CASE PEDIATRIC SURGERY

HISTORY You are asked to see a three-week-old female infant. The mother gives a history of coughing and choking fits during feeding. The infant has just been fed and you notice abdominal distension which, on careful questioning, mother has noted following most feedings. Physical examination is unremarkable. LABORATORY DATA CBC: Normal Chest X-Ray: attached figure Abdominal X-Ray: Shows gaseous distention of stomach and small bowel but no air-fluid levels QUESTIONS: 1. The most likely diagnosis in this infant is: a. Gastro esophageal reflux with aspiration pneumonia b. Esophageal atresia with tracheoesophageal fistula and aspiration pneumonia c. Primary pneumonia with gastric dilatation secondary to the respiratory distress d. Tracheoesophageal fistula without esophageal atresia (H fistula) with aspiration pneumonia. 2. You next step of diagnosis and/or treatment is: a. Humidifier, antibiotics and sequential chest x-rays b. Answer A, plus subsequent cine esophagram c. A and B, plus anti-reflux procedure for chalasia 3. The infant had a normal cine esophagram. You next step is: a. Esophagoscopy with intratracheal instillation of methylene blue under positive pressure b. Discharge the patient after improvement or RUL pneumonia c. Bronchoscopy to rule out bronchial abnormality d. Esophagoscopy to look for esophagitis secondary to gastroesophageal reflux

4. Definitive therapy of this condition is: a. Right thoracotomy with fistula division and primary tracheal and esophageal repair b. Left thoracotomy with fistula division and primary tracheal and esophageal repair c. Esophageal diversion, gastrostomy d. Left cervical exploration with fistula division and primary tracheal and esophageal repair e. Anti-reflux procedure 5. Complications of this operation might include: a. Esophageal leak b. Reconstitution of tracheoesophageal fistula c. Empyema d. Neck abscess e. Gas bloat syndrome, with inability to vomit 6. This (these) complication(s) should be handled by: a. Immediate thoracotomy and drainage b. Re suture of esophagus c. Drainage of neck abscess and esophageal repair d. Drainage of neck abscess and observation e. Reassurance that gas bloat syndrome is self-limited

Fig. The right upper lung field is obscured and there is loss of volume. Notice particularly that the right upper lobe is involved and bear in mind that an infant is recumbent most of the time.