Abstract: BACKGROUND: Eosinophilic esophagitis (EE) is often missed or underdiagnosed in children, particularly in the setting of reflux disease associated with tracheoesophageal fistula (TEF). Intermediate esophagitis (IE) is a recently described condition, which includes characteristics of gastroesophageal reflux disease and EE but does not present with enough eosinophils on biopsy to diagnose EE. Here we present a case series of EE and IE associated with TEF, and their clinical manifestations. METHODS: A retrospective analysis including clinical presentation, endoscopic and pathologic findings, and treatment of 4 patients with EE and 4 patients with IE who presented between 2003 and 2007 was performed. RESULTS: Male dominance was found equally in both groups (75%), and most patients had a personal history of atopy (87.5%). Food allergies were seen mainly in the EE group (75%). The most frequent primary symptoms in both groups were dysphagia for solids (75%) and for liquids (25%). The median age at diagnosis was 9.8 vs 11.2 years in the EE and IE groups, respectively. On endoscopy, both groups had similar findings including furrows (EE, 75%; IE, 66.6%) and white plaques (EE, 50%; IE, 33.3%). In both groups, almost all patients had basal cell hyperplasia on biopsy (EE, 100%; IE, 75%). Degranulated surface eosinophils (50%) and eosinophilic abscess (25%) were found in the EE group only. Elongated rete papillae were more often seen in EE biopsies (50%) compared with IE biopsies (25%). Peripheral serum eosinophilia was seen in all EE patients and in 33% of the IE patients. The only effective treatment with complete resolution of the symptoms was the topical or systemic application of steroids. CONCLUSIONS: The diagnosis of EE and IE is frequently missed or delayed. Eosinophilic esophagitis should be suspected in reflux disease refractory to conventional treatment, particularly in the setting of TEF. Intermediate esophagitis represents an entity that includes findings of gastroesophageal reflux disease and EE. Endoscopic biopsies are diagnostic for both conditions and allow institution of specific medical treatment.
Abstract: Lung torsion is a very rare event that has been described after trauma, spontaneously, and post-thoracic surgery, with only 8 cases reported in the pediatric literature. We present the first case report of lung torsion complicating tracheoesophageal fistula repair. The diagnosis was suggested on chest ultrasonogram and Doppler and confirmed by computed tomographic scans. On exploration, a 90 degree rotation of the right middle and lower lobes in a clockwise direction was found. A complete interlobar fissure and an absent inferior pulmonary ligament were identified as predisposing factors. The lobes were untwisted, and lobar fixation was performed to prevent retorsion. Postoperatively, the patient recovered complete lung function, and the patient's chest radiologic and ultrasonographic examination results normalized. Lung torsion is an extremely uncommon event. It causes clinical deterioration in the face of normal arterial blood gases and requires a high index of suspicion for diagnosis. Resection of the twisted lung or lobe may be unnecessary if diagnosis is made early and vascular occlusion is partial. Patients with complete interlobar fissures may benefit from pulmonary lobe fixation as a prophylaxis against occurrence or recurrence of this complication.
