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    Morning Report: Laura Lascurain MD PGY 3 May 1, 2015

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    Emily Eresuma
    This document presents the case of a 7-year-old girl who presents with 2-3 months of dysphagia to solids and recent episodes of hyperventilation, chest pain, and dizziness. Her exam is notable for pale turbinates and mild weight loss. The differential diagnosis includes eosinophilic esophagitis, achalasia, GERD, and infectious esophagitis. Eosinophilic esophagitis is an allergic inflammatory condition involving eosinophils that presents with dysphagia and is diagnosed by biopsy. Achalasia involves incomplete LES relaxation and loss of peristalsis. Alkaline ingestions can cause liquefactive necrosis and

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    Morning Report: Laura Lascurain MD PGY 3 May 1, 2015

    Uploaded by

    Emily Eresuma
    380 views19 pages
    This document presents the case of a 7-year-old girl who presents with 2-3 months of dysphagia to solids and recent episodes of hyperventilation, chest pain, and dizziness. Her exam is notable for pale turbinates and mild weight loss. The differential diagnosis includes eosinophilic esophagitis, achalasia, GERD, and infectious esophagitis. Eosinophilic esophagitis is an allergic inflammatory condition involving eosinophils that presents with dysphagia and is diagnosed by biopsy. Achalasia involves incomplete LES relaxation and loss of peristalsis. Alkaline ingestions can cause liquefactive necrosis and

    Original Description:

    Pediatric Morning Report blog, Primary Children's Hospital

    Original Title

    Morning Report Esophagus 05.01.2015

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    This document presents the case of a 7-year-old girl who presents with 2-3 months of dysphagia to solids and recent episodes of hyperventilation, chest pain, and dizziness. Her exam is notable for pale turbinates and mild weight loss. The differential diagnosis includes eosinophilic esophagitis, achalasia, GERD, and infectious esophagitis. Eosinophilic esophagitis is an allergic inflammatory condition involving eosinophils that presents with dysphagia and is diagnosed by biopsy. Achalasia involves incomplete LES relaxation and loss of peristalsis. Alkaline ingestions can cause liquefactive necrosis and

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    380 views19 pages

    Morning Report: Laura Lascurain MD PGY 3 May 1, 2015

    Uploaded by

    Emily Eresuma
    This document presents the case of a 7-year-old girl who presents with 2-3 months of dysphagia to solids and recent episodes of hyperventilation, chest pain, and dizziness. Her exam is notable for pale turbinates and mild weight loss. The differential diagnosis includes eosinophilic esophagitis, achalasia, GERD, and infectious esophagitis. Eosinophilic esophagitis is an allergic inflammatory condition involving eosinophils that presents with dysphagia and is diagnosed by biopsy. Achalasia involves incomplete LES relaxation and loss of peristalsis. Alkaline ingestions can cause liquefactive necrosis and

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 19

    Morning Report

    Laura Lascurain MD PGY 3


    May 1, 2015

    The Case
    HPI: 7 year old girl presents with trouble swallowing.
    2-3 months of dysphagia to solids only at dinner
    2 weeks ago she developed hyperventilation, chest
    pain, and dizziness while at home. The episode was
    self limited.
    No dysphagia to liquids or drooling.
    No witnessed foreign body ingestion.
    ROS: No fever, +mild weight loss, no rash, no voice
    changes or aphonia, unclear if worse when laying
    down

    PMH
    Full term NSVD, No hospitalizations or
    surgeries, she has mild allergic rhinitis
    No medications
    NKDA, allergic to dairy
    Family history of Crohn Disease in maternal
    GF, asthma in brother

    Exam

    Vitals normal with normal saturations


    Height 12%ile, Weight 7%ile
    GEN: well appearing, anxious child
    HEENT: pale turbinates, tonsils 2+ and symmetric, otherwise WNL
    CV: RRR, no m/g
    RESP: CTAB, no wheezing, breathing comfortably, symmetric exam
    ABD: NTND, +BS, no organomegaly
    EXT: warm, no clubbing
    GU: Tanner I female
    NEURO: alert, oriented, CN intact II-XII, grossly normal strength and
    tone, reflexes 2+ and symmetric: biceps, triceps, patellar
    SKIN: No rashes, small ulceration on LLL

    Differential
    7 year old PH girl with new onset dysphagia
    to solids

    Differential
    Sensory/Other
    Globus sensation
    Vocal Cord Dysfunction
    Anxiety

    Infection

    Retropharyngeal abscess
    Epiglottitis
    Central nervous system infection
    Tetanus, Diphtheria, Poliomyelitis, Botulism
    Stomatitis

    Infectious pharyngitis
    Peritonsillar abscess
    Infectious esophagitis: CMV, Candida

    Differential
    Ingestion/Trauma

    Caustic ingestion
    Esophageal foreign body
    Esophageal perforation
    Oropharyngeal trauma

    Neuromotor

    Cerebral palsy
    Miller Fisher syndrome
    Central nervous system tumor
    Dystonic reaction
    Myasthenia gravis
    Nutcracker esophagus

    Achalasia
    Diffuse esophageal spasm
    Post-surgical

    Differential
    Inflammatory

    Stevens-Johnson syndrome
    Eosinophillic Esophagitis
    Rheumatic disease (eg, juvenile systemic sclerosis, dermatomyositis)
    Crohn's disease
    GERD stricture
    Tonsillar/adenoid hypertrophy

    Anatomic

    Vascular ring
    Esophageal Stricture
    Esophageal Web
    Thyroid enlargement (eg, acute suppurative thyroiditis)
    Esophageal tumor
    Hiatal hernia

    Eosinophillic Esophagitis
    Allergic inflammatory condition of the
    esophagus involving eosinophils
    Presents with epigastric pain, vomiting, or
    dysphagia
    Diagnosis made by endoscopic biopsy showing
    infiltration of the lining with eosinophils
    Food allergy plays a significant role
    Management is controversial

    Eosinophillic Esophagitis

    Eosinophillic Esophagitis
    Linear or
    longitudinal
    furrows are
    mucosal
    grooves that
    run parallel to
    the long axis
    of the
    esophagus
    with white
    plaques or
    exudates can
    coat the
    esophagus

    Mucosa
    appears
    pale,
    congested
    , or has
    decreased
    vascularit
    y

    Achalasia
    Pathology: Incomplete relaxation of the LES and
    lack of normal peristalsis
    Loss of ganglion cells in esophagus
    Dorsal motor nuclei reduction of vagus nerve
    Usually with antibodies to the Auerbach plexus

    Presentation: dysphagia, regurgitation,


    recurrent pneumonia, weight loss, chest pain
    Usually in early childhood

    Treatment: Balloon dilation, botox, or myotomy

    Achalasia

    Birds Beak

    GERD
    GER: return of gastric contents into esophagus
    GERD: FTT or esophageal symptoms
    pain, inflammation, bleeding, hoarseness,
    laryngitis, cough, apnea, recurrent pneumonia
    More common in infants than children

    Diagnosis difficult
    Upper GI
    pH probe
    Endoscopy

    Esophageal Infections
    Rare in healthy children
    CMV and candida more likely
    More common in higher risk children
    HIV, DM, cancer, long term steroid use

    Acid/Base Ingestions

    Acidic

    Taste bad
    Cause pain
    Usually spit out
    Rare esophageal damage

    Alkaline
    Tasteless
    Cause liquefactive
    necrosis and intense
    inflammation in the
    esophagus
    Symptoms (drooling,
    dysphagia, stridor,
    retractions) can be
    immediate or delayed

    Management of Alkaline
    Ingestion
    *Upper endoscopy 12-24 hours after
    ingestion
    Initial management is observation
    Except for suspected perforation

    Do NOT induce emesis- increases exposure


    Do NOT place an NG-risk of perforation
    Symptoms of perforation:
    Chest and back pain, subcutaneous
    emphysema, fever, hypotension

    Other Esophageal Issues


    Pill Induced Esophagitis
    Common in adolescents who take pills dry
    *Tetracycline, doxycycline, ASA, NSAIDs, slow
    release potassium

    Spontaneous esophageal perforation


    Rare, but happens in *Ehlers Danlos and Marfans

    Coin Ingestion
    *get a CXR

    Thanks!

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