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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
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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
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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
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Upper endoscopy Gangrenous appearance of the esophageal and gastric mucosa, distally to duodenum
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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
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Spare ampullar of vater
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Procedures Post operative period
Total gastrectomy, distal exclusion of esophagus, feeding jejunostomy and tracheostomy Post operative period Remained critical and septic
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Further laparotomies Findings Procedures Pancreatic necrosis
Perforated esophageal and duodenal stumps Procedures Pancreatic necrosectomy Esophageal drain and controlled duodenostomy
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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
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pH < 3 or > 11 Extent of injury Type of agent Concentration
Quantity Physical form Duration of contact
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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
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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
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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
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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
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Acute problems Laryngeal spasm, edema Perforation
Upper gastrointestinal bleeding Acute pancreatitis Death Tracheoesophageal fistula Aorto-enteric fistula
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Chronic problems Esophageal stricture Gastric outlet obstruction
Esophageal carcinoma 90% of 3rd degree and 30% of 2nd degree burn stricture
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Management Resuscitation Endoscopy Conservative management
Operative management
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Zwischenberger JB et al. Am J Respir Crit Care Med 2001
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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
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Grade 1 Endoscopic view of Grade 1 corrosive esophagitis. The mucosa of the upper esophagus reveals hyperemia
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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
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Grade 2b Endoscopic photograph of Grade 2b corrosive esophagitis. Note the presence of circumferential ulceration with whitish exudates.
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Grade 3 Endoscopic view of Grade 3 corrosive esophagitis. Irregular-shaped deep ulcerations with areas of brown-black discoloration are observed.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Outcome Depends on Amount of caustic substances ingested
Severity of injury Clinical status
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Our patient Unknown amount of caustic substances ingestion
Clinically unstable Metabolic acidosis Acute renal failure Endoscopic Zargar’s grade IIIb Therefore operative management
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Upper airway injury Esophageal necrosis Gastric perforation
Duodenal involvement pH<7.2, base deficit > 16, two fold level of serum AST
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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
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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
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Acknowledgement Prof. S Law Dr. D Tong
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