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 do 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 do 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 5 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