Obstructive bronchitis and recurrent pneumonia in esophageal achalasia in a child: A CARE compliant case report

RATIONALE

Esophageal achalasia is characterized by impaired relaxation of the cardia and dilation of the intrathoracic part of the esophagus. We describe the late presentation of achalasia in an 11-year old girl.

PATIENT CONCERNS

She suffered from recurrent pneumonia, obstructive bronchitis, and problems with swallowing solid food. Her family noted a wet pillow in the morning.

DIAGNOSES

This case report describes the typical symptoms of achalasia in children in order to facilitate earlier diagnosis of this rare disease. Our patient was admitted to a pediatric hospital for treatment of severe pneumonia, low-grade fever, and pancreatitis. A computed tomography (CT) scan of the thorax showed massive dilation of the esophagus and infiltration and partial atelectasis of the right lung. An upper gastrointestinal contrast study confirmed massive dilation of the esophagus and stenosis at the level of the cardia.

INTERVENTIONS

We performed laparoscopic Heller myotomy combined with Dor fundoplication. Bronchoscopic lavages were conducted in the pre- and postoperative period to relief obstruction of bronchi by purulent mucus secretions.

OUTCOMES

A further upper gastrointestinal contrast study demonstrated patency of the cardia and fast propulsive movement of contrast agent into the stomach. At follow up 2 months after the operation, the girl had gained 3 kg of body weight, and her respiratory, gastrointestinal, and swallowing symptoms had subsided. At follow-up 12 months after the operation, no recurrent symptoms of achalasia were recorded.

LESSONS

Late presentation of achalasia in children can mimic respiratory and gastrointestinal diseases. Laparoscopic Heller myotomy combined with Dor fundoplication is feasible and advisable in children suffering from achalasia of the cardia.

Mortality and economics in short bowel syndrome

The incidence of patients with short-bowel syndrome (SBS) has increased over the years due to progress of intensive care medicine and parenteral nutrition techniques. These techniques have significantly improved the prognosis of neonates, children and adults who have lost major parts of their intestinal tract. Long-term survival is possible and does not depend primarily on the length of the remaining bowel but on complications such as parenteral nutrition-associated cholestasis, recurrent septicaemia, central venous catheter infections, and the motility of the remaining intestine. Thus, the overall related mortality in infants with SBS ranges from 15 to 25%, and in adults from 15 to 47%, depending on the age of the patients, the underlying disease, and the duration on total parenteral nutrition. Home parenteral nutrition (HPN) significantly decreases the complication rate and improves the psychological situation of the patient. Additionally, HPN reduces in-hospital cost significantly. Nevertheless, the annual costs/patient are between $100000 and $150000. The mortality rate of SBS patients on HPN is about 30% after 5 years, which is still lower than the 5-year survival rate of intestinal grafts, and it is about equal to patients' survival after intestinal transplantation. However, the overall costs of a successful intestinal transplantation are already lower after 2 years when compared with the cost of a prolonged HPN programme.

Child pedestrian injuries at tram and bus stops

In order to analyse these injuries and to create guidelines for prevention, injuries at bus or tram stops were analysed retrospectively. Medical records were analysed and questionnaires were sent to the parents in order to obtain detailed information about the mode and physical sequelae or post-traumatic behavioural disturbances of the injury.Thirty children of a median age of 9.5 years (2.7-15.3 years) were treated within a 6-year period. Sixteen out of 30 children (53.3%) were injured on their way to school and 3 (10.0%) on their way to kindergarten. Nine out of 30 children (30%) were injured when crossing the street from behind the bus or the tram. Five children (16.7%) were injured by buses, 6 (20.0%) by trams and 19 (63.3%) by passing motorised vehicles. Twelve (40.0%) were injured in the presence of accompanying adults. In 17 of 30 cases (56.7%) the visibility of the vehicle and/or the child was obstructed. The median Injury Severity Score (ISS) was 4.5 (1-75) and the mortality rate 2 out of 30 (6.7%), both children had been killed at bus stops alongside country roads. Nine out of 28 surviving children (32.1%) suffer from minor physical sequelae and 6 (21.4%) from post-traumatic behavioural disturbances. Crossing the road from behind a bus in the area of a stop alongside a country road is extremely dangerous. It is mandatory to increase the safety at bus stops along country roads.

Vehicles reversing or rolling backwards: an underestimated hazard

OBJECTIVES

A retrospective analysis of injuries caused by vehicles that were reversing or rolling backwards to establish guidelines for prevention was performed.

PATIENTS AND METHODS

Medical records and questionnaires completed by parents for 32 children admitted to the Department of Pediatric Surgery, Graz, within the past eight years, were analysed.

RESULTS

The median age was 2.1 years (1.0-14.0 years). Fourteen of 32 of the cars were driven by family members (43.8%); three were rolling backwards without a driver (9.4%). The median injury severity score was 3 (1-27) and the most common injuries were contusions (40.6%), fractures (31.3%), and lacerations/burns (21.9%). Most incidents occurred in driveways (37.5%) or farmyards (21.9%). Altogether 70.3% of children sustained "run-over" injuries, 29.6% were hit by the rear bumper or injured by a breaking window.

CONCLUSIONS

Toddlers playing in driveways or farmyards are at risk of a injury caused by reversing vehicles/vehicles rolling backwards.

Bunk beds--a still underestimated risk for accidents in childhood?

A retrospective analysis of 218 bunk-bed accidents and a random sample survey with 991 family interviews were performed in order to establish guidelines for bunk-bed accident prevention. Falls from the top bed during sleep (35.1%) or while playing (34.4%) and falling off the ladder (23.2%) are the leading causes of bunk-bed accidents. Of the 218 children, 91 (41.7%) had sustained major injuries, including 3 polytrauma, 7 skull fractures, 44 cerebral concussions, 33 long bone fractures, 2 Lisfranc injuries, and 2 lacerations of the spleen. Of these accidents, 58.3% resulted in minor injuries with 18 fractures in other locations than the long bones or cranial vault, 89 contusions and sprains, 18 skin lacerations and 2 tooth fractures. A total of 23.8% of the accidents occurred in children under 3 years of age. The random sample survey demonstrated that in relation to age groups of children 30.8% (0%-45.8%) of families interviewed had been using bunk beds, with peaks at 3 years (29.8%), 7 years (36.5%) and 11 years (45.8%) of age. Of these bunk beds, 75.3% were equipped with side-rails, 57.3% had placed carpets alongside the bunk bed and 43.0% had used night lights.

CONCLUSION

There is only one recommendation: no bunk beds!!!

Reconstruction of part of the distal tibial growth plate with an autologous graft from the iliac crest

We describe the reconstruction of a defect of the medial malleolus which was the result of an accident in a ten-year-old child. A graft from the iliac crest, with the apophyseal cartilage and perichondrium, was used for reconstruction of the medial malleolus, the growth plate and the adjacent metaphyseal defect, respectively. The soft-tissue defect was covered with a free scapular flap with microvascular anastomosis. Three years after the injury stability of the ankle is excellent with adequate growth of the reconstructed epiphyseal plate.

Undescended testicles: an epidemiological review

In a retrospective study the records of 447 boys (median age 5 y, age range 2 wk to 12 y) undergoing orchidopexy in a university hospital paediatric surgical department over a 2-y period were analysed for epidemiological factors related to disturbed testicular descent by comparison with the notes of an equal number of otherwise healthy male trauma patients matched for age. There were higher rates of peripartal asphyxia and intrauterine growth retardation (reflected by lower birthweights in combination with equal gestational age distribution), more complicated deliveries, an increased incidence of congenital malformations and more frequent occurrence of a number of chronic diseases in the families of affected boys. First- and second-born boys were over-represented in the study group. A cyclical pattern for the month of birth is suggested by the data, but this did not reach statistical significance. Neither was any statistical difference found for premature delivery, the incidence of extra-uterine fertilization, hormonal treatment of the mother while pregnant, twin pregnancies, threatened or imminent abortions or parental age. The literature dealing with this topic was reviewed. Discrepancies between different studies can be explained, at least in part, by considering different forms of undescended testicles as different nosological entities that should be assessed separately in forthcoming research.

Morbidity and mortality of the short-bowel syndrome

From 1976 to 1998 we have treated 17 neonates with short-bowel syndrome. Those 8 patients who had an intact ileocecal valve as well as the total colon preserved did significantly better than the 9 children without ileocecal valve and > 50% missing colon. In addition to the length of the intestinal remnants, motility had a major impact on the incidence of complications and final outcome. Four patients died (23.5%). All of them had an intestinal length of less than 30 cm, severe dysmotility, no ileocecal valve and an incomplete colon. The average duration of hospitalization of the children weaned from parenteral nutrition (n = 11) was 8.5 months. The majority of them still need supplementation of vitamins and/or trace elements. Two children suffer from recurrent d-lactic acidemia. Six children have a significant psychomotor developmental delay with three suffering from congenital cerebral abnormalities.

Highchair accidents

In order to establish guidelines for highchair accident prevention we investigated causes, mode and complications of highchair accidents by the following methods: The charts of 103 children attending our Accident & Emergency department for highchair related injuries were studied retrospectively. Questionnaires were sent to the parents to obtain detailed information about the mode of accident. They were also asked to suggest preventive measures. In addition, a random sample survey was performed with 163 families inquiring about the rate of highchair use and the incidence of highchair related accidents. Of the 103 infants, 15.5% had sustained a skull fracture, 13.6% a brain concussion, 2.0% limb fractures and 68.9% a simple contusion of the head or lacerations to the scalp or face. The questionnaires were fully completed by 61.2% of parents. Every second family reported that their infant had tried to stand up in the highchair before falling off (only one child had been wearing a restraint). In a further 14.3% of accidents the highchair tipped over. Eighty-seven percent of parents would appreciate a pre-installation of restraints, 54.0% requested more informative instructions for users, and 33.3% asked for products with better stability. The random sample survey revealed a highchair use rate of 92%; 18% of families used highchairs equipped with restraints, and 6% reported highchair accidents sustained by their children. We conclude that most highchair accidents occur when unrestrained infants try to stand up. Pre-installed child restraints, better manuals for users and increased highchair stability should be recommended as promising accident prevention strategies.