CASE PRESENTATION

Dr.Yazeed Owiwi

Pediatric Surgery Department

FCPS-II Trainee, PGR-III

CASE HISTORY

• Patient name Tayyab.

• Sex Male

• Age 2 and half years old.

• Date of admission 24th march 2011.

CHIEF COMPLAINT:

• Persistent fluid leaking through right chest tube for the

last 1 month.

History of Present Illness:

Treatment given outside PIMS…

At presentation…

(Day 7 after swallowing button battery)

Gastrografin study.

Day 8

Esophagoscopy.

Day 9

• Esophagoscopy was attempted twicely.

• Button battery was removed.

• It was apparently intact.

Day 14.

Esophageal stent placed

3rd week.

Barium swallow

4th week.

Patient brought to PIMS

5th week

• Sick looking, emaciated child.

• Pale.

• Right chest tube placed with food particles and saliva

coming out.

Day 1 of admission

• Pt kept NPO.

• N/G suction.

• Antibiotic cover.

• PPN started.

• Blood tranfused.

• Serial x-rays taken.

Day 7 of Admission

• Esophagoscopy done

Findings:

1. Food particles enterapted in esophagus.

2. Lower 1/3 of esophagus was hyperaemic & edematous.

3. SEMS found occuping lower 1/3 of esophagus.

4. Endoscopy was unable to pass further upto stomach

due to edema.

Day 10 of Admission

• Feeding Jejunostomy placed.

• Enternal feeding started.

3rd week of admission

• No fluid leaking from chest tube.

• Chest tube clamped for 24 hours and removed in next

day.

2 days latter..

• Pt discharged from ward with regular follow up in OPD.

After 2 weeks..

• Pt presented to us with

High grade fever.

Productive cough.

Abdominal distension.

Vomiting.

• Pt admitted in PICU.

• Kept NPO.

• Blood & sputum C/S sent.

• Gastrograffin study done thru jejunostomy.

• Barium swallow study was done.

• Chest tube re-inserted in right side.

Chest x-ray..

Gastrograffin study…

Barium swallow…

Chest x-ray after intubation…

Overview

• Esophageal perforation is rare

• Roughly 300 cases reported per year

• The diagnosis is commonly missed/delayed

• Mortality is high

• Most lethal GI perforation

• Mortality falls with early dx/intervention

• Survival depends on rapid dx and surgery

• Within 24 hours of rupture: 70-75% survival

• Within 25-48 hours: 35-50% survival

• Beyond 48 hours: 10% survival

Etiology:

• Traumatic Causes (MORE COMMON):

• Endoscopy or dilation procedures

• Stent placement most common cause (up to 25% cases)

• Vomiting or severe straining

• Stab wounds / penetrating trauma

• Blunt chest trauma (rarely)

• Non-Traumatic Causes (LESS COMMON):

• Neoplasm / Ulceration of esophageal wall

• Ingestion of caustic materials

Oesophageal perforation after button

battery ingestion

• Button batteries are frequently swallowed by children.

• Significant damage may occur within very short period

_ Mucosal damage: 1 hr after ingestion.

_ Transmural damage: within 4 hrs.

• Mechanisim of damage:

(Alkali, Electric charge, Pressure).

• May lead to eosophagotracheal fistula.

• All button battaries impacted in esophagus should be

removed immediately( 24-48 hrs).

• Short period of observation is warranted.

Anatomy

• Esophagus lacks serosa

• More likely to rupture

• Site of rupture:

• More commonly on left side

• Due to instrumentation: distal esophagus

• Spontaneous: posterolateral esophagus

• Tears are usually longitudinal

Pathophysiology

• Air, Saliva, and Gastric contents released

• mediastinitis

• pneumomediastinum

• empyema

• can progress to sepsis, shock, resp failure

Presentation

• Pain

• lower anterior chest / upper abdomen

• may radiate to left shoulder / back

• Vomiting >> Hematemesis

• hematemesis: think Mallory-Weiss/varices

• Dyspnea

• Cough (precipitated by swallowing)

• Fever

On Exam

• Subcutaneous Emphysema

• Fever

• Tachycardia

• Tachypnea

• Cyanosis

On Exam…

• Upper Abdominal Rigidity

• Pneumothorax/Hydrothorax

• Respiratory Failure

• Sepsis

• Shock

Initial Imaging: X-ray

• PA and Lateral chest films

• Look for:

• Hydrothorax (L side > R side)

• Pneumothorax

• Hydropneumothorax

• Pneumomediastinum

• SubQ emphysema

• Mediastinal widening

• Pleural Effusion (L side > R side)

Initial Imaging: X-ray

• Upright abdominal film

• Look for subdiaphragmatic air

Interventional Imaging

• Look for extravasation of contrast

• Evaluate location and size of rupture

• Options

• Gastrografin Study

• Water-soluble contrast

• Barium Esophagram

• Positive in 22% of pts with non-diagnostic

Gastrografin study results

CT scan

• Should be used if interventional study:

• Cannot be performed (sedation, etc)

• Cannot localize rupture or is nondiagnostic

• Look for:

• Tear in esophageal wall

• Pneumomediastinum

• Abscess in pleural space or mediastinum

• Commuication of esophagus with fluid collections

What to do next

• ICU admission

• NPO

• NG suction

• Broad-spectrum Abx

• Pain control: Narcotics

Indications for conservative mgmt

• No clinical signs of infection

• Perforation is contained / walled-off

What to do next…

• Early surgical intervention reduces mortality rate:

1st 24 hours!

“He looks sick!”

“I’m going to call the surgeons!”

THANK YOU