1. Management of Corrosive Ingestion
Joint Hospital Grand Round
United Christian Hospital
Dr WN Fong

2. Background

3. Introduction Accidental - 80% children
Intentional - adolescents and adults
Extensive damage to aerodigestive tract
 Perforation
 Death
Alkaline > Acid
Management is complicated ( young, psychotic, suicidal and alcoholic)

4. Corrosive Agent Alkaline corrosives – pH ≧12 Acid corrosive – pH <2
Granular, paste and liquid
Drain and over cleanser
Washing detergents
Cosmetic and soaps
Button batteries
Acid corrosive – pH <2
Toilet bowl cleansers (sulfuric, HCl)
Antirust (HOCl, oxalic)
Battery fluid (sulfuric)
Swimming pool and slate cleanser (HCl)

5. Corrosive Agent Mild Alkaline – pH 10.8 to 11.4 Sodium carbonate
Ammonium hydroxide
Bleaches ( sodium and calcium hypochlorid and hydrogen peroxide)

6. Pathogenesis and Pathology
Degree of injury
Agent
Concentration
Quantity
Physical state
Duration of exposure

7. Alkali
Liquefaction necrosis (potent solvent x lipoprotein lining)
Thrombosis of adjacent vessels
Heat production
Acid
Coagulation necrosis
Eschar formation

8. Anatomical Cricopharyngeal area Aortic arch Tracheal bifurcation
Lower esophageal sphincter
Antrum (fasting) / body (after meal)

9. Consequence Short Term Long Term Mild mucosal erythema Ulceration
Hemorrhage
Perforation (during first 2 weeks)
Long Term
Stricture formation
Gastric outlet obstruction
Shortening of esophagus altered LES
Change in esophagus motility
 GERD which accelerate stricture formation
CA esophagus

10. Clinical Features Oropharyngeal pain Dysphagia with drooling saliva
Hoarsiness and stridor
Dysphagia/ odynophagia
Retrosternal chest pain, radiate to back
Hematemesis
Cervical emphysema
mediastinitis
Epigastric pain
Retching
Emesis of tissue, blood or coff ee ground material
peritonitis
Tachypnea,
Shock
Metabolic acidosis
coagulopathy

11. Management Acute Phase Airway Fluid resuscitation
Assess the severity of injury
Emergency surgery
Controversies : neutralization, use of steriod/ antibiotics

12. Endoscopy Radiography
Evaluation of Injury
Endoscopy
Radiography

13. Endoscopy Laryngoscopy Potential airway obstruction OGD Gold standard
Within hrs
Should be avoid from D5 – D15 (risk of perforation)
Classification (I, IIa, IIb and III)

14. Classification of corrosive injury
Degree of Injury
Depth
Endoscopic Findings I
Superficial mucosal injury
Mucosal hyperemia & edema
IIA
Partial thickness injury – patchy
Mucosal sloughing
Superficial ulcers
IIB
Partial thickness injury - circumferential
Deep ulcerations
III
Transmural injury
Periesophageal and/or perigastric extension
Eschar formation
Full thickness necrosis
Brownish black or gray ulcers

15. Radiography Plain X-ray CXR AXR
Contrast radiography ie water-soluble or thin barium
Double contrast CT if evidence of duodenum abnormality

16. Role of Surgery Acute Phase – emergency measure
Evidence of perforation
Shock, acidosis, coagulopathy and who ingested large amount of corrosive
3rd degree burn on endoscopy
Early surgical intervention may improve outcome in grade 3 injury. Gastrointest Endosc. 91;37:

17. Controversy

18. Neutralization Absolute Contraindicate Relative Contraindicate
Gastric lavage
Induce vomiting
Relative Contraindicate
Milk and water
Activated charcoal
Exothermic reaction and
obscure subsequent endoscopy

19. Steriod Animal study – decrease stricture formation
Human study – inconclusive
Review of 13 publications – Howell Am J Emerg Med 1992;10:421-5
Stricture significantly reduced in those with advance injury receiving steriod
RCT – Anderson KD N Eng J Med 1990;323:
steriod do not prevent stricture
Recommend dose
30-40mg methyl prednisolone or dexamethasone 1mg/kg/day
Duration : > 3 weeks

20. Antibiotics No clear data support its use No RCT in human avaliable
Consensus :
Antibiotics should be given in patient treated with steriod
Otherwise antibiotics is not advocated

21. Acid Suppression Esophageal shortening altered LES
Esophageal dysmotility
 GERD – accelerate stricture formation

22. Flowchart – Managment of caustic ingestion
Deterioration
 Laparoscopy

23. United Christian Hospital July 03’ – June 04’
Case Series
United Christian Hospital
July 03’ – June 04’

24. Patient Endoscopic grade Intervention Outcome 1 2 3 4 Tracheostomy
OGD N
Good 2
Grade 2
Steriod Y
good 3
Grade 3
trachesotomy
Transhiatal esophagectomy + total gastrectomy + feeding j + esophagostomy
Plan for esophageal reconstruction with colonic interposition 4
Grade 2b
Total gastrectomy + feeding j + esophagostomy
OGD – no stricture ( 2 months)
Reconstruction : esophago-jejunostomy

25. Patient Endoscopic grade Intervention Outcome 5 6 Tracheostomy Grade 3
OGD
Trachesotomy
Transhiatal esophagectomy + esophagostomy
Total gastrectomy
Whipple operation
Splenectomy Y
Death 6
Grade 4
Total gastrectomy + esophagostomy, duodenostomy
Plan for reconstruction in QMH 6/12 later

26. Bring Home Message Airway Early endoscopy is indicated
Surgery ??
Magnitude of surgery ??
Early surgical intervention may decrease mortality

27. Thank You