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!