1. CORROSIVE INGESTION INJURIES

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

3. 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

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

6. -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

7. 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.

8. 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.

17. Acute phase – Presentation
and
Management

18. 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

25. 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

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

34. Timing of Tissue Damage and Repair
Injury Time
Acute injury Day 0
Inflammation, vascular thrombosis days
Granulation tissue days
Fibrosis ,stricture weeks

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

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

37. 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

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

39. 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

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

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

45. 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

46. 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

49. 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

50. 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.

51. 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
fold increased risk
Many authors recommend endoscopic surveillance beginning 20 years after caustic injury.

52. 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

62. 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

64. 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

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

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

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

68. 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