Corrosive injury to upper Corrosive injury to upper gastrointestinal tract: Still a gastrointestinal tract: Still a

major surgical dilemma major surgical dilemma

World J Gastroenterol. 2006 Aug 28;12(32):5223-8.World J Gastroenterol. 2006 Aug 28;12(32):5223-8.

INTRODUCTIONINTRODUCTION

corrosive injury to the gastrointestinal corrosive injury to the gastrointestinal system has become less system has become less

Up to date knowledge on the best Up to date knowledge on the best management approach therefore be management approach therefore be lackinglacking

two contrasting cases of corrosive injurytwo contrasting cases of corrosive injury Medline search to perform a literature Medline search to perform a literature

review review

CASE REPORTS(CASE REPORTS(Case 1)Case 1) 22-year-old male ; accidental ingestion of a cu22-year-old male ; accidental ingestion of a cu

pful of 30% pful of 30% caustic sodacaustic soda s/s: his voice was hoarse;short of breath and ds/s: his voice was hoarse;short of breath and d

rooling his saliva rooling his saliva he had a red, swollen tongue and his oropharyhe had a red, swollen tongue and his orophary

nx was oedematous and inflamednx was oedematous and inflamed management:intubated to secure his airway ; management:intubated to secure his airway ; supportive treatments :intravenous proton pusupportive treatments :intravenous proton pu

mp inhibitor (PPI) and total parental nutrition mp inhibitor (PPI) and total parental nutrition (TPN). (TPN).

Early esophagogastroscopy: generally inflameEarly esophagogastroscopy: generally inflamed oropharynx and esophagitisd oropharynx and esophagitis

Barium meal : two weeks later showed a Barium meal : two weeks later showed a long slong stricture segmenttricture segment from just distal to the hypop from just distal to the hypopharynx to the oesophago-gastric junctionharynx to the oesophago-gastric junction

successfully managed with repeated progressisuccessfully managed with repeated progressively time vely time spaced dilatationspaced dilatation using a guide wire using a guide wire under fluoroscopyunder fluoroscopy

CASE REPORTS(CASE REPORTS(Case 2)Case 2) A 33-year-old male ; ingestion of battery acid A 33-year-old male ; ingestion of battery acid

((hydrochloric acidhydrochloric acid)) s/s: hoarseness and stridor s/s: hoarseness and stridor management: intubated to secure his airway ; management: intubated to secure his airway ; supportive treatments: intravenous PPI, TPN fsupportive treatments: intravenous PPI, TPN f

or nutrition, or nutrition, steroidssteroids and broad-spectrum and broad-spectrum antiantibioticsbiotics for laryngeal edema and positive blood for laryngeal edema and positive blood cultureculture

Early endoscopy: inflammation and ulceration Early endoscopy: inflammation and ulceration of the pharynx and esophagusof the pharynx and esophagus

Endoscopy was repeated :Upper esophagus wEndoscopy was repeated :Upper esophagus was relatively spared. Lower esophagus showed as relatively spared. Lower esophagus showed a circumferential burn with slough. Similar fina circumferential burn with slough. Similar findings were noted on the mid-body of the stomdings were noted on the mid-body of the stomach and the antrumach and the antrum

readmitted : readmitted : gastric outlet obstructiongastric outlet obstruction Endoscopy: a normal esophagus with an ulcerEndoscopy: a normal esophagus with an ulcer

ated and scarred gastric pylorusated and scarred gastric pylorus Roux-en-Y gastrojejunostomy was performed sRoux-en-Y gastrojejunostomy was performed s

ubsequently in order to bypass the strictureubsequently in order to bypass the stricture

DISCUSSIONDISCUSSION Failure to recognize the seriousness of the acciFailure to recognize the seriousness of the acci

dent and to provide adequate therapy could rdent and to provide adequate therapy could result in serious morbidity and mortalityesult in serious morbidity and mortality

Children account for more than 80% Children account for more than 80% adult is more often of suicidal intentadult is more often of suicidal intenttend to tend to

be more seriousbe more serious The mortality rate is between 10% to 20% and The mortality rate is between 10% to 20% and

rises to 78% in cases of attempted suicide rises to 78% in cases of attempted suicide The extent of the injury depends on the type of The extent of the injury depends on the type of

agent, its concentration agent, its concentration

PathophysiologyPathophysiology esophageal versus gastric injury in cases of esophageal versus gastric injury in cases of acidacid and and alal

kalikali ingestion ingestion acid is said to “lick the esophagus and bite the pyloriacid is said to “lick the esophagus and bite the pylori

c antrum(coagulation necrosis )c antrum(coagulation necrosis ) alkaline : more uniformly severe mucosal injury to the alkaline : more uniformly severe mucosal injury to the

esophagus(liquefaction necrosis) esophagus(liquefaction necrosis) resulting in deeperesulting in deeper tissue injury r tissue injury

Our patient who ingested battery acid developed partiOur patient who ingested battery acid developed partial gastric outlet obstructional gastric outlet obstruction

However, the distinction between the expected sites oHowever, the distinction between the expected sites of gastrointestinal injury following acid versus alkali ingf gastrointestinal injury following acid versus alkali ingestion is not always clear. estion is not always clear.

Burn classificationBurn classification

are classified in similar fashion to thermal burare classified in similar fashion to thermal burn of the skin n of the skin

but at present, no definite measurements of thbut at present, no definite measurements of the depth can be made, and is subjective.e depth can be made, and is subjective.

Endoscopic ultrasound may provide an answeEndoscopic ultrasound may provide an answer r

Oropharyngeal burns and clinical symptoms hOropharyngeal burns and clinical symptoms have a low predictive value for severity of esophave a low predictive value for severity of esophageal injury ageal injury

Early versus late endoscopyEarly versus late endoscopy Early endoscopy :Early endoscopy :most appropriate measuremost appropriate measure based on based on

which clinical decisions are madewhich clinical decisions are made to verify directly the healing state of the mucosa and to verify directly the healing state of the mucosa and

may be of value in predicting which patients require fmay be of value in predicting which patients require further early intervention urther early intervention

early endoscopy in the hands of a less-experienced enearly endoscopy in the hands of a less-experienced endoscopist could be hazardous doscopist could be hazardous

difficult to assess the depth; difficult to assess the depth; in the upper third of the esophagus, the scope is not pain the upper third of the esophagus, the scope is not pa

ssed beyond this point.ssed beyond this point.

Complications of corrosive Complications of corrosive ingestioningestion

Severe complications,often Severe complications,often life threateninglife threatening are are common : tracheobronchial fistula, severe haecommon : tracheobronchial fistula, severe haemorrhage secondary to gastric involvement, aormorrhage secondary to gastric involvement, aortoenteric fistula or gastrocolic fistula, stricturestoenteric fistula or gastrocolic fistula, stricturesand perforationand perforation

Stricture formationStricture formation, by far, remains the main lon, by far, remains the main long-term complication of this injuryg-term complication of this injury

Early use of steroids and Early use of steroids and antibiotic: Prevention of stricture antibiotic: Prevention of stricture

formationformation Corticosteroids inhibit the transcription of certCorticosteroids inhibit the transcription of cert

ain matrix (for fibrosis)ain matrix (for fibrosis) Animal experiments have shown: stricture forAnimal experiments have shown: stricture for

mation is reduced mation is reduced Several authors have found corticosteroids ineSeveral authors have found corticosteroids ine

ffectiveffective Intra-lesional corticosteroidIntra-lesional corticosteroid therapy has show therapy has show

n beneficial effects for refractory esophageal sn beneficial effects for refractory esophageal strictures trictures

no convincing evidence supporting no convincing evidence supporting the use of the use of antibioticsantibiotics in reducing in reducing stricture formation stricture formation

general consensus :antibiotic general consensus :antibiotic treatment should only be treatment should only be commenced when treated with commenced when treated with steroids or there are signs of steroids or there are signs of infection infection

Routine use of nasogastric (NG) Routine use of nasogastric (NG) tubetube

significant lower incidence of stricture fsignificant lower incidence of stricture formation with routine use of NG tube for ormation with routine use of NG tube for 15 day15 day

long-term indwelling nasogastric insertilong-term indwelling nasogastric insertion is known to cause long strictures of ton is known to cause long strictures of the esophagushe esophagus

We do not advocate the use of a NG tubeWe do not advocate the use of a NG tube

Experimental studies to prevent Experimental studies to prevent stenosisstenosis

cytokines have been used successfullycytokines have been used successfully Epidermal growth factor (EGF)Epidermal growth factor (EGF) Interferon-g (IFN-g)Interferon-g (IFN-g) interferon-a-2b and octreotideinterferon-a-2b and octreotide antioxidant, such as vitamin E and methylpredantioxidant, such as vitamin E and methylpred

nisolonenisolone all these studies are only carried out on animalall these studies are only carried out on animal

s and these treatments have not been tested os and these treatments have not been tested on humans.n humans.

ManagementManagement

The acute management: securing the airway, paiThe acute management: securing the airway, pain relief and adequate intravenous fluid n relief and adequate intravenous fluid

nil by mouthnil by mouth plain chest radiograph: signs of perforationplain chest radiograph: signs of perforation dil dil

uted barium swallow uted barium swallow antidote such as water or milk does not seem to antidote such as water or milk does not seem to

prevent stenosis prevent stenosis Endoscopy is the diagnostic procedure of choiceEndoscopy is the diagnostic procedure of choice

Patients with perforation require Patients with perforation require immediate surgeryimmediate surgery Gastric acid suppression with PPIs and H2-antagonists Gastric acid suppression with PPIs and H2-antagonists

are often usedare often used esophageal strictures was managed with frequently esophageal strictures was managed with frequently rere

peated dilatationpeated dilatation (first patient) (first patient) Early dilatation is not recommended due to associateEarly dilatation is not recommended due to associate

d high incidence of perforation (3 to 6 wk)d high incidence of perforation (3 to 6 wk) esophageal dilatation has proved to give good results esophageal dilatation has proved to give good results

in in short stricturesshort strictures but might be dangerous for long an but might be dangerous for long and narrow esophageal stricturesd narrow esophageal strictures

Complex strictures: fluoroscopic guidanceComplex strictures: fluoroscopic guidance

intense PPI therapyintense PPI therapy and and repeated dilatationrepeated dilatation will reduce will reduce the number of esophageal resection and reconstructive the number of esophageal resection and reconstructive surgerysurgery

steroidsteroid use is limited :severe laryngeal edema use is limited :severe laryngeal edema pathophysiologypathophysiology of corrosive injury is important in plan of corrosive injury is important in plan

ning both acute and on-going management.ning both acute and on-going management. Scar retraction begins as early as the end of the second Scar retraction begins as early as the end of the second

week and lasts for 6 moweek and lasts for 6 mo esophagectomyesophagectomy : prior to the scar tissue maturation mi : prior to the scar tissue maturation mi

ght increase the risk of anastomostic stenosisght increase the risk of anastomostic stenosis delaying major reconstructive surgery for at least 6 modelaying major reconstructive surgery for at least 6 mo

nthnth EmergencyEmergency: in cases of perforation and contamination : in cases of perforation and contamination

of the mediastinumof the mediastinum

Risk of carcinomaRisk of carcinoma

The association of lye stricture and carcinoma The association of lye stricture and carcinoma of the esophagus has been known(at least 100of the esophagus has been known(at least 1000 times greater)0 times greater)

The interval between lye ingestion and the devThe interval between lye ingestion and the development of carcinoma ranges between 25 to elopment of carcinoma ranges between 25 to 40 years 40 years

operative risk may exceed the potential risk of operative risk may exceed the potential risk of cancer.cancer.

The risk of gastric cancer is less knownThe risk of gastric cancer is less known

CONCLUSIONCONCLUSION treatment of patients with corrosive injuries is both treatment of patients with corrosive injuries is both coco

ntroversial and inconclusiventroversial and inconclusive each patient must be evaluated individuallyeach patient must be evaluated individually The The general consensusgeneral consensus is that the initial treatment is s is that the initial treatment is s

upportive; ensuring the airway is patent and to establiupportive; ensuring the airway is patent and to establish haemodynamic stability.sh haemodynamic stability.

Early endoscopyEarly endoscopy has a crucial role in both diagnosing has a crucial role in both diagnosing the severity of the injury, as well as, in managing the pthe severity of the injury, as well as, in managing the patient.atient.

Total parenteral nutritionTotal parenteral nutrition is a useful adjunct. is a useful adjunct.

OperationOperation :patients who have ingested large am :patients who have ingested large amounts of corrosive substance and in whom tissuounts of corrosive substance and in whom tissue necrosis is highly likely.e necrosis is highly likely.

Immediate surgical interventionImmediate surgical intervention :extensive necr :extensive necrosis noted on endoscopy and with evidence of posis noted on endoscopy and with evidence of perforationerforation

intractable esophageal stricturesintractable esophageal strictures :dilatation is d :dilatation is dangerous or impossible, surgical intervention mangerous or impossible, surgical intervention may be unavoidable.ay be unavoidable.

Diligent Diligent follow-upfollow-up