I thought the baby was just choking, until the doctor said it was a slit in the esophagus...

time:2022-10-07 04:39:46source:monlittlebaby.com author:Baby bones
I thought the baby was just choking, until the doctor said it was a slit in the esophagus...

*For medical professionals only for reference Children brought by their parents to see a doctor, but small problems are often the early or initial manifestations of the disease, and doctors cannot ignore or relax their vigilance. Below, the author will share with you a seemingly "simple" case of being admitted to the hospital due to cough for 3 days, and will study and discuss with you colleagues. The case-sharing child, female, was admitted to the hospital on January 22 because of "coughing for 3 days". History of present illness: 3 days before admission, the child developed paroxysmal 2-3 dry coughs without obvious incentives, mostly after feeding, usually spit up milk, no fever, convulsions, no nasal congestion, runny nose, no spit, no Shortness of breath and wheezing, he came to our hospital for treatment, and the outpatient department planned to be admitted to the hospital with "bronchopneumonia? Heart disease?" Since the onset, the child has no diarrhea, no barking cough, hoarseness, no hemoptysis, night sweats, afternoon hot flashes, no pale face, profuse sweating, no listlessness, no restlessness, poor sleep, and mental fatigue. Poor milk, no weight gain, milk intake per meal is about 15ml-30ml/time, stool is normal, and the amount of urination on the day of admission is less than usual. Personal history: 3rd birth, 3rd birth, gestational week: 37+5 weeks, the size of twins, natural birth; no asphyxia, rescue, jaundice; birth weight 2.3kg, length 48cm; feeding method in infancy: mixed feeding (birth to date). Time to add complementary food: vitamin A + D 0.5 months. Feeding now: breast milk, formula. The twins were well fed and had normal weight gain. Physical examination: T: 37.4°C, P: 142 times/min, R: 36 times/min, WT: 2.6kg <-3SD, conscious, tired, marble-like patterns on the skin, thin subcutaneous fat, skin elasticity Relaxed, superficial lymph nodes were not palpable. No nasal flap, no cyanosis around the mouth, no congestion in the throat, soft neck, and no resistance. The three concave sign was negative, the breath sounds of both lungs were coarse and symmetrical, and phlegm sounds and coarse moist rales could be heard in both lungs. The heart sounds were strong and rhythmic, and a 3/6-level murmur could be heard in the precordial area. The abdomen was flat and soft, with no obvious mass, no palpable enlargement of the liver and spleen under the ribs, and normal bowel sounds. The extremities were warm, there was no marble pattern, and the capillary refill time (CRT) was less than 2 seconds. Neurological examination revealed no abnormalities. Auxiliary examination: Color Doppler echocardiography in the other hospital showed atrial horizontal shunt: consider patent foramen ovale and a little tricuspid valve regurgitation. Admission diagnosis: 1. Bronchopneumonia; 2. Patent foramen ovale; 3. Severe protein-energy malnutrition. Laboratory examination After admission, we reviewed the baby's heart color Doppler ultrasound showed: 1. Ventricular septal defect (perimembranous); 2. Patent foramen ovale, small atrial septal defect was not ruled out; 3. Left ventricular systolic function was normal. Color ultrasound report blood routine: white blood cell count 12.3 (109/L), platelet count 288 (109/L), neutrophil percentage 27.8 (%), hemoglobin 98 (g/L), lymphocyte percentage 60.1 (%), ultrasonography Sensitive C-reactive protein 1.60 (mg/L). Procalcitonin 0.14 (ng/L). Chest X-ray: consistent with changes in bronchopneumonia. Before treatment, after admission, the blood oxygen saturation fluctuated at about 91%, the inspiratory tri-concave sign was positive, and there were symptoms of dyspnea at the same time. Therefore, Bao was immediately given low-flow oxygen inhalation, and ceftriaxone was given to fight infection for 1 week. After that, it was changed to cefoperazone sodium and sulbactam sodium for anti-infective treatment. After treatment, the child's dyspnea improved and he was able to deoxygenate, but the pulmonary rales did not improve, and he was still prone to choking during feeding. Is the pacifier inappropriate? However, after changing the small pacifier to the baby, the choking still did not improve. At the same time, the results of the chest X-ray reexamination came out. The reexamination of the original bronchial pneumonia after treatment was compared with the previous comparison: the absorption of the lesions in the upper right lung field improved, and the lesions in the lower left lung field progressed. Pneumonia has improved after treatment, but what is the cause of choking milk and coughing? Asked about the medical history, the child had a cough after every meal since birth, and there was no improvement after changing the pacifier. Considering that the baby had a cardiac malformation, esophagotracheal fistula could not be ruled out, so a bronchoscopy was arranged. Sure enough, bronchoscopy findings: tracheal mucosal congestion and edema, C-type cartilage, and a small amount of secretions accumulated in the lumen, which was removed by suction. There is a longitudinal gap about 3mm long in the membranous part about 1cm above the carina, overflowing with viscous secretions. The gastric tube was indwelled to the corresponding position, and the diluted methylene blue was injected into the esophagus through the gastric tube. It can be seen that the methylene blue infiltrated into the trachea through the above gap. Esophagotracheal fistula was diagnosed. After showing the bronchoscopy images to the family members of the children, the family members tried to understand in their own way: "Doctor, do you mean that a slit has been opened on my baby's esophagus, and is it connected to the trachea?" I gave a positive answer, After communicating with the family and obtaining their consent, we transferred the child to surgery for surgical treatment. Congenital esophageal atresia and tracheoesophageal fistula Congenital esophageal atresia and tracheoesophageal fistula, referred to as esophageal atresia-tracheal fistula, is a serious congenital developmental malformation. The incidence rate is 1/(3000-4000) live births, and preterm immature infants are more common. Half of the cases were accompanied by other deformities, of which 25% were life-threatening or requiring emergency surgery, such as anal atresia, intestinal malrotation, and intestinal atresia. Congenital heart disease is the most common comorbid malformation. ▌ The etiology is not yet clear. May be related to inflammation, vascular dysplasia, or genetic factors. During the development of the primitive foregut in the embryonic stage, the penetration and separation of the original foregut are blocked, and esophageal atresia and esophagotracheal fistula can be formed. It can be divided into five pathological types: ▌ The typical clinical manifestations are salivation after birth, with foamy saliva overflowing from the mouth and nostrils. Such as feeding water or milk, after sucking one or two mouths, it will cause choking, and then the milk will overflow from the mouth and nose, and there will be respiratory distress and cyanosis at the same time. The same symptoms occurred every time I tried breastfeeding. ▌ On physical examination, the abdomen is significantly distended, and percussion sound is tympanic, but in type I and type II children cannot swallow gas, and there is no communication between the trachea and the distal esophagus, so there is no gas in the gastrointestinal tract, and the abdomen is flat and collapsed shape. Diagnosis 1. Prenatal B-ultrasound examination with disappearance of gastric vesicles and polyhydramnios. 2. After birth, if the newborn has vomiting, choking, cough, cyanosis and other symptoms during the first feeding, the possibility of esophageal atresia should be immediately thought of. 3. After the X-ray filming catheter is inserted to the blind end, inject 1ml of air to take the film immediately, which can clearly show the blind end and location of the blocked esophagus. Type V diagnosis requires fiberoptic bronchoscopy and esophagography. 4. CT three-dimensional reconstruction. Treatment and prognosis Treatment methods are: surgery. Low birth weight, severe cardiac malformation, and multiple malformations are important prognostic factors. Summary: This case shows the importance of earnestly inquiring about the medical history, and every detail cannot be ignored. Since birth, the child has cough every time he eats, and the effect of anti-infective treatment is not good. Combined with the existence of cardiac malformation, the disease of tracheoesophageal fistula should be considered. References: [1] Zhu Futang Practical Pediatrics 8th Edition First release: Pediatrics Channel in the medical community Author of this article: Li Huili Editor in charge: Xiang Yu You want to see the pediatric clinical knowledge doctor station app 👇 1. Scan the second below QR code 2. Click "Download Now" to download the Doctor Station App, and subscribe anytime, anywhere~ Copyright statement This article is original, please contact - End - for reprinting. the timeliness, and the accuracy and completeness of the cited materials (if any), etc., and do not undertake any commitments and guarantees caused by the outdated contents, the possible inaccuracy or incompleteness of the cited materials, etc. responsibility. Relevant parties are requested to check separately when adopting or using it as a basis for decision-making.
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