Oesophagitis, caustic ingestion and oesophageal injury — branching viva

Station opening

Examiner: "Classify oesophageal injury in a child and tell me which one you never let out of your sight." [1]

Strong candidate (must-hit)

• Separates oesophageal injury into the chronic oesophagitides (reflux, eosinophilic, infective and pill oesophagitis) and acute injury (caustic ingestion, button battery and mechanical foreign body); frames the distinction by timescale — oesophagitis over weeks, caustic over hours, a battery over two hours; and names the oesophageal button battery as the one that must be removed within two hours because it burns liquefactively at its negative pole and can form a fatal fistula. [1] [7]

Weak candidate

• "Oesophagitis is just reflux, and if a child swallows something we watch and wait for it to pass." [1]

Branch A — The 18-month-old with a suspected button battery

Examiner: "An 18-month-old is drooling and refusing feeds; a 20 mm lithium cell is missing from a toy. What is your diagnosis, what confirms it, and what do you do?" [1]

Strong

• Diagnoses a suspected oesophageal button battery; confirms with an urgent neck, chest and abdomen radiograph showing the halo or double-ring sign on the frontal view and the step-off on the lateral view, reading the negative-pole orientation; escalates for emergent endoscopic removal within two hours; gives honey 10 mL every 10 minutes up to six doses because the child is over twelve months, within twelve hours and can swallow, or sucralfate in hospital, without delaying removal; and admits for surveillance of the delayed aorto-oesophageal fistula. [1] [2]

Weak

• "It looks like a coin; I will admit for observation and repeat the X-ray in the morning." [1]

Branch B — The 2-year-old who swallowed drain cleaner

Examiner: "A 2-year-old drank decanted drain cleaner an hour ago and has oral burns and drooling. What injury is this, what must you avoid, and how do you proceed?" [8]

Strong

• Identifies a strong-alkali caustic ingestion causing deep liquefactive necrosis; assesses and protects the airway first because oedema can obstruct; keeps the child nil by mouth with analgesia and fluids; explicitly avoids inducing vomiting, neutralising, and passing a blind nasogastric tube; arranges endoscopy at twelve to twenty-four hours to grade the burn on the Zargar scale; and plans nutrition, stricture surveillance and a dilatation programme for a deep (grade 2b or 3) burn. [7] [9]

Weak

• "Give milk to neutralise it and make him vomit to get the chemical out." [8]

Branch C — The 9-year-old with a food bolus impaction

Examiner: "A 9-year-old arrives with food stuck in the oesophagus and a history of slow eating and one previous episode. What is the likely underlying diagnosis and how do you manage him?" [11]

Strong

• Relieves the acute impaction endoscopically and takes oesophageal biopsies at the same time; suspects eosinophilic oesophagitis given the dysphagia, slow eating and prior impaction, especially with a history of atopy; confirms histologically with fifteen or more eosinophils per high-power field and the endoscopic furrows, rings and exudates; and starts one of the three first-line treatments — a proton pump inhibitor, an elimination diet, or a swallowed topical corticosteroid — with dilatation and biologic therapy for refractory or fibrostenotic disease. [11]

Weak

• "Push the food through with a fizzy drink and send him home; it is just a one-off." [11]

Branch D — The teenager with pill oesophagitis

Examiner: "A teenager took a doxycycline capsule at bedtime with a sip of water and now has sudden retrosternal pain and odynophagia. What has happened and how do you manage it?" [7]

Strong

• Recognises pill (medication-induced) oesophagitis, where a tablet held against the mucosa — classically doxycycline, a bisphosphonate, potassium, iron or an NSAID taken with too little water and lying down — causes a localised chemical burn, often at the aortic-arch narrowing; manages it by stopping or substituting the drug, giving analgesia and mucosal protection, and confirming with endoscopy only if the diagnosis is unclear or symptoms persist; and prevents recurrence by counselling to take tablets upright with a full glass of water and to remain upright afterwards. [7]

Weak

• "That is just reflux; start a proton pump inhibitor and continue the doxycycline as prescribed." [7]

Close

Examiner: "Give me your one-sentence summary of the oesophageal button battery." [1] [2]

Strong

• "An oesophageal button battery is a surgical emergency because it generates hydroxide at its negative pole and burns through the wall within two hours, so it is removed endoscopically within two hours with honey or sucralfate as a bridge, and the child is then watched for up to three weeks for the aorto-oesophageal fistula that can bleed fatally." [1] [2]