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

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

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

introduction
INTRODUCTION
  • 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
CASE REPORTS(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).
slide4
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
CASE REPORTS(Case 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
slide6
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
DISCUSSION
  • 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
Pathophysiology
  • 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
Burn classification
  • 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
Early versus late endoscopy
  • 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
Complications of corrosive ingestion
  • 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
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
slide13
no convincing evidence supporting the use of antibiotics 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
Routine use of nasogastric (NG) tube
  • 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
Experimental studies to prevent stenosis
  • 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
Management
  • 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
slide17
Patients with perforation require immediate 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
slide18
intense PPI therapy 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
Risk of carcinoma
  • 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
CONCLUSION
  • 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.
slide21
Operation :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
ad