Corrosive injury to upper gastrointestinal tract still a major surgical dilemma
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Corrosive injury to upper gastrointestinal tract: Still a major surgical dilemma . World J Gastroenterol. 2006 Aug 28;12(32):5223-8. INTRODUCTION. corrosive injury to the gastrointestinal system has become less Up to date knowledge on the best management approach therefore be lacking

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Corrosive injury to upper gastrointestinal tract: Still a major surgical dilemma

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Corrosive injury to upper gastrointestinal tract still a major surgical dilemma l.jpg
Corrosive injury to upper gastrointestinal tract: Still a major surgical dilemma

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


Introduction l.jpg
INTRODUCTION major surgical dilemma

  • corrosive injury to the gastrointestinal system has become less

  • Up to date knowledge on the best management approach therefore be lacking

  • two contrasting cases of corrosive injury

  • Medline search to perform a literature review


Case reports case 1 l.jpg
CASE REPORTS( major surgical dilemma Case 1)

  • 22-year-old male ; accidental ingestion of a cupful of 30% caustic soda

  • s/s: his voice was hoarse;short of breath and drooling his saliva

  • he had a red, swollen tongue and his oropharynx was oedematous and inflamed

  • management:intubated to secure his airway ;

  • supportive treatments :intravenous proton pump inhibitor (PPI) and total parental nutrition (TPN).


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  • Early esophagogastroscopy: generally inflamed oropharynx and esophagitis

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

  • successfully managed with repeated progressively time spaced dilatation using a guide wire under fluoroscopy


Case reports case 2 l.jpg
CASE REPORTS( esophagitisCase 2)

  • A 33-year-old male ; ingestion of battery acid (hydrochloric acid)

  • s/s: hoarseness and stridor

  • management: intubated to secure his airway ;

  • supportive treatments: intravenous PPI, TPN for nutrition, steroids and broad-spectrum antibiotics for laryngeal edema and positive blood culture

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


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

  • readmitted : gastric outlet obstruction

  • Endoscopy: a normal esophagus with an ulcerated and scarred gastric pylorus

  • Roux-en-Y gastrojejunostomy was performed subsequently in order to bypass the stricture


Discussion l.jpg
DISCUSSION spared. Lower esophagus showed a circumferential burn with slough. Similar findings were noted on the mid-body of the stomach and the antrum

  • Failure to recognize the seriousness of the accident and to provide adequate therapy could result in serious morbidity and mortality

  • Children account for more than 80%

  • adult is more often of suicidal intenttend to be more serious

  • The mortality rate is between 10% to 20% and rises to 78% in cases of attempted suicide

  • The extent of the injury depends on the type of agent, its concentration


Pathophysiology l.jpg
Pathophysiology spared. Lower esophagus showed a circumferential burn with slough. Similar findings were noted on the mid-body of the stomach and the antrum

  • esophageal versus gastric injury in cases of acid and alkali ingestion

  • acid is said to “lick the esophagus and bite the pyloric antrum(coagulation necrosis )

  • alkaline : more uniformly severe mucosal injury to the esophagus(liquefaction necrosis) resulting in deeper tissue injury

  • Our patient who ingested battery acid developed partial gastric outlet obstruction

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


Burn classification l.jpg
Burn classification spared. Lower esophagus showed a circumferential burn with slough. Similar findings were noted on the mid-body of the stomach and the antrum

  • are classified in similar fashion to thermal burn of the skin

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

  • Endoscopic ultrasound may provide an answer

  • Oropharyngeal burns and clinical symptoms have a low predictive value for severity of esophageal injury


Early versus late endoscopy l.jpg
Early versus late endoscopy spared. Lower esophagus showed a circumferential burn with slough. Similar findings were noted on the mid-body of the stomach and the antrum

  • Early endoscopy :most appropriate measure based on which clinical decisions are made

  • to verify directly the healing state of the mucosa and may be of value in predicting which patients require further early intervention

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

  • difficult to assess the depth;

    in the upper third of the esophagus, the scope is not passed beyond this point.


Complications of corrosive ingestion l.jpg
Complications of corrosive ingestion spared. Lower esophagus showed a circumferential burn with slough. Similar findings were noted on the mid-body of the stomach and the antrum

  • Severe complications,often life threatening are common : tracheobronchial fistula, severe haemorrhage secondary to gastric involvement, aortoenteric fistula or gastrocolic fistula, stricturesand perforation

  • Stricture formation, by far, remains the main long-term complication of this injury


Early use of steroids and antibiotic prevention of stricture formation l.jpg
Early use of steroids and antibiotic: Prevention of stricture formation

  • Corticosteroids inhibit the transcription of certain matrix (for fibrosis)

  • Animal experiments have shown: stricture formation is reduced

  • Several authors have found corticosteroids ineffective

  • Intra-lesional corticosteroid therapy has shown beneficial effects for refractory esophageal strictures


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  • no convincing evidence supporting the use of stricture formationantibiotics in reducing stricture formation

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


Routine use of nasogastric ng tube l.jpg
Routine use of nasogastric (NG) tube stricture formation

  • significant lower incidence of stricture formation with routine use of NG tube for 15 day

  • long-term indwelling nasogastric insertion is known to cause long strictures of the esophagus

  • We do not advocate the use of a NG tube


Experimental studies to prevent stenosis l.jpg
Experimental studies to prevent stenosis stricture formation

  • cytokines have been used successfully

  • Epidermal growth factor (EGF)

  • Interferon-g (IFN-g)

  • interferon-a-2b and octreotide

  • antioxidant, such as vitamin E and methylprednisolone

  • all these studies are only carried out on animals and these treatments have not been tested on humans.


Management l.jpg
Management stricture formation

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

  • nil by mouth

  • plain chest radiograph: signs of perforation diluted barium swallow

  • antidote such as water or milk does not seem to prevent stenosis

  • Endoscopy is the diagnostic procedure of choice


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  • Patients with perforation require stricture formationimmediate surgery

  • Gastric acid suppression with PPIs and H2-antagonists are often used

  • esophageal strictures was managed with frequently repeated dilatation (first patient)

  • Early dilatation is not recommended due to associated high incidence of perforation (3 to 6 wk)

  • esophageal dilatation has proved to give good results in short strictures but might be dangerous for long and narrow esophageal strictures

  • Complex strictures: fluoroscopic guidance


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  • intense PPI therapy stricture formation and repeated dilatation will reduce the number of esophageal resection and reconstructive surgery

  • steroid use is limited :severe laryngeal edema

  • pathophysiology of corrosive injury is important in planning both acute and on-going management.

  • Scar retraction begins as early as the end of the second week and lasts for 6 mo

  • esophagectomy : prior to the scar tissue maturation might increase the risk of anastomostic stenosis

  • delaying major reconstructive surgery for at least 6 month

  • Emergency: in cases of perforation and contamination of the mediastinum


Risk of carcinoma l.jpg
Risk of carcinoma stricture formation

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

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

  • operative risk may exceed the potential risk of cancer.

  • The risk of gastric cancer is less known


Conclusion l.jpg
CONCLUSION stricture formation

  • treatment of patients with corrosive injuries is both controversial and inconclusive

  • each patient must be evaluated individually

  • The general consensus is that the initial treatment is supportive; ensuring the airway is patent and to establish haemodynamic stability.

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

  • Total parenteral nutrition is a useful adjunct.


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  • Operation stricture formation :patients who have ingested large amounts of corrosive substance and in whom tissue necrosis is highly likely.

  • Immediate surgical intervention :extensive necrosis noted on endoscopy and with evidence of perforation

  • intractable esophageal strictures :dilatation is dangerous or impossible, surgical intervention may be unavoidable.

  • Diligent follow-up


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