CORROSIVE INGESTION INJURIES

OVERVIEW Definition Pathophysiology Acute phase management and classification. Management and prevention of late sequelae Conclusion

DEFINITION A caustic or corrosive substance can be defined as something that eats away or destroys tissues. Typically acids or alkali. Sometimes used to describe oxidizing agents an desiccants

PATHOPHYSIOLOGY ACIDS Pungent and very bitter usually only a small amount is ingested. Cause coagulative necrosis. The coagulum offers some protection to underlying tissues.

-More severe damage to the stomach due to pyloric spasm and accumulation in the antrum. - This typically causes strictures in the pre-pyloric area where the acid pools. - When a large amount has been ingested the entire stomach and even small bowel can be involved

PATHOPHYSIOLOGY ALKALI Strong alkali are tasteless and odorless, they can be ingested in large quantities. Higher viscosity than acids and longer passage time through the esophagus. Esophageal injury is greater with alkali than acids.

They dissolve lipoproteins on the mucosal surface resulting in rapid penetration into muscular layers. Prolonged exposure causes liquefaction necrosis as well as a severe inflammatory reaction that results in vascular thrombosis and necrosis.

Acute phase – Presentation and Management

SYMPTOMS AND SIGNS Larynx and Pharynx Esophagus Stomach Hoarseness Stridor Hoarseness Laryngitis Esophagus Dysphagia Odynophagia Stomach Epigastric pain Hematemesis Perforation Hypotension Fever Chest pain Peritonitis

ENDOSCOPY Must be done within 12-48h Dangerous between day 5-15 (tissue softening increases the risk of perforation) Third degree burn to hypopharynx is a contraindication Small diameter flexible endoscope Advanced under direct visualization Minimal air insufflations

COMPLICATIONS Edema Ulceration Bleeding Perforation Metabolic acidosis Early: Edema Ulceration Bleeding Perforation Metabolic acidosis Shock Sepsis Airway obstruction Death

Timing of Tissue Damage and Repair Injury Time Acute injury Day 0 Inflammation, vascular thrombosis 1 - 7 days Granulation tissue 10 - 21 days Fibrosis ,stricture 3 weeks

INVESTIGATIONS AXR and CXR: -Air under the diaphragm -Pneumothorax -Pleural effusion Endoscopy Laryngoscopy Contrast studies-exclude distal obstruction

MANAGEMENT Acute phase Airway evaluation and protection -Dyspnea -Hoarseness -Stridor Fluid resuscitation PPI / H2 blockers IV antibiotics

PREVENTION OF ESOPHAGAL STRICTURES TPN- NPO allows re-epithelialisation, No randomized study. Intraluminal stent- Controversial . PPI or H2 blockers- protect injured mucosa from gastric acid. I.V antibiotics. ?? Corticosteroid

MANAGEMENT Contra indicated: Induced emesis Gastric lavage Activated charcoal Neutralizing agents

Gastric Feeding FEEDING STRATEGIES Feeding Jejunostomy Oral Appropriate in 1st degree burns. Gastric Feeding Cannot be used if stomach is involved. Risk of reflux into esophagus. Risk of vomiting Post Treitz feeding tube Advantageous if it can be safely and correctly placed. Feeding Jejunostomy Ideal Feed while protecting the injured upper gastrointestinal tract. Parenteral Nutrition

INDICATIONS FOR EMERGENCY SURGERY Signs of perforation Peritonitis Extravisceral air Mediastinitis Retrosternal chest pain Fever Tachycardia Shock

LATE SEQUELAE OF CORROSIVE INGESTION 1) Esophageal stricture 2) Gastric stricture 3) Tracheo-Esophageal fistula 4) Esophageal cancer

MANAGEMENT OF BENIGN STRICTURE Balloon or Bougie dilatation No data to support the superiority of one over the other. Strictures caused by caustic ingestion are often complex ( > 2cm long, tortuous or diameter precludes the passage of a endoscope). Complex stricture is more difficult to treat and tend to recur. Refractory strictures : recur in 2-4days or require more than 7-10 dilatations

MANAGEMENT OF ESOPHAGEAL STRICTURE Stents (intraluminal self expandable plastic stents) An option in refractory stricture. Not first line management for benign strictures Goal is to hold the stricture open for a prolonged time allowing tissue to remodel before removing the stent Complications Growth of granulation tissue into the lumen of the stent. Migration Perforation

SURGERY Distal esophagectomy and primary anastomosis Esophagectomy + esophagostomy with feeding Jejunostomy ,followed by colonic interposition graft. Jejunal free graft with microvascular anastomosis Gastric transposition- more suitable for malignant disease. Sleeve resection of short strictures are usually not successful

GASTRIC STRICTURES Patients typically present with features of gastric outlet obstruction. These signs can be masked by a concomitant esophageal stricture. Contrast studies are good means of evaluating strictures and planning operative intervention. Feeding jejenostomy can be used to improve the patient’s nutritional status and ensure the success of surgery.

CARCINOMA A strong association exists between caustic injury and squamous cell carcinoma of the esophagus. 1-7% of patients with squamous ca has a history of caustic ingestion 1000-3000 fold increased risk Many authors recommend endoscopic surveillance beginning 20 years after caustic injury.

CONCLUSION The degree of damage caused by corrosive substance is determined by the type of substance, concentration, amount ingested and intent. In the acute phase resuscitation and early endoscopy and layngoscopy is fundamental. Patients with signs of perforation need emergency surgery. Esophageal and gastric burns may result in strictures. Steroids do not prevent strictures but intra-luminal steroids can be used to decrease the amount of dilatations. Surgical management of strictures must be well timed to allow also for psychological and nutritional rehabilitation

A. Thickening formula reduces reflux episodes Which of the following statements is true regarding reflux: A. Thickening formula reduces reflux episodes B. Proton pump inhibitors have been found to improve infant irritability C. Treatment with PPI’s for three months is indicated in patients with endoscopic ally proven reflux esophagitis D. Acute life threatening events have definitively been linked to gastro esophageal reflux disease E. Erythromycin has been proven to be beneficial in patients with GERD

The ER calls you at 7 PM to see a 2 year old who swallowed an unknown quantity of vanilla scented hair relaxer. You ask about the presence of facial or oral lesions and you are told none are evident but the patient is not fully cooperative for a complete exam. You know the endoscopy suite is only on emergency status so you A. Request the ER attending to call the ENT service. B. Request the ER attending to notify the endoscopy suite for an emergent study. C. Proceed to the ER for your own assessment and finding no lesions or respiratory distress, you recommend sending the patient home on bismuth subsalicylate to return for F/U in one week. D. Proceed to the ER for your own assessment and finding no lesions you or respiratory distress, you recommend symptomatic treatment and endoscopy the following morning

Barium contrast study is very important diagnostic tool in all of the below except A-Malrotation B-Achalasia C-GERD D- Stricture

Nissan fundoplication is indicated for all except: A. Institutionalization B. Intractable pain C. Recurrent bleeding D. Recurrent aspirations E. Neurological impairment

ENT complications of GERD may include all of the following except: A. Sinusitis B. Otalgia C. Laryngitis hoarseness D. Glue ear E. Recurrent epistaxis

Clinical scenario A 2 years old Yemeni boy admitted throughout ER with Hx. of ingestion of acid used in a vehicle almost 10 days back , admitted for 10 days in Jazan in PICU, Patient is suffering from persistent vomiting of whatever he Took describe the abnormality in the photo what is the treatment