular wall with each bite. The sutures in the back wall of the anastomosis are tied intraluminally. Then, the front part of the anastomosis is performed with sutures tied on the outside. Before finishing the anastomosis, an 8 French or 10 French tube is passed into the stomach. This helps protect the lumen from inadvertent closure and also allows for gastric decompression. Others feel the placement of an intraluminal tube or stent causes an increased risk of stricture or leak, and choose not to use it. 14) The use of a chest drain is optional. We usually place a drain and leave it until a contrast study is obtained on day 4 or 5. The chest incision is then closed in layers. The ribs should be approximated with one 3-0 absorbable suture. This suture should be tied gently so that the intercostal space is not obliterated. The skin is closed with a 5-0 absorbable subcuticular suture.

Answer 20

1) Child placed in a left lateral decubitus position. A small axilla ray roll is placed under the chest to enlarge the right-sided intercostal spaces. 2) Surgeon stands to the right of the patient (infant’s back), with the assistant opposite. (Consider opposite positioning for right-sided aorta) 3) Patient’s arm is positioned over the head. Leave tube in place so it can be advanced during the operation. 4) A slightly curved 4-5cm long incision is made 1cm below the inferior tip of the scapula. 5) Via muscle sparing approach, open the auscultatory triangle and retract the muscles (latissimus dorsi posteriorly and the serratus anterior anteriorly). If the serratus muscle needs to be transected, this should be done as low as possible to preserve the long thoracic nerve. The fourth or fifth intercostal space is then entered. 6) Via extrapleural approach, the pleura is gently pushed away from the endothoracic fascia, first in the middle of the incision so that an infant rib spreader can be inserted and opened. 7) As rib spreader is further opened, gently push away the pleura even more posteriorly until the posterior mediastinum is exposed. 8) The distal fistula may start from the trachea directly underneath the azygos vein, in which case the azygos vein is transected between 3-0 or 4-0 absorbable ligatures or simply cauterized and divided. If the distal fistula originates more cephalad on the trachea, the vein can be left intact. Recently, a relationship between division of the azygos vein and the development of an anastomotic leak has been suggested. 9) The distal esophagus is easily found because it distends with each inspiration and the vagus nerve is intimately attached. Once identified, the distal segment should be followed proximally to locate where the fistula enters the trachea. The fistula should be dissected and mobilized close to the trachea, which will spare as many vagal nerve branches as possible. The fistula can be encircled with a vessel loop or suture to aid in exposure. 10) There are several ways to ligate the fistula on the tracheal side. Ligation without division can result in a higher recanalization rate. We prefer to divide the fistula sharply after placing traction sutures at each end. A series of 5-0 PDS (Ethicon, Inc., Sommerville, NJ) sutures are then used to close the tracheal side, taking care not to compromise the tracheal lumen. Another option is to apply a single 5-mm clip across the fistula where it connects to the membranous trachea. We have found this technique to be simple and efficient and results in a smaller pouch remnant on the posterior tracheal wall. However, there are anecdotal reports of clip migration and recanalization of the fistula using this technique. The tracheal closure can be checked by irrigating with warm water and applying a higher ventilation pressure to assess for an air leak. 11) Identify proximal pouch by asking anesthesiologist to push on the repogle tube. A traction suture is sometimes helpful for traction during blunt dissection. 12) Once mobilized, the tip of the proximal pouch is amputated to expose lumen and mucosa. 13) An end to end anastomosis is done with 5-0 absorbable sutures, starting in the middle of the back wall of each esophageal segment, including both mucosa and muscular wall with each bite. The sutures in the back wall of the anastomosis are tied intraluminally. Then, the front part of the anastomosis is performed with sutures tied on the outside. Before finishing the anastomosis, an 8 French or 10 French tube is passed into the stomach. This helps protect the lumen from inadvertent closure and also allows for gastric decompression. Others feel the placement of an intraluminal tube or stent causes an increased risk of stricture or leak, and choose not to use it. 14) The use of a chest drain is optional. 103,104 We usually place a drain and leave it until a contrast study is obtained on day 4 or 5. The chest incision is then closed in layers. The ribs should be approximated with one 3-0 absorbable suture. This suture should be tied gently so that the intercostal space is not obliterated. The skin is closed with a 5-0 absorbable subcuticular suture.

Answer 21

A gasless abdomen is the signature of EA without distal fistula. The standard initial treatment is a gastrostomy with laryngotracheobronchoscopy during the same anesthesia, to exclude a proximal fistula and other associated tracheobronchial anomalies. In EA without a distal fistula and in the absence of a duodenal obstruction, the stomach is usually small, which can make insertion of the gastrostomy difficult. Once placed, bolus feedings should be instituted to enlarge both the small stomach and the distal pouch.

Answer 22

1) Upper pouch bougienage - Weighted bougie is passed through the mouth into the upper pouch. - Forward pressure applied 1-2x/day x 6-12 weeks, before attempting delayed primary repair. 2) Electromagnetic field - Magnets used to pull together metallic bullets in two ends of the esophagus to shorten the gap. 3) Nylon thread attached to silver olives within each lumen - Olives were pushed toward each other over time until two ends of the esophagus pressed together and created a fistula. 4) Tacking sutures to approximate ends, then placing a bridging silk suture. 5) Multi- staged, extrathoracic elongation of Kimura - Upper part of esophagus is mobilized, and initially brought out as an end cervical esophagostomy. - Every 2-3 weeks, the esophagus and its cutaneous stoma are surgically mobilized and translocated down the anterior chest wall until enough length is achieved. 6) Foker technique - Traction sutures on both proximal and distal pouches exit through the chest wall and are serially pulled in opposite directions until the pouches approximate. - Induces esophageal growth and expedite approximation of pouches, allowing for earlier primary repair (10-14 days). 7) Internal traction sutures 8) Intraoperative techniques - Foker traction done intraop: achieve length after 20-30mins of traction on the esophageal ends. - Circular myotomy: Upper part of esophagus, to decrease tension. (modification: use balloon catheters or cuffed endotracheal tubes inflated in the upper esophageal pouch) —> complications include leak, impaction of food particles, ballooning, esophageal pseudodiverticulum, stricture - Distal pouch circular myotomy in addition to proximal myotomy (modifications: spiral upper pouch myotomy with oblique suture closure of the muscular layer to minimize diverticula formation, improve motility) - Create full thickness anterior flap of upper pouch wall. When folded distally, flap can be rolled into a tube and attached to the lower esophageal segment. (Mod: Create 5mm posterior flap or anterior esophageal flap, plus end to end oblique anastomosis with spatulated distal esophagus.) - Completely mobilize distal esophagus down to the esophageal hiatus of the diaphragm. Part of fundus may be brought up into the chest to facilitate anastomosis. - Combined abdominal and thoracic procedure. Ligate and divide left gastric artery, with transverse or diagonal division of the lesser curvature of the stomach, and mobilization of the gastric cardia and upper fundus into the chest. Add partial fundoplication to treat anticipated GER. - Collis gastroplasty with Nissen fundoplication to lengthen distal end. Other maneuvers: - Postoperative head flexion - Paralysis of striated muscles of the neck - Mech vent support to minimize esophageal disruption

Answer 23

1) Lower birthweight (<1500g/prematurity) 2) Major CHD 3) Severe associated anomalies and ventilator dependency 4) Long gap length between two ends of esophagus

Answer 24

1) Twin birth 2) Preoperative intubation 3) BW <2500g 4) Long gap atresia 5) Anastomotic leak 6) Postoperative intubation > 4 days 7) Inability to feed at the end of 1 month

Answer 25

B Identify and preserve vagus nerve. Recurrent laryngeal nerve is quite high and does not come across. Syed/MCQ

Answer 26

A Long gap oesophageal atresia is an indication of cervical oesophagostomy. Syed/MCQ

Answer 27

C Procedure includes: Left-sided approach is preferred. Incision 1 cm above and parallel to medial third of clavicle. Ligate and divide external jugular vein. Retract carotid sheath with its contents (carotid artery, vagus nerve and internal jugular vein) laterally. Identify and preserve recurrent laryngeal nerve. Syed/MCQ

Answer 28

Answer: 3 - Abnormal posterior positioning of the tracheoesopha-geal septum Explanations: •The infant most likely has a tracheoesophageal fistula (TEF) and esophageal atresia. TEF occurs due to abnormal septation of the caudal foregut during the fourth and fifth weeks of embryonic de-velopment. • Under normal conditions, the trachea forms as a diverticulum of the foregut and develops a complete septum that separates it from the esophagus. • Fistula formation in conjunction with esophageal atresia (EA) occurs during an abnormal posterior positioning of the tracheoe-sophageal septum, resulting in a retained connection between the trachea and esophagus. • Isolated EA without TEF commonly occurs when the esophagus fails to recanalize during week 8 of embryonic development. StatPearls

Answer 29

D Fundoplication is the procedure for correction of gastroesophageal reflux if medical treatment fails. Oesophageal dilatation is for correction of oesophageal stricture. If dilatation fails in stricture may needs resection and anastomosis or oesophageal replacement. Aortopexy may be required in severe tracheomalacia. Syed/MCQ

Answer 30

E R stands for renal anomaly. VACTERL stands for vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal anomalies and limb abnormalities. Syed/MCQ

Answer 31

E E stands for ear deformities. CHARGE is an abbreviation for Coloboma, heart defects, atresia choanae (also known as choanal atresia), growth retardation, genital abnormalities and ear abnormalities. Syed/MCQ

Answer 32

E Choice of operation is oesophagostomy and gastrostomy when the patient is not fit. Syed/MCQ

Answer 33

B Identify and preserve vagus nerve. Recurrent laryngeal nerve is quite high and does not come across. Syed/MCQ

Answer 34

A Long gap oesophageal atresia is an indication of cervical oesophagostomy. Syed/MCQ

Answer 35

C Procedure includes Left-sided approach is preferred. Incision 1 cm above and parallel to medial third of clavicle. Ligate and divide external jugular vein. Retract carotid sheath with its contents (carotid artery, vagus nerve and internal jugular vein) laterally. Identify and preserve recurrent laryngeal nerve. Syed/MCQ

Answer 36

A Tube oesophagogram is done in prone position to visualise H-type fistula. Syed/MCQ

Answer 37

B In neonates right-sided, while in adults left-sided pneumothorax occurs because of close adherence of aorta to oesophagus on the left side in infants, which provides additional support. Oesophagoscopy offers no diagnostic advantage and may actually enlarge the perforation, making subsequent repair more difficult. Decision of treatment in oesophageal perforation depends on site of perforation, whether perforation is free or contaminated, the interval from injury to diagnosis and systemic response to injury. Syed/MCQ

Answer 38

C Incidence of dysphagia is about 50 percent. Only about 10 percent require surgery up to 10 years of age. Leakage is seen in 10–20 percent of cases. By one thoracotomy, the incidence of scoliosis increases to 10 percent, and by second thoracotomy it increases to 20 percent. Syed/MCQ

Answer 39

B 8–12 cm Syed/MCQ

Answer 40

B Oesophageal atresia with distal tracheoesophageal fistula. The incidence is A ≤ 1 percent, B 86 percent, C 1 percent, D 4 percent, and E 8 percent. Syed/MCQ

Answer 41

C Gastrointestinal anomalies are found in 24 percent of cases. Syed/MCQ

Answer 42

B 10–20 percent of cases. Syed/MCQ

Answer 43

C 2–5 percent of cases Syed/MCQ

Answer 44

A Right cervical incision. Syed/MCQ

Answer 45

B 6–8 percent Syed/MCQ

Answer 46

A Left anterior thoracotomy is preferred for aortopexy. Syed/MCQ

Answer 47

D All A, B and C are indications for oesophageal replacement. Syed/MCq

Answer 48

D Right, transverse or left colon may be used. Syed/MCQ

Answer 49

A Right thoracotomy is preferred method of oesophageal replacement with colon, as most of thoracic oesophagus is situated more towards right side than left. Syed/MCQ

Answer 50

B Sodium hydroxide is an alkali. Ammonium hydro-oxide comes in the category of ammonia. Sodium hypochlorite and sodium polyphosphate are detergents. Hydrochloric acid is an acid. Other alkalis include potassium hydro-oxide. All above cause caustic stricture of oesophagus. Syed/MCQ

Answer 51

A Acid ingestion causes coagulative necrosis, while after alkali ingestion liquefactive necrosis occurs. Syed/MCQ

Answer 52

C Fiberoptic endoscopy is indicated within 24–48 hours. In case of pharyngeal burn with stridor, early oesophagoscopy is contraindicated because of upper airway obstruction. In case of alkali ingestion, induction of vomiting is contraindicated because the alkali is mostly neutralised by gastric acid, and consequences of acid regurgitation may induce further injury. Syed/MCQ

Answer 53

E The grading of oesophageal injury after caustic ingestion is grade 0 is normal, grade I is hypermia, grade IIa is blister and superficial ulcer, grade IIb is deep discrete or circumferential ulcer, grade IIIa is small scattered area of necrosis, grade IIIb is extensive necrosis and perforation. Syed/MCQ

Answer 54

D Stricture longer than 5 cm has poor prognostic sign. Syed/MCQ

Answer 55

A objects found within the oesophagus should generally be considered impacted. Because impacted oesophageal foreign bodies may lead to significant morbidity (and even mortality), removal of impacted oesophageal foreign bodies is mandatory. Batteries located in the oesophagus should be removed urgently because of the risk of oesophageal burns and resultant complications. The procedure of choice is flexible fibreoptic endoscopy. most swallowed foreign bodies pass harmlessly through the GI tract once they have reached the stomach. Button (disc) batteries in the stomach or intestines do not need to be removed immediately, as they generally pass through the lower GI tract without difficulty. Button batteries retained in the stomach or at a fixed spot in the intestines should be removed. The ingestion of multiple magnets may lead to the development of pressure necrosis and subsequent perforation as the opposite poles of the magnets will become attracted to one another. This may be particularly true when the magnets are ingested at intervals. However, a single magnet poses no such risk and should spontaneously pass. SPSE 1

Answer 56

D most complications of paediatric foreign body ingestion are due to oesophageal impaction, and this usually occurs at one of three typical locations. The most common site of oesophageal impaction is at the thoracic inlet. This is defined as the area between the clavicles on chest radiograph, and the site of anatomical change from the skeletal muscle to the smooth muscle of the oesophagus. The cricopharyngeus sling at C6 is also at this level and may ‘catch’ a foreign body. About 70% of blunt foreign bodies that lodge in the oesophagus do so at this location. Another 15% become lodged at the mid- oesophagus, in the region where the aortic arch and carina overlap the oesophagus on chest radiograph. The remaining 15% become lodged at the lES at the gastro-oesophageal junction. Children with pre-existing oesophageal abnormalities (e.g. repair of a tracheo-oesophageal fistula) are likely to have foreign body impaction at the site of the abnormality. If a child with no known oesophageal pathology has a blunt foreign body lodged at a location other than the three typical locations described above, the possibility of a previously unknown oesophageal abnormality should be considered. This latter population makes up a small minority of oesophageal ingestions overall. SPSE 1

Answer 57

C Endoscopy (oesophagoscopy) is by far the most commonly used means of oesophageal foreign body removal and is usually the procedure of choice. most children with oesophageal foreign bodies are stable from a cardiovascular and respiratory standpoint. Endoscopy usually can be delayed until the child’s stomach is emptied and a surgical team is assembled. However, pointed objects and batteries should be removed as rapidly as possible to avoid further injury to the oesophageal mucosa and subsequent mediastinitis. Because endoscopy is relatively invasive and expensive, other methods of oesophageal foreign body removal have been investigated and are probably more cost-effective when used appropriately. These have been performed most commonly on children with oesophageal coins, and should be performed only in previously healthy children whose ingestion of a blunt object was witnessed less than 24 hours prior to the procedure. Foley catheter method: blunt foreign bodies may be removed by use of a Foley catheter. Typically, the patient is restrained in a head-down position on a fluoroscopy table, and an uninflated catheter is inserted distal to the object. The catheter balloon is then inflated and gently withdrawn, drawing the foreign body with it. on some occasions, the object is dislodged and passed into the stomach. Progress is typically monitored fluoroscopically. This procedure is performed without radiographic monitoring at some centres with extensive experience and does not require general anaesthesia. Bougienage method: blunt oesophageal foreign bodies may be advanced into the stomach with a bougie. While the child is sitting upright, the lubricated instrument is gently passed down the oesophagus, dislodging the object. The object is then expected to pass through the rest of the GI tract; thus, this procedure should not be performed on children with known lower GI tract abnormalities. A brief observation period and a repeat radiograph should follow any removal procedure to rule out retained foreign bodies and other complications (e.g. pneumomediastinum). In recent studies, the bougienage method has been shown to be far more cost-effective than endoscopy, for properly selected patients. Spontaneous passage: blunt foreign bodies located at the lES often pass spontaneously within several hours of ingestion. This has been best studied in coin ingestions. Previously healthy children may be given food and drink and have repeat radiographs 24 hours following ingestion. often, the coin passes through the lES, and a removal procedure can be avoided. Although blunt foreign bodies located in other areas of the oesophagus are less likely to spontaneously pass, this strategy may be an appropriate alternative for stable children with normal oesophageal anatomy and a foreign body in the thoracic inlet or the midoesophagus. This may be most successful in asymptomatic children. Follow-up imaging should be arranged to ensure transit, and once the oesophagus is clear, nearly all foreign bodies are evacuated – 97% in one large series. SPSE 1

Answer 58

D Bronchoscopy should be performed in any patient with a definitive or suspected diagnosis of a tracheobronchial foreign body in order to confirm the diagnosis and to remove the foreign body. most practitioners recommend rigid bronchoscopy, which should be done as soon as the patient is deemed stable. Spiral CT of the chest would not contribute to the care of this child and would subject her to unnecessary radiation. Bronchodilators are of benefit in a child with reactive airway disease, but this history indicates a probable ingested foreign body as a cause of the wheezing. The Heimlich manoeuvre is widely recommended as a first-aid measure but is of dubious efficacy in the stable patient and can sometimes displace an inhaled object into a relatively riskier location. It should be reserved for complete airway obstruction without other available resources. oesophagoscopy is of no value in this context, as the child’s symptomatology indicates the foreign body is affecting the tracheobronchial tree. SPSE 1

Answer 59

B A wide variety of radiological findings are possible after aspiration of a foreign body. As recently reported by Bittencourt et al. (2006) the most common finding is unilateral hyperlucency distal to the obstructing material (see Table 24.1). Identification of the foreign body is relatively rare (<25%), and the development of pneumonia is a late finding. SPSE 1

Answer 60

C The most common location of aspirated foreign bodies is the right main bronchus as indicated by several investigators on the subject. The proposed mechanism for this asymmetrical distribution is the more direct course that the right bronchus follows after the tracheal bifurcation when compared with the left bronchus. A recent review (Saki et al., 2009) found the distribution of aspirated foreign bodies to be as follows: ● right mainstem bronchus in 560 (55.1%) ● left mainstem bronchus in 191 (18.8%) ● trachea in 173 (17.1%) ● vocal cords in 75(7.4%) ● both bronchi in 16 (1.6%). SPSE 1

Answer 61

B Saki et al. (2009) review the presenting symptoms in their series, as well as in the available data reported in literature. In their review, coughing was the most common symptom (73%), and this was seen consistently in the publications on the subject. It is important to note, however, that a significant minority of patients will present late with no appreciable history. These patients may manifest persistent pneumonia or lung abscesses, in which case a high index of suspicion of a foreign body aspiration needs to be maintained. SPSE 1

Answer 62

E Numerous reports have recently been published illustrating the many complications associated with the ingestion of multiple magnets. If more than one magnet is ingested, the magnets may be attracted to one another leading to pressure necrosis between two loops of intestine. ultimately, this may result in a perforation or an enteric fistula. Should an enteroenteric fistula occur, malabsorption and diarrhoea may ensue. Intestinal obstruction has also been reported, both secondary to the magnets themselves, and as a consequence of an acute intestinal volvulus. SPSE 1

Answer 63

D long-standing foreign bodies are at risk of embedding themselves within the surrounding tissues, making them particularly challenging to remove by endoscopic means. Rigid bronchoscopy under general anaesthesia is the treatment of choice as it provides optimal conditions for foreign body removal. Sufficient anaesthesia is required for the procedure in order to prevent laryngospasm, for which topical anaesthesia with tetracaine or lidocaine is an important adjunct. The presence of localised oedema is an indication for systemic corticosteroid therapy, either before or after the procedure. Tracheostomy is occasionally indicated in foreign body extraction, especially when the foreign object is impacted in the subglottic region, or if the foreign body is large and obstructs the glottis during removal. Racemic adrenalin is useful in the treatment of laryngotracheitis as it leads to mucosal vasoconstriction and the reduction of oedema via alphaadrenergic receptors located in the airway. However, it has not been shown to be of benefit in the context of an airway foreign body. SPSE 1

Answer 64

C Button batteries within the stomach or intestine do not need to be removed immediately, as the vast majority will pass through the lower GI tract without difficulty. Button batteries retained in the stomach or at a fixed point in the intestine should be removed. Generally, these patients may be managed on an outpatient basis. Serial daily radiographs are not required, and as long as the patient remains asymptomatic, weekly radiographs may be obtained if it cannot be recovered after straining the stool. Intervention is required when symptoms arise (e.g. peritonitis, bowel obstruction), or if the foreign body has been retained more than 2 weeks in the same location. It is important to realise that it is often difficult to clearly define its location based on plain radiographs. If the battery is suspected to be in the stomach, it should be removed by endoscopy. The administration of ipecac or other emetic agent is not indicated and may result in aspiration. SPSE 1

Answer 65

D In the year 2000, in the united States, foreign body aspiration accounted for more than 17 000 emergency department visits and 160 deaths in children aged 14 years or younger. Airway foreign bodies are the fifth most common cause of death in children younger than 1 year. The peak ages during which aspiration of foreign bodies occur are the toddler through preschool ages, although foreign bodies have been found in the airways of patients of all ages and sizes. Foreign body aspiration occurs with a slight male predominance and is typically (although not always) witnessed by a friend or family member. SPSE 1

Answer 66

E Disc batteries do not usually cause problems unless they become lodged in the GI tract. The most common location that disc batteries become lodged, resulting in clinical consequences, is the oesophagus. Batteries that successfully traverse the oesophagus are unlikely to lodge at any other location, and are effectively neutralised by GI secretions. They can be managed expectantly. oesophageal damage can occur in a relatively short period of time when a disc battery is lodged in the oesophagus. liquefaction necrosis may occur as a result of the production of sodium hydroxide when current is produced by the battery (usually at the anode). However, the necrosis is multifactorial as electrochemical analysis ex vivo suggests that thermal, caustic and toxic phenomena are all contributing factors. Perforation has occurred as rapidly as 6 hours after ingestion, with maximal effects occurring in as little as 2 hours. lithium batteries make up only 1% of all battery ingestions overall, but although they contain no alkaline material they tend to be larger and have a greater voltage, and have been shown to cause similar mucosal damage as alkaline batteries. SPSE 1

Answer 67

A General anaesthesia provides optimal conditions for the removal of most airway foreign bodies. In patients with laryngeal foreign bodies (not tracheobronchial), removal without anaesthesia can be attempted. Rigid bronchoscopy is the primary tool for evaluating and treating aspirated foreign bodies. Forceps remain the most commonly employed instrument for retrieval, but the Fogarty catheter has been described to aid in extracting material inaccessible to grasping instruments. In cases that result in fragmentation of the foreign body, a second endoscopy may be required. Should foreign material completely obstruct the airway of a pulmonary segment on repeat bronchoscopy, the surgeon should be prepared to perform a segmentectomy as required. SPSE 1

Answer 68

B Typical foreign body impaction occurs in the area of the cricopharyngeus muscle, at the level of the aortic arch, or at the loS. Impaction at another site may indicate an underlying anatomical abnormality, but is non-specific. In one series of patients, an impacted food bolus was associated with an abnormality in 70% of cases; tacks or other solid objects are more commonly seen in children without underlying pathology. Impaction at an older age (>5 years) has been noted to be associated with an increased likelihood of detecting an underlying anatomical abnormality. A follow-up oesophagram may be indicated if the diagnosis remains a possibility. The male-to-female ratio for aspirated foreign bodies in young children is 1 : 1, although in adolescents, males are more commonly affected than females. There is no correlation with an underlying anatomical abnormality based on gender or if the aspiration is witnessed. SPSE 1

Answer 69

A This description is classic for a lactobezoar, which is a compacted mass of undigested milk concretions. Although case series describing this entity are small, prematurity is a consistently described risk factor. It has been reported with virtually every milk product available, including breast milk and soy-based formulae. They frequently present with partial or complete gastric outlet obstruction in neonates or infants. AXR findings include a soft-tissue mass within a large stomach air bubble. ultrasound and contrast radiographs can further support the diagnosis. CT scan of the abdomen subjects the child to needless radiation and is not indicated. upper endoscopy is technically demanding in neonates and is not justified given the working diagnosis. The preferred treatment for a presumed lactobezoar is initiation of intravenous hydration, and the cessation of enteral feedings. Resolution of symptoms and the radiological findings provide confirmatory evidence of the diagnosis. While gastric perforation has been reported in the context of a lactobezoar, laparotomy should only be reserved for rare cases of complication. SPSE 1

Answer 70

A OA is of five types. The commonest type is oA with distal ToF, with an incidence of 85.8%. This is also known as type ‘C’ oA. The next common type is the pure oA with no fistula. The incidence of this anomaly is 7%–8%. SPSE 1

Answer 71

E VACToRl association is a spectrum of clinical conditions in the human neonate that includes vertebral (V), anorectal (A), cardiac (C), tracheo-oesophageal (To), renal (R) and limb (l) defects. This spectrum of anomalies has not been recognised as a specific syndrome in humans but rather represents a non-random association of congenital defects of poorly known aetiology and pathogenesis and its components have been variable. SPSE 1

Answer 72

D The predictive value of prenatal ultrasonography in the diagnosis of oA is only 20%–40%. Presence of anechoic shadow in the fetal neck with a small or absent stomach bubble on ultrasound associated with the maternal polyhydramnios is suggestive of oA antenatally. Fetal mRI may be an important adjunct for the prenatal diagnosis of oesophageal anomalies. oA is rarely diagnosed antenatally. SPSE 1

Answer 73

E most neonates with oA are diagnosed early in life. The earliest clinical sign is excessive salivation. Feeding is followed by regurgitation, choking and coughing. There may be associated cyanosis, respiratory distress, inability to swallow and inability to introduce a nasogastric tube into the stomach. Some babies with distal fistula may distend their stomach, leading to elevation of the diaphragm and subsequent pulmonary compromise. SPSE 1

Answer 74

D An ECHo is essential before taking the patient to the oR. ECHo is useful in diagnosing associated cardiac anomalies that could alter the prognosis in these patients. It also reveals the site of the aortic arch. Babies with right-sided aortic arch may need a left thoracotomy for ToF repair. SPSE 1

Answer 75

E In babies with oA and ToF, bronchoscopy is useful. Bronchoscopy is performed using a rigid bronchoscope. It is usually done just before positioning the patient for the oA and ToF repair. Bronchoscopy has several advantages. It provides information about the site, size, location and number of fistulas. It allows placement of guide wire through the fistula allowing for better identification of the fistula during repair. In babies who have a distal ToF with severe gastric distension and ineffective ventilation, bronchoscopy can be used to block the fistula site temporarily using a Fogarty catheter and save the baby. In patients with recurrent ToF repair following previous open or thoracoscopic repair of oA and ToF, bronchoscopy can be used for injection of glue at the recurrent fistula site. SPSE 1

Answer 76

E oesophageal stricture is a common problem after oA repair. most babies benefit from a few dilatations. The factors implicated in the pathogenesis of these stricture are tension on the anastomosis, two-layered anastomosis, anastomotic leak, use of non-absorbable silk suture, GoR and ischaemia at the site of repair. A single-layered interrupted absorbable-suture anastomosis with minimum tension is preferred and helps prevent this complication. Anastomotic leak after oA repair produces scarring in the area of anastomosis and forms a stricture that may need several dilatations or even resection. There is a high incidence of GoR in patients with oA and ToF. Antireflux treatment should be considered in all these patients after ToF repair. Some of these patients may have recurrent strictures and may need fundoplication with dilatation of the stricture or even resection of the stricture. There is no evidence that either the transpleural or extrapleural approach increases/decreases incidence of stricture formation. SPSE 1

Answer 77

E There is a high incidence of GoR in patients with oA and ToF. This may be because of the shortened intra-abdominal portion of the oesophagus. Also, there is altered motility at the site of anastomosis leading to reduced clearance which makes the effects of reflux more permanent. medical antireflux treatment should be considered in all these patients after ToF repair. Some of these patients may have recurrent strictures and may need fundoplication with dilatation of the stricture or even resection of the stricture. A short, floppy Nissen’s wrap has been shown to be better than the traditional Nissen’s wrap. This has shown to produce less dysphagia than the original technique. SPSE 1

Answer 78

D Tracheomalacia is defined as a weakness in the wall of the trachea. It may be mild, moderate and severe in variety. most cases are mild to moderate, and usually get better as the child grows. The severe variety is where there is a complete collapse of the anterior and posterior walls of the trachea at expiration or when the child coughs. This type may benefit from surgical treatment. Although almost 75% of patients with oA and ToF have tracheomalacia, only about 20%–25% of patients are symptomatic from it. Typical presentation is with ‘barking’ cough. Symptoms may be difficult to distinguish from recurrent ToF, oesophageal stricture or GoR. In severe cases the child may have acute, life-threatening apnoeic spells and may benefit from aortopexy. The weak trachea is compressed between dilated oesophagus and aorta, and this pressure can be relieved by doing an aortopexy that fixes the aorta to the sternum and prevents it from compressing trachea. SPSE 1

Answer 79

D oA and distal ToF associated with duodenal atresia is a difficult problem to manage. Since there is a communication between the trachea and distal oesophagus the air tends to take the path of least resistance and it escapes from the trachea into the distal oesophagus and then into the GI tract. If the child is intubated it is difficult to ventilate the child because of the reason mentioned above. If there is an associated duodenal atresia the problem becomes worse; the stomach and duodenum continue to distend till they burst/perforate making the child very sick. Therefore oA and distal ToF associated with duodenal atresia is an emergency and needs immediate treatment – emergency thoracotomy and ligation of fistula. The other option is to do an immediate bronchoscopy and place a Fogarty balloon catheter in the fistula to block it as a temporising manoeuvre. Performing a gastrostomy would complicate the problem even more and may lead to immediate demise of the child from inability to ventilate. Diagnosis is mostly clinical and based on plain X-rays. upper GI contrast studies are not required to make a diagnosis. SPSE 1

Answer 80

E H-type ToF is an anomaly where there is a connection between the trachea and the oesophagus without oesophageal atresia. Babies with this type of anomaly usually present late with symptoms of choking with feeds, excessive gas in the GI tract with distension, or with recurrent pneumonia. The overall incidence of this anomaly is about 4.2% of all the oA anomalies. Diagnosis can be made by cine prone oesophagram or by rigid bronchoscopy. At the time of bronchoscopy, a guide wire is placed through the fistula to help identify the fistula at the time of surgery. Surgical repair is usually performed through a cervical approach and the fistula is divided and closed. During the surgical repair the recurrent laryngeal nerve (contralateral more than ipsilateral) is at risk of injury. SPSE 1

Answer 81

D Surgical repair of oA can be accomplished by either the open thoracotomy approach or the by the thoracoscopic approach. The right side is the usual site of entry. In cases where there is a right-sided aortic arch, a left-sided approach is used. The most preferred route is the extrapleural approach because leakage from the anastomosis with potential infection would be contained outside the pleura thus preventing an empyema. The first step is to identify the fistula and divide it. Next the upper pouch is mobilised and an end-to-end interrupted singlelayer absorbable suture anastomosis is performed without tension. In cases where the gap between the two ends is greater, a flap from the upper pouch may help bridge the gap. SPSE 1

Answer 82

C In patients with type ‘C’ anomaly with a large ToF the air follows the path of least resistance and bypasses the lung. This distends the stomach and creates a risk of gastric perforation. Pushing the endotracheal tube beyond the fistula is an important first step to solve this problem. This may not always be successful since the fistula may be low or at the bifurcation of the trachea. The other options are to perform either an emergency bronchoscopy with balloon occlusion of the fistula or an emergency thoracotomy and ligation of the fistula. Performing a gastrostomy would complicate the problem even more and may lead to immediate demise of the child from inability to ventilate. If the child’s condition permits and the anaesthetist is happy with intraoperative patient stability, both a ligation of fistula and oesophageal anastomosis may be accomplished. SPSE 1

Answer 83

D Congenital stenosis of the oesophagus is a rare condition. There are three types: (1) a membranous web or a diaphragm, (2) fibromuscular thickening and (3) narrowing secondary to tracheobronchial remnants. The length of the narrow segment is usually less than 3 cm. Types 1 and 2 are located in the mid-portion of the oesophagus while type 3 is seen in the distal third of the oesophagus. Type 1 is the rarest and type 2 is the commonest variety of oesophageal stenosis. The first two conditions may be treated with dilatation but the third type usually needs surgical excision and end-to-end oesophageal anastomosis. SPSE 1

Answer 84

B LTOC is a rare anomaly. It involves a midline communication between the larynx, trachea and oesophagus. It is classified into four types: type I is limited to the larynx; type II extends beyond the cricoid lamina to the cervical trachea; type III involves the entire trachea down to the carina; type IV extends beyond the carina to involve one or both of the main bronchi. Several other anomalies may be associated with lToC. oA with ToF may occur in 20%–36% of patients with lToC. Type I anomaly may not require surgical correction, but types II, III and IV do need surgical correction. A right thoracotomy and extrapleural approach is used for repair. The approach may be lateral through the tracheo-oesophageal groove or anterior by opening the anterior wall of trachea. There is a high risk of injury to the recurrent laryngeal nerve, which is greater with the lateral approach than with the anterior approach. Treatment of this anomaly is complex and needs a multidisciplinary approach. Survival is poor and ranges from 50% to 75%. It is also associated with a lot of morbidity. Inability to wean the patient from the ventilator, pharyngo-oesophageal dysfunction and GoR are common postoperative problems. SPSE 1

Answer 85

B Caustic ingestion in children is a major health hazard with around 5000 cases per year in the united States. It most commonly occurs in children aged 1–3 years. Boys are more frequently involved than girls. In children older than 5 years, nonaccidental injury is very likely. Among adolescents, females predominate and the cause is usually intentional. Approximately 20% of caustic ingestions result in some degree of oesophageal injury. SPSE 1

Answer 86

C The pH and physical form of the substance ingested play an important role in the site and type of injury. A pH >12 or <1.5 is associated with severe corrosive injuries. Strong alkalies in both liquid and granular form are the principal cause of severe injuries. These include sodium hydroxide (lye), potassium hydroxide and sodium carbonate. unlike alkalies, which do not have much taste, strong acids are bitter, burn on contact and are usually expectorated. When they are swallowed, they pass rapidly through the oesophagus and cause most substantial damage in the antrum of the stomach. This is due to pooling of swallowed acid proximal to the pylorus, which goes into spasm on contact with acid. The injury tends to be worse when the stomach is empty. The duodenum and proximal small intestine are relatively protected by pylorospasm. Ferrous sulphate in both tablet and capsule form may induce caustic injury to the oesophagus and stomach. SPSE 1

Answer 87

C In cases of acid ingestion, the duodenum and proximal small bowel are relatively protected by pylorospasm. most injuries occur in the antrum of the stomach and tend to be worse when the stomach is empty. Acid ingestion causes coagulation necrosis with a hard eschar formation. The protective coagulum layer at the site limits acid penetration through the mucosa. SPSE 1

Answer 88

C Alkalis tend to be tasteless and odourless, so large quantities can be ingested. The solid form results in more oropharyngeal and supraglottic injuries because of limited quantities of ingestion. In cases of alkali ingestion, liquefactive necrosis occurs with destruction of the epithelium and submucosa, and may extend through the muscle layer. A friable discoloured eschar forms, beneath which tissue destruction continues until all the alkali has neutralised. The principal sites of damage are the areas of hold up such as cricopharyngeal area, the midoesophagus where it is crossed by the aortic arch and left main stem bronchus, and immediately proximal to the gastro-oesophageal junction. SPSE 1

Answer 89

B most children with caustic ingestion remain asymptomatic and do not develop signs of corrosive injuries. others present with signs of oral burns, retrosternal pain, tachycardia, dyspnoea and agitation. The extent and severity of injury depends on the concentration and form of the ingested substance. oesophageal injury without any evidence of oropharyngeal injury can occur in up to 10% of cases. Drooling and inability to swallow indicate severe posterior pharyngeal or upper oesophageal injury. Acute respiratory distress may occur as a result of posterior pharyngeal oedema or upper airway burns. Severe injuries can also result in oesophageal perforation with mediastinitis, shock and surgical emphysema in the neck and chest. SPSE 1

Answer 90

A Initial management, irrespective of the type of caustic ingestion, is directed at achieving haemodynamic and respiratory stability. Attempts to remove the ingested substance by emesis or lavage are strictly contraindicated as they may reintroduce the corrosive material onto the epiglottis, vocal cords and larynx. No neutralising chemicals should be given as they produce heat when interacting with the ingested substance, which may increase the severity of the injury. After stabilisation of the patient, chest and abdominal radiographs are obtained as a baseline and to rule out free air in the mediasternum or abdomen. likewise, contrast oesophagram is not helpful in the early stages of acute injury, unless there is a strong suspicion of perforation, or endoscopy cannot be performed for some reason. Water-soluble contrast should always be used in case perforation is present. urgent surgery is reserved for rare cases of severely charred oesophagus when oesophagectomy is performed and cervical oesophagostomy and feeding jejunostomy or gastrostomy is established. upper gastrointestinal endoscopy is usually performed 24–48 hours after injury. SPSE 1

Answer 91

C The timing of fibre-optic endoscopy is not universally agreed, but it is thought to be safe and more accurate if done within 24–48 hours after injury. This is because it takes 12–24 hours for the injured areas of the oesophagus and stomach to demarcate. The risk of perforation is high after 4–7 days, as there is completion of necrotic tissue sloughing and early granulation. Endoscopy helps to grade the severity of the injury, plan management and predict long-term outcomes. Perforation is a severe complication that may be accompanied by mediastinitis and even mortality. In the presence of pharyngeal burns with stridor, early oesophagoscopy is contraindicated because of the risk of aggravating the airway obstruction. Indirect laryngoscopy is useful in these cases. Although an attempt is made to visualise the entire upper gastrointestinal tract, it is not always necessary and can be potentially dangerous and increases the risk of perforations. This can be avoided by examining the oesophagus only to the level of first significant injury. SPSE 1

Answer 92

D The role of steroids in caustic injuries is still a mater of debate. Animal experiments have suggested that steroids inhibit inflammatory response and decrease the risk of stricture formation and perforation. However clinical trials and retrospective reviews showed no statistical difference in prevention of strictures. Anderson et al. (1990) showed that with first- and second-degree oesophageal injuries, strictures developed in 5% of the steroid-treated patients and none of the controls, with third-degree injuries strictures occurred in 90% of the steroidtreated children and 100% of the controls. Stricture formation is thus related to the degree of burn irrespective of steroid treatment. It has been suggested that antibiotics should be used concomitantly along with steroids. This is based on animal studies where the risk of steroid-induced complications was shown to be higher. There is no evidence that it decreases incidence of malignancy. SPSE 1

Answer 93

B The routine use of broad-spectrum antibiotics in caustic injuries still remains a matter of debate. They are definitely indicated where there is clinical evidence of oesophageal or gastric perforation. There is no evidence to show any decrease in rate of stricture formation or perforation following antibiotic usage. Some authors advocate use of antibiotics along with steroids to decrease steroid-induced complications. If considered, their use may more be justified in full-thickness injuries because of the risk of mediastinitis or peritonitis secondary to loss of mucosal and muscular barrier. However, the role of both steroids and antibiotics in caustic ingestion is still controversial. SPSE 1

Answer 94

C The routine use of a nasogastric tube is not recommended in all cases of caustic ingestion. Introduction of a nasogastric tube before endoscopy should be avoided as it may result in a perforation. It should be passed only after the degree and severity of caustic injury has been assessed at endoscopy. For patients with severe injuries, nasogastric tube may be passed for early feeding. It can also function as an intraluminal stent. There is no evidence to show that a period of nil by mouth is of any benefit. oral feeding should be commenced as soon as the patient is able to swallow saliva. SPSE 1

Answer 95

E The severity of complications relates to the depth of injury. Superficial mucosal injuries are painful but resolve without long-term sequelae. Deep caustic injuries result in healing by fibrosis and subsequent stricture formation. Full-thickness injuries can result in perforation and posterior fistula formation with either the trachea or aorta. Gastric outlet obstruction is less common, but can occur specially after strong-acid ingestion resulting in the need for a partial gastrectomy. The risk of oesophageal cancer after caustic strictures is around 5% with a latent period of 15–40 years. Hence lifelong surveillance is important in these cases. Barrett’s oesophagus has also been reported following sodium hydroxide ingestion (lye). SPSE 1

Answer 96

D oesophageal dilatations are the mainstay treatment of oesophageal strictures. These are usually commenced 3–4 weeks after injury. These should be done at least once a week, commencing with catheters that are at least one or two French sizes smaller than the estimated diameter of the stricture. If dilatations fail and a dense stricture develops, it requires further management. localised strictures may be resected with end-to-end anastomosis. local steroid injections have been combined with dilatation with some success. In those cases that have failed dilatation, various oesophageal bypass/substitution procedures such as colonic interposition, gastric tube oesophagoplasty, jejunal interposition, gastric advancement and colonic patch procedures have been used. Pyloroplasty is often combined with some of these procedures, but in itself is not a method for treatment of oesophageal strictures. SPSE 1

Answer 97

A Generally oesophageal dilatation is quite effective in moderate oesophageal injuries. Poor prognostic factors include delay in presentation, extensive grade III injury, ongoing oesophageal ulceration, a dense fibrotic stricture that cracks on dilatation, a stricture longer than 5 cm, and inadequate lumen patency despite repeated dilatations over a 9–12 month period. There is no difference in outcome or severity based on age at presentation. SPSE 1

Answer 98

A oesophageal dilatation should not be performed immediately following ingestion, as it has an increased risk of perforation. It is usually best to wait for 3–4 weeks until the acute lesion has healed and fibrosis has developed. once commenced, to be effective, routine weekly dilatations are recommended. A water-soluble contrast study is usually done 7–10 days following injury to assess the presence of a stricture. The incidence and severity of gastro-oesophageal reflux must be investigated and excluded as a contributing cause of persisting stricture. Gastro-oesophageal reflux must be managed surgically before definitive procedures are attempted. There is no need for prolonged antireflux medications once gastro-oesophageal reflux is surgically corrected. Because of an increased risk of oesophageal cancer following caustic strictures (5%) and a long latent period of 15–40 years, lifelong surveillance is necessary. oesophageal stents can be used to maintain the patency of the lumen and prevent adhesions of the de-epithelialised area of the oesophagus. If used, stents should be left in place for at least 6 weeks. Not all cases of failed dilatation respond to stents and in many cases these are not tolerated well. SPSE 1

Esophagus, Esophageal Atresia, TEF Flashcards

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