4 yo boy with dysphagia & 65 yo woman with alopecia

Transcription

1 September 11, yo boy with dysphagia & 65 yo woman with alopecia Jonathan Wasserman, MS IV

2 Patient History 4 yo M in USOGH p/w 1 day h/o dysphagia, poorly described abd. pain No significant PMH, PSH Met all developmental milestones Immunizations UTD O/E: Mild LUQ tenderness, guaiac neg. Otherwise benign exam 2

3 KUB (per report) Dilated loops of small bowel and nml colonic gas. Stomach bubble not seen. consistent with partial SBO vs. early total SBO 3

4 Upper GI Series Filling defects within small bowel Normal gas distribution in large bowel Courtesy Dr. PH Weinstock, Children s Hospital, Boston 4

5 Hospital Course EGD attempted but unable to advance endoscope into gastric lumen, pt. remained symptomatic Patient underwent exploratory laparotomy, gastrotomy Upon entering the stomach, a large mass was identified within the lumen of the stomach and extending through the duodenum and proximal jejunum At the time of surgery, patient s grandmother, who had been babysitting earlier in the week, was contacted, but delayed coming to hospital while she searched for a missing wig. 5

6 Pathology Rapunzel Syndrome Trichobezoar Courtesy Dr. PH Weinstock, Children s Hospital, Boston 6

7 FB Ingestion Accounts for a large number of ED visits, particularly within pediatric hospitals Useful history often unavailable Aprox deaths per year in U.S. from FB ingestion and resultant complications 1,2,3 Peak incidence: 6 months-6 yrs In adults: psychotic, mental retardation, impairment due to EtOH or 2 o gain. 4 1 Panieri E, Bass DH. The management of ingested foreign bodies in children-a review of 663 cases. Eur J Emerg Med 1995;2: Webb WA. Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc 1995;41: Schwartz GF, Polsky HS: Ingested foreign bodies of the gastrointestinal tract, Am Surg 42:236, Blaho KE, Merigian KS, Winbery SL, Park LJ, Cockrell M. Foreign body ingestions in the emergency department: case reports and review of treatment. J Emerg Med 1998;16:21-6 7

8 SSx of FB aspiration/ingestion Airway obstruction Cough Wheeze Stridor Alimentary obstruction Choking/Drooling (Inability to swallow=total obstruction) Emesis Melena Abdominal Pain Change in bowel sounds 8

9 Bottlenecks for FBs in GI Tract Cricopharyngeus Lower esophageal sphincter Pyloric sphincter Ileocecal valve 9

10 Radiologic work-up of suspected FBI Plain films are primary modality for evaluation. Radio-opaque materials (coins, batteries, etc) Soft-tissue reaction adjacent to radio-lucent FBs May swallow contrast-soaked cotton ball to lodge proximal to obstruction Barium swallow-to identify radio-lucent objects (wig) CT-provides information re: size, type, location and orientation; identification of complications HHMD-avoids time, radiation and cost of radiography, can detect aluminum. 10

11 3D-CT in evaluating FBI 77 yo F w/ dementia p/w lower abd pain and fever -Exam and labs WNL KUB substantial amount of small bowel gas US & CT Enlarged small intestine suggesting ileus Maximum Intensity Projection (MIP) CT reconstruction (medication blister pack in ileum) Takada M et al. 3D-CT Diagnosis for Ingested Foreign Bodies. Am J Emerg Med 2000; 18:

12 Radiologic w/u of FBI: 2 pearls Failure to locate an object radiographically does not preclude its presence Rule of Thumb: esophageal FBs align in the coronal plane, tracheal FBs align in the sagittal plane 12

13 21 month old with difficult micturition Coin (5 rupee) lodged in cricopharynx Shah NJ, et al. Bombay Hosp J 2001; 43:

14 Management of FB in GI Tract Remove sharp FB or esophageal FB >24 hrs laryngoscope/foley/bougienage Pt. in Trendelenberg Protect the airway! If in stomach, doesn t necessarily require removal even if sharp Urgent intervention: Patient in acute distress Suspect perforation Do NOT induce vomiting (ipecac) this is only used for liquid, dissolved drugs. Do NOT use force Do NOT assume FB must be removed Do NOT miss additional FBs (repeat films!) 14

15 Special Cases Disc batteries If lodged in esophagus, potential erosion, liquefactive necrosis, heavy metal poisoning If reach stomach, usually pass uneventfully, follow KUB National Button Battery Hotline (202) Sharp objects Risk of perforation Assess radiographs for SQ emphysema, pneumomediastinum If enter stomach, expectant management with QD films to monitor progress of FB 15

16 Instruments used in FB removal Indirect laryngoscope & forceps Roth Net 16

17 Rule of 2 s in Pediatrics (not Meckel s) Objects > 2 inches won t pass the 2 nd portion of duodenum in a patient < 2 years old In adults, straight objects > 6-10 cm won t negotiate duodenal sweep and removal is indicated. Anything that passes through the throat will probably pass through the anus Round objects >2.5 cm less likely to pass pylorus 17

18 77 yo F with N/V x 12 hrs Pt. reported abd. cramps & clear emesis Nausea worsened progressively diffuse pain Denied BRBPR, melena, fever, chills Denied new foods, sick contacts LBM on DOA No further hx provided PMH: HTN, Chol, macular degen (legally blind) PSH: s/p lap. cholecystectomy 1998 ROS otherwise negative 18

19 77 yo F with N/V x 12 hrs O/E: T 99.9 o P 117 RR 20 BP 144/88 Abd: + LLQ tenderness Ø shake tenderness/peritoneal signs Rectal: Normal tone, guaiac N 4 L 0 Bd Presumptive Dx: Diverticulitis 19

20 Abdominal Plain Films No free air clips AFLs Jejunum 4cm Pelvic FB R scoliosis Upright Supine 20

21 CT reveals intra-luminal FB I + /O - No Pneumoperitoneum Transition Point Proximal dilated bowel Distal decompression 21

22 Coronal CT reconstruction 22

23 Coronal CT reconstruction 23

24 Coronal CT reconstruction Unrelated hepatic cysts 24

25 Hospital course Patient admitted for exploratory laparotomy Noted at laparotomy were moderate turbid flud (later found to be sterile pus), a phytobezoar and a sharp metalic object within the jejunum, later identified to be a paper clip. small bowel resection side-to-side anastomosis Patient did well and was d/c ed to rehab on POD # 5. 25

26 Summary FB Ingestion large number of ED visits Major bottlenecks=cricopharynx, GEJ, pylorus, ileocecal valve LOOK IN THESE LOCATIONS Workup may include orthogonal plain films, barium swallow, CT, 3D-CT, HHMD Remove if Sx, sharp, long, battery Once FB enters stomach, expectant mgmt often appropriate, follow sharps with serial radiographs 26

27 References Behrman RE and Vaughan VC Nelson Textbook of Pediatrics 12 th ed Blaho KE, Merigian KS, Winbery SL, Park LJ, Cockrell M. Foreign body ingestions in the emergency department: case reports and review of treatment. J Emerg Med 1998;16:21-6 Eisen GM et al. Guideline for the management of ingested foreign bodies. Gastrointest Endosc 2002; 55: Goh YH and Tan NG. Radiological Features of Unusual Ingested Foreign Bodies. Singapore Med J 2001; 42: Panieri E, Bass DH. The management of ingested foreign bodies in children-a review of 663 cases. Eur J Emerg Med 1995;2:83-7 Rothrock SG, Green SM Hummel CB. Plain abdominal radiography in the detection of major disease in children: a prospective analysis Ann Emerg Med 1992; 21: Takada M et al. 3D-CT Diagnosis for Ingested Foreign Bodies Am J Emerg Med 2000; 18: Webb WA. Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc 1995;41:

28 Acknowledgements Thanks to: Peter Weinstock, MD, PhD (Children s Hospital) Daniel Saurborn, MD Pamela Lepkowski Larry Barbaras and Cara Lyn D amour 28