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2. Caustic ingestion Introduction  A common medical problem occurs in the pediatric population.  The majority occurred in young children between one and 5 years of age  Boys accounting for 50 to 62 percent of cases in children younger than 12 years of age.  Female predominance occurred in teens older than 13 years  Most are accidental and ingested small amounts of substance l The majority of caustic ingestion in teens 13 years of age and adults are intent of self-harm or related to attempted suicide. l In such cases the amount ingested may be large and the injury to the esophagus and stomach often severe. 2

3. Why is more common in children? l lack of education and safety measures such as Child safety caps Warning labels Easily accessible to children Handled in similar food container Use of secondary containers Attractive containers 3

4. Type of caustic material or esophageal injury Alkaline substance Acid substance Hot pepper sauce Boiled water 1. Alkaline: Most common caustic ingestion –Cleaning agents (NaOH), drain openers, bleaches (36.6%), toilet bowel cleaners, oven cleaner ( 23%), Hair relaxers ( Ca and lithium hydroxide ) and detergents… 2. Acids: 5% all caustic ingestion –Toilet bowel cleaners ( sulfuric, hydrochloric ), anti rust compounds ( hydrochloric, oxalic, hydrofluoric ), swimming pool cleaners ( hydrofluoric ), Battery fluid ( sulfuric) 4

5. Mechanism of esophageal injury Alkaline Versus Acid Alkaline substance  PH > 7  Tasteless, odorless →larger amounts  liquefaction necrosis direct extension, deeper injuries  Esophageal injury is common  In stomach, partial neutralization by gastric acid may result limited injury  Duodenal injury is less common Acid substance  PH < 7  Pungent odor and noxious taste  Coagulation necrosis formation of a coagulum layer : limit the depth of injury  Less esophageal injury  More gastric injury, antral ulcer  As the acid toward the pylorus, pyloro spasm impairs emptying into the duodenum 5

6. Caustic ingestion  3 year old boy arrives in ER after drinking unknown substance  What do you want to ask on history? 6

7. The severity of injury to the gastrointestinal tract is dependent on: The agent PH Amount ingested Ingested Type of agents ( liquid, gel or solid ) Concentration Tissue contact time 7

8. The type of ingested agents Powdered or crystalized particles are more likely to affect the oropharynx, pharynx area and upper esophagus with adhere to mucosa and thus may lead to more injury due to increased contact time. l Liquid agents pass through the esophagus reaching the stomach and small bowel, which increased surface area exposure and leads to injury that is more extensive, thereby leading to more circumferential injury 8

9. Pathologic severity of injury 1. First-degree: u Superficial mucosal damage u Focal or diffuse erythema, edema, hemorrhage u Without scar formation 2. Second-degree u Mucosal and sub-mucosal damage u Ulcerations, exudates, vesicle formation, granulation, fibroblastic reaction u Scar formation 3. Third-degree u Trans-mural u Deep ulcers and black discoloration and perforation of the wall 9

10. What is clinical presentation? 1. Vary widely  Hoarseness, stridor, dyspnea Airway evaluation  Perforation: (During first 2 weeks)  Retro-sternal or back pain  Localized abdominal tenderness, rebound, rigidity, Psoas sign, obturator sign  Massive hematemesis  Dysphagia, odynophagia, drooling, feeding refusal, nausea, vomiting, abdominal pain 2. Visible mouth lesions such as erythema and or ulceration of the lips and oral mucosa. 3. Early signs and symptoms may not correlate with the severity and extent of tissue injury 4. Oropharyngeal burns (-):10-30% esophageal burns(+)  Oropharyngeal burns (+): 70% esophageal burns(+) 10

11. What is complication sign and symptoms? l The signs and symptoms such as fever, tachypnea, tachycardia, respiratory distress, chest pain, irritability, abdominal pain and distension are suggestive for l Esophageal and/or l Gastric perforations 11

12. Management and treatment Taking careful history and physical examination Airway assessment and evaluating of the mouth for oral lesions, possible nasotracheal or endotracheal intubation Identity of the ingested material, its pH, estimated volume, and the approximate timing of the ingestion, accidental or intentional, because of suicidal attempts. Anti acid therapy Charcoal administration is not recommended because it does not absorb caustic agent. Neutralization NPO Intravenous fluid Induced vomiting is contraindicated after caustic ingestion, to avoid re-exposing and increasing perforation, IV antiemetic recommended. symptomatic patient To minimize the reflux of gastric contents into the esophagus, thereby minimizing esophageal injury, initiation of proton pump inhibitors and H2 blockers is recommended 24 hours after caustic ingestion. 12

13. Management and treatment corticosteroids are of no benefit and do not significantly decrease the incidence of strictures after a caustic ingestion and therefore corticosteroids remain a controversial treatment for stricture prevention but in general are no longer recommended. Corticosteroid ?? Esophagogastroduodenoscopy (EGD) is the best tool in the initial evaluation of patients who involved with caustic ingestion. The recommended timing of endoscopy is 12 to 48 hours after caustic ingestion, although it has been reported safe to perform endoscopy up until 96 hours. Endoscopy is generally avoided 5 to 15 days after caustic ingestion, because associated with highest risk of perforation. Endoscopy Antibiotics Barium swallow In severe esophageal and gastric necrosis, antibiotic therapy should be started in the setting of caustic ingestion with associated signs of infection, peritonitis, or mediastinitis and serial visit, pediatric surgical consult should be considered and emergency esophagogastrectomy may be required. Follow up Endoscopy long-term complication of caustic ingestions is stricture formation follow up barium swallow considered to detect esophageal stricture. The incidence of stricture for a grade 2b burn may be as high as 71%, and anywhere from 75% to 100% stricture rate after grade 3 caustic burns. Esophageal cancer is a late complication of caustic ingestion Rate of 1000 to 3000 times higher than the normal population Incidence ranges from 2% to 30%. Time of presentation 10 to 30 years from the time of caustic ingestion. Esophageal cancer is a late complication of caustic ingestion Rate of 1000 to 3000 times higher than the normal population Incidence ranges from 2% to 30%. Time of presentation 10 to 30 years from the time of caustic ingestion. 13

14. What are ways to reduce the caustic ingestion l Keep out of reach of children l Increase level of education and safety measures l Child safety caps l Avoid of use secondary container l Warning label l Warning card Reduce risk of caustic ingestion 14

15. Thanks for your attention Eram Garden, Shiraz 15