1. Joint Hospital Surgical Grand Round Dr. WH She Queen Mary Hospital
Think before you drink
Joint Hospital Surgical Grand Round
Dr. WH She
Queen Mary Hospital

2. 52/M Bipolar and delusional disorder
Drank unknown amount of self made cocktail
Strong acidic solution, pH < 2
Coca Cola
Complained of dysponea and epigastric pain
Physical examination
Tachycardia
Tenderness and guarding over epigastrium

3. Resuscitated and intubated Blood results
Metabolic acidosis (pH 7.2, HCO3 -13 mmol/L, base excess -14 mmol/L)
Acute renal failure (201 umol/L)
Raised AST level (252 U/L)
Chest X-ray – no abnormality detected

4. Upper endoscopy
Gangrenous appearance of the esophageal and gastric mucosa, distally to duodenum

8. Laparotomy
Findings
Full thickness gangrene of stomach with fundal perforation
Esophagus
Mucosal gangrene, spare muscle and adventitia
Duodenum
1st part gangrenous changes
Some involvement of 2nd part
Patches fat necrosis at pancreatic tail
Proximal jejunum normal

10. Spare ampullar of vater

12. Procedures Post operative period
Total gastrectomy, distal exclusion of esophagus, feeding jejunostomy and tracheostomy
Post operative period
Remained critical and septic

15. Further laparotomies Findings Procedures Pancreatic necrosis
Perforated esophageal and duodenal stumps
Procedures
Pancreatic necrosectomy
Esophageal drain and controlled duodenostomy

19. Caustic ingestion Accidental Intentional Usually in children
Usually adults
Higher concentration
Larger amount
More severe
Gumaste VV et al. Am J Gastroenterol 1992
Schaffer SB et al. J La State Med Soc 2000
Satar S et al. Am J Ther 2004
Mckenzie LB et al. Pediatrics 2010

20. pH < 3 or > 11 Extent of injury Type of agent Concentration
Quantity
Physical form
Duration of contact

21. Acid Lick the esophagus and bite the pyloric antrum
Coagulation necrosis
Eschar formation, prevent deeper tissue penetration
Estrera A et al. Ann Thorac Surg 1986
Gumaste VV et al. Am J Gastroenterol 1992
Ertekin C et al. Hepatogastroenterology 2004

22. Acid Pool in stomach Example Pyloric spasm
Gastric perforation and stricture
Example
Hydrochloric acid, sulphuric acid
Toilet bowl cleaners or swimming pool cleaners
Schaffer SB et al. J La state Med Soc 2000
Kochhar R. et al. J Gastroenterol Hepatol 2004
Tohda G et al. Surg Endosc 2008

23. Alkaline Highly viscous, longer duration of contact
More uniformly severe mucosal injury to esophagus
Liquid form
More distal injuries
Solid form
Adhere to mucosa of mouth, upper airway and esophagus
Spare stomach
Deeper injury
Schaffer SB et al. J La State Med Soc 2000

24. Alkaline Liquefactive necrosis Example
Denaturation of proteins and collagen
Sponification of fats
Dehydration of tissues
Thrombosis of blood vessels
Example
Drain cleaners
Hair relaxers
Detergents
Disk batteries
Schaffer Sb et al. J La State Med Soc 2000
Ertekin C et al. Hepatogastroenterology 2004

25. Acute problems Laryngeal spasm, edema Perforation
Upper gastrointestinal bleeding
Acute pancreatitis
Death
Tracheoesophageal fistula
Aorto-enteric fistula

26. Chronic problems Esophageal stricture Gastric outlet obstruction
Esophageal carcinoma
90% of 3rd degree and 30% of 2nd degree burn  stricture

27. Management Resuscitation Endoscopy Conservative management
Operative management

28. Zwischenberger JB et al. Am J Respir Crit Care Med 2001

29. Endoscopy Classification by Zargar Normal findings 1
Normal findings 1
Edema, hyperaemia of mucosa 2a
Friability, blisters, haemorrhaging, erosions, whitish membranes, exudates, and superficial ulcerations 2b
Deep discrete or circumferential ulcerations in addition to grade 2a 3a
Small scattered areas of multiple ulcerations and area of necrosis (brown-black or grayish discoloration) 3b
Extensive necrosis
Zargar SA et al. Gastroenterology 1989
Zargar SA et al.Gastrointest Endosc 1991
Zargar SA et al. Am J Gastroenterol 1992

30. Grade 1
Endoscopic view of Grade 1 corrosive esophagitis. The mucosa of the upper esophagus reveals hyperemia

31. Grade 2a
Endoscopic image of Grade 2a corrosive esophagitis. The mucosa of most of the circumference of the upper esophagus shows erythema. Several tiny whitish exudates are seen over the erythematous mucosa

32. Grade 2b
Endoscopic photograph of Grade 2b corrosive esophagitis. Note the presence of circumferential ulceration with whitish exudates.

33. Grade 3
Endoscopic view of Grade 3 corrosive esophagitis. Irregular-shaped deep ulcerations with areas of brown-black discoloration are observed.

34. Endoscopy Timing of upper endoscopy Early endoscopy No consensus yet
First 24 hours
Assess the severity and extent of injury
Risk of perforation
Minimal force and insufflation and not beyond the first burned area
We believe early upper endoscopy can help to identify patients who might be able to undergo conservative or require urgent operative treatment. The morbidity is low especially in experienced hands.
Ramasamy K et al. J Clin Gastroenterol 2003
Tohda G Et al. Surg Endosc 2008
Cheng HT et al. BMC Gastroenterol 2008
Celik B et al. Dis Esophagus 2009

35. Endoscopy Unable to assess the depth of lesion
Despite concomitant use of endoscopic ultrasound
Kirsh MM et al. Ann Thorac Surg 1976
Chiu HM et al. Gastrointest Endosc 2004

36. Three phases of tissue injury from alkaline ingestion
Onset
Duration
Inflammatory response 1
Acute necrosis
1-4days
Coagulation of intracellular proteins inflammation 2
Ulceration and granulation
3-5days
3-12days
Tissue sloughing
Granulation of ulcerated tissue bed 3
Cicatrization and scarring
3 weeks
1-6months
Adhesion formation scarring
Lack of collagen deposition in phase 2

37. Conservative management
Clinically stable without peritonitis
Usually for Zargar’s grade I and II
Grade III injury in the absence of clinical and biological signs of severity
Low mortality rate
Zerbib P et al. Ann Surg 2011

38. Operative management Clinically unstable or signs of perforation Aim
Resect the necrotic tissues
Prevent extension of the injury to the adjacent organs
Delayed presentation or operation
Massive ingestion of strong corrosive agents
Cattan P et al. Ann Surg 2000

39. Esophago-gastrectomy, cervical esophagostomy and feeding jejunostomy
High mortality rate
Pancreatoduodenectomy
Extensive duodenal necrosis
Reconstruction
Stable, and survive from complications
Sarfati E et al. Br J Surg 1987
Cattan P et al. Ann Surg 2000

40. Use of nasogastric tube
Controversial
For
Decrease incidence of stricture formation and allowed nutritional support
Ramasamy K et al. J Clin Gastroenterol 2003
Atabek C et al. J Pediatr Surg 2007

41. Use of nasogastric tube
Against
Long term indwelling N/G insertion would cause long strictures of the esophagus
Gumaste VV et al. Am J Gastroenterol 1992
Ramasamy K et al. J Clin Gastroenterol 2003

42. Use of steroid Debatable For Decrease strictures Dosage matters
Methyl predinisolone 40-60mg/day iv/ 1.5-2mg pred /day
Howell JM et al. Am J Emerg Med 1992
Mamede RC et al. Dis Esophagus 2002
Pelclova D et al. Toxicol Rev 2005

43. Use of steroid Against Randomized trial Meta-analyses
Risk of the use of steroids
Randomized trial
No difference
Small sample size
Meta-analyses
19% (steroid treated group) vs 40% rate of stricture
Anderson KD et al. N Engl J Med 1990
Pelclova D et al. Toxicol Rev 2005
Ramasamy K et al. J Clin Gastroenterol 2003

44. Outcome Depends on Amount of caustic substances ingested
Severity of injury
Clinical status

45. Our patient Unknown amount of caustic substances ingestion
Clinically unstable
Metabolic acidosis
Acute renal failure
Endoscopic Zargar’s grade IIIb
Therefore operative management

46. Upper airway injury Esophageal necrosis Gastric perforation
Duodenal involvement
pH<7.2, base deficit > 16, two fold level of serum AST

47. Poor biochemical predicting factors
pH < 7.2
Base deficit > 16 mmol/L
Two fold increase of serum AST
We consider age over 65 years, preoperative pH < 7.2, base deficit >16, twofold level of serum AST, and presence of gross hematuria to be the important factors predicting postoperative hospital mortality in patients presenting with corrosive ingestion injuries who require emergency surgery
Between January 1995 and December 2005, 71 consecutive patients who underwent esophagogastrectomy for corrosive ingestion injuries were retrospectively reviewed. Of them, 41 survived and 30 (42.3%) died during the perioperative period. Logistic regression analyses were used to model markers for postoperative mortality, including descriptive data, clinical symptoms/signs, and laboratory data
Chou SH et al. World J Surg 2010

48. Conclusions Difficult to manage High morbidities and mortality
Early recognition of the type, amount and duration of caustic ingestion
Decision on appropriate investigations and treatments

49. Acknowledgement
Prof. S Law
Dr. D Tong