Karina Javalkar, MS4 September 2018 Ed. by John Lilly, MD - - PowerPoint PPT Presentation

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Sep 06, 2023 126 likes •274 views

RADY 403 Case Presentation Karina Javalkar, MS4 September 2018 Ed. by John Lilly, MD Presentation 1 day old male born via SVD, pregnancy complicated by polyhydramnios, admitted to the NICU with profuse oral secretions and inability to

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Karina Javalkar, MS4 September 2018 RADY 403 Case Presentation

Ed. by John Lilly, MD

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Presentation

1 day old male born via SVD, pregnancy complicated by polyhydramnios, admitted to the NICU with profuse oral secretions and inability to tolerate feeds. NG and OG tubes attempted to be passed, but were unsuccessful. Prenatal History: Healthy mom, prenatal labs wnl, no ABO incompatibility Ultrasound showing polyhydramnios, otherwise wnl

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List of imaging studies

◼ Chest X-ray ◼ Fluoroscopy (post-operative)

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Imaging studies from PACS 1- Initial X-ray

Unsuccessful passage

f NG tube

Air in the stomach and bowel

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Imaging studies from PACS 2- s/p fistula ligation, open gastrostomy

NG tube in esophageal pouch Surgical clips Bibasilar atelectasis

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Imaging studies from PACS 3- s/p esophagoplasty

NG tube in the stomach Decreased lung volumes (atelectasis vs. aspiration)

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Imaging studies from PACS 4- Barium Swallow

Contrast passage through distal esophagus and into the stomach Narrowing at anastomotic site without leak

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Discussion: Esophageal Atresia with Tracheoesophageal Fistula

◼ Type A is the most common (85%) ◼ Majority have polyhydramnios in utero ◼ May be part of VACTERL association ◼ Esophageal atresia types present at birth ▪

Excessive drooling, secretions

▪ Inability to feed

▪ Respiratory distress (aspiration)

◼ H-type may present later (months/years) ▪

Prolonged history of respiratory distress with feeds, recurrent pneumonia etc

Image obtained from UpToDate.com Data from: Clark, DC. Esophageal atresia and tracheoesophageal fistula. Am Fam Physician 1999;59:910. TEF types classified according to the scheme developed by EC Vogt in 1929, as modified by Gross.

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Discussion: Clinical and Radiographic Evidence

◼ Inability to pass NG tube ◼ Chest/abdominal X-ray ▪

NG tube coiled in esophageal pouch suggests esophageal atresia

▪ Air in the stomach and bowel if TEF present

◼ Water-soluble contrast in esophagus for fluoroscopy

confirms the presence of esophageal atresia

◼ Upper GI series with thickened water-soluble contrast, or

endoscopy + bronchoscopy for isolated TEF diagnosis

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Discussion: Patient treatment and further workup

◼ Surgical repair ▪

+/- G-tube

▪ Fistula ligation

▪ Esophagoplasty

◼ Workup for VACTERL ▪

Vertebral defects - Spine US

▪ Anal atresia - Physical exam

▪ Cardiac defects (PDA, ASD, VSD)- Echocardiogram

▪ TracheoEsophageal fistula

▪ Renal anomalies - Renal US

▪ Limb abnormalities - Physical exam

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Discussion: Complications and long-term outcomes

◼ Complications ▪

Anastomotic leak

▪ Esophageal stricture

▪ Recurrent fistulae

◼ Long-term outcomes ▪

Dysphagia, GERD, respiratory tract infections

▪ Routine monitoring of symptoms

▪ Barrett esophagus risk is 4x the general population

▪ Routine endoscopic surveillance required

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UNC Top Three

1. Radiograph showing an enteric tube coiled in the upper

esophagus + excess gas in the GI tract may suggest esophageal atresia with distal tracheoesophageal fistula

2. Fluoroscopy can be used for diagnosis and to evaluate for

double fistulas, post-operative leaks or strictures

3. Further imaging (echocardiogram, renal US, spine US) is

indicated to evaluate for VACTERL association

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References

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Haller J, Slovis T, Joshi A. Abdominal Imaging: Esophagus. Pediatric Radiology: An Introduction for Medical Students, Residents, and Pediatric Healthcare Providers 3rd edition, p.111-113.

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Oermann C, Redding G, Hoppin A. Congenital anomalies of the intrathoracic airways and tracheoesophageal fistula. UpToDate 2018. https://www.uptodate.com/contents/congenital-anomalies-

f-the-intrathoracic-airways-and-tracheoesophageal-

fistula?search=tracheoesophageal%20fistula&source=search_result&selectedTitle=1~102&usage_type= default&display_rank=1

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Thurston M, Gaillard F. Congenital tracheo-oesophageal fistula. Radiopaedia 2005-2018. https://radiopaedia.org/articles/congenital-tracheo-oesophageal-fistula

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University of Virginia. Esophageal Atresia. University of Virginia Pediatric Radiology Course 2013. https://www.med-ed.virginia.edu/courses/rad/peds/abd_webpages/abdominal2.html