Chapter 77: Esophageal Emergencies

Question 1

most common pathogen associated with dysphagia as primary symptom

Answer 1

Candidal species

Question 2

most frequent cause of esophageal perforation

Answer 2

Iatrogenic perforation

Question 3

Boerhaave’s syndrome

Answer 3

full-thickness perforation of the esophagus after a sudden rise in intraesophageal pressure

mechanism: sudden, forceful emesis

common site: distal esophagus on the left side

coughing, straining, seizures, and childbirth have been reported as causing perforations as well

Question 4

characteristic of FB that may lodged distal to the pylorus

Answer 4

• irregular or sharp edges
• wide (>2.5 cm) or long (>6 cm)

Question 5

Signs and symptoms in children with FBI

Answer 5

• refusal or inability to eat
• vomiting
• gagging and choking
• stridor
• neck or throat pain
• drooling

A high degree of suspicion is necessary for unwitnessed ingestions in children, especially in those <2 years of age

Question 6

Circumstances Warranting Urgent Endoscopy for Esophageal Foreign Bodies

Answer 6

• Ingestion of sharp or elongated objects (including toothpicks, aluminum soda can tabs)
• Ingestion of multiple foreign bodies
• Ingestion of button batteries
• Evidence of perforation
• Coin at the level of the cricopharyngeus muscle in a child
• Airway compromise
• Presence of a foreign body for >24 h

Question 7

Esophagus

Three anatomic constrictions (adult)

Answer 7

1. At the cricopharyngeus muscle (C6)
2. At the level of the aortic arch (T4)
3. At the gastroesophageal junction (T10 to T11)

The** pediatric** esophagus gets two additional areas of constriction:
1. At the thoracic inlet (T1)
2. At the tracheal bifurcation (T6)

Question 8

Classic symptom of GERD

Answer 8

Heartburn

Question 9

Most commonly identified in food impaction

Answer 9

Meat

*impaction of food containing bony fragments requires emergency endoscopy
*bolus should not be allowed to remain impacted for >12 to 24 hours
*The use of proteolytic enzymes, which contains papain, to dissolve a meat bilus is contraindicated - severe mucosal damage and esophageal perforation

Question 10

Button battery ingestion

Period when perforation can occur from ingestion

Answer 10

within 6 hours of ingestion

see 77-3

*Button batteries that have passed the esophagus can be managed expectantly, as long as follow-up in 24 hours can be ensured
* Repeat films should be obtained at 48 hours to ensure that the cell has passed through the pylorus, which may not occur if the battery is of large diameter and/or the patient is <6 years old

Question 11

ingestion of sharp objects

If intestinal perforation occurs, it is usually at the ___

Answer 11

ileocecal valve

*the American Society for Gastrointestinal Endoscopy guidelines recommend removal of sharp objects by endoscopy while they are in the stomach or duodenum

Question 12

Narcotic Ingestion (body packers)

Endoscopy is contraintdicated

Answer 12

True

*Rupture of even one such packet may be fatal, and endos copy is contraindicated because of the risk of iatrogenic packet rupture