Happy Monday!
March 2, 2015
Prep
A 6-year-old boy presents with a 3-day history of a limp. He had
an upper respiratory tract infection for 1 week, but there is no
history of trauma. On physical examination, his temperature is
100.4F, he does not bear weight on the right leg, and there is
decreased abduction and internal rotation at the right hip. The
white blood cell count is 8x10^3 and the erythrocyte
sedimentation rate is 20.
Of the following, the MOST likely diagnosis is
A. Avascular necrosis of the femoral head
B. Juvenile rheumatoid arthritis
C. Septic arthritis
D. Slipped capital femoral epiphysis
E. Transient synovitis
Let’s hear about our patient:
Let’s take a look:
Vitals:
General:
HEENT:
CV/Resp:
Abd:
GU:
Ext:
Neuro:
What’s going on?
What will you do?
Evaluation of dysphagia
Swallowing
1.
2.
3.
4.
5.
Bolus presses down epiglottis, covers glottis. Insp. muscles inhibited.
UES relaxes
Peristalsis triggered and bolus moved to stomach
LES relaxes
Secondary peristaltic waves
What’s the difference?
Is it regurgitation of undigested food or
phlegm and actual vomiting or partially
digested food?
• Test substance with litmus paper
– Alkaline Ph = regurgitation
– Acidic Ph = emesis
Differentials
Oropharyngeal
Vs.
Esophageal
H&P findings
• H&P may uncover diagnosis in 75% of
patients…who are adults
• But infants, as usual, are nonspecific!
– Poor interest
– Neck muscle strain
– Stridor
– Drooling between meals
H&P specifics
Oropharyngeal
Esophageal
• Delayed swallow initiation
• Postnasal regurgitation
during swallow
• Cough with swallow
• Drooling
• Persistent throat clearance
• Neurologic: sudden onset
• Infectious or AI: sub-acute
• External mass effect:
progressive
• Retrosternal chest pain or
“sticking” sensations with
swallowing
• Presence of symptoms
with swallowing both solids
and liquids: motility
dysfunction
• Difficulty with just solids:
obstructive
• Pain: esophagitis
Dysphagia Evaluation Options
Modified Barium Swallow Study
• Observes the oropharyngeal phase (anatomical features
of mouth and throat)
– Liquids, semisolids, and solid foods are tested
• May reveal aspiration
Barium Esophagography
• Observation of esophageal phase of swallowing
• Evaluates for extraesophageal causes of dysphagia
(which could be missed by endoscopy)
Dysphagia Evaluation Options
Fiberoptic Endoscopy
• Through nostril to view pharyngeal soft tissue structures
directly, immediately before & after swallowing
• May detect laryngeal penetration of food bolus,
incomplete clearance
• Sensory testing
– Puff of air to stimulate laryngeal adductor reflex (how we protect
our airway!)
Upper Endoscopy
• Observe esophageal mucosal appearance, obtain bxs
• May reveal remnant food particles (possibly dysmotility)
Dysphagia Evaluation Options
Looking for:
1. Presence or absence of peristalsis
2. % Relaxation of LES (N is >75%)
3. Pressure of LES (N is <26mm Hg)
4. Comparison of intra-esophageal and
intra-gastric pressures
Manometry (if suspecting
motility problems)
Our patient’s evaluation
Our patient’s evaluation
Manometry results:
No peristalsis
LES pressure 46mm Hg (N 15-35mm Hg)
Partial relaxation of LES
Intra-abdominal pressure < intra-thoracic pressure
Esophageal Achalasia
Failure of smooth muscle fibers of LES to relax, increased LES tone,
lack of peristalsis of esophagus
• 1 in 100,000, No gender predomination
• <5% of patients present before adolescence
– Time to diagnosis in children is approx 28 months
• Common presentation:
– Dysphagia and regurgitation
– Chest pain behind the sternum, nocturnal cough
– Weight loss
• Frequently worse with solids
Triple A: achalasia,
What AR disorder is achalasia a part of? alacrima, hypoadrenalism
•
• Secondary etiology is parasitic infection with Trypansoma cruzi,
causing? Chagas
Esophageal Achalasia
• Initial procedure for esophageal dysphagia: barium
swallow study or Upper GI endoscopy
– BSS more sensitive and increased by use of solid boluses
– BSS will detect achalasia in 70-95%
• Imaging results: esophagus appears dilated, with
narrowing of distal portion that resembles bird’s beak
• Gold standard is manometry
– Perform prior to endoscopy
– Then perform upper GI to apply therapy
Esophageal Achalasia
• Aim to reduce resting LES pressure
• Botulinum toxin injected into LES during Upper Endoscopy
– 66% of patients have improvement for 6-28 months (avg 16 mths)
• Most children require pneumatic dilatation or surgical
myotomy of LES
– Dilatation: 2-6% risk of perf
– Surgical: Heller myotomy gives relief in 70-90%
• Subsequent reflux esophagitis (? partial fundoplication)
How’d our
patient do?
Have a great day!
Noon Conference:
Radiology Lecture
Series