1. Corrosive injury to upper gastrointestinal tract: Still a major surgical dilemma World J Gastroenterol. 2006 Aug 28;12(32):5223-8.

2. INTRODUCTION corrosive injury to the gastrointestinal system has become less corrosive injury to the gastrointestinal system has become less Up to date knowledge on the best management approach therefore be lacking Up to date knowledge on the best management approach therefore be lacking two contrasting cases of corrosive injury two contrasting cases of corrosive injury Medline search to perform a literature review Medline search to perform a literature review

3. CASE REPORTS(Case 1) 22-year-old male ; accidental ingestion of a cupful of 30% caustic soda 22-year-old male ; accidental ingestion of a cupful of 30% caustic soda s/s: his voice was hoarse;short of breath and drooling his saliva s/s: his voice was hoarse;short of breath and drooling his saliva he had a red, swollen tongue and his oropharynx was oedematous and inflamed he had a red, swollen tongue and his oropharynx was oedematous and inflamed management:intubated to secure his airway ; management:intubated to secure his airway ; supportive treatments :intravenous proton pump inhibitor (PPI) and total parental nutrition (TPN). supportive treatments :intravenous proton pump inhibitor (PPI) and total parental nutrition (TPN).

4. Early esophagogastroscopy: generally inflamed oropharynx and esophagitis Early esophagogastroscopy: generally inflamed oropharynx and esophagitis Barium meal : two weeks later showed a long stricture segment from just distal to the hypopharynx to the oesophago-gastric junction Barium meal : two weeks later showed a long stricture segment from just distal to the hypopharynx to the oesophago-gastric junction successfully managed with repeated progressively time spaced dilatation using a guide wire under fluoroscopy successfully managed with repeated progressively time spaced dilatation using a guide wire under fluoroscopy

5. CASE REPORTS(Case 2) A 33-year-old male ; ingestion of battery acid (hydrochloric acid) A 33-year-old male ; ingestion of battery acid (hydrochloric acid) s/s: hoarseness and stridor s/s: hoarseness and stridor management: intubated to secure his airway ; management: intubated to secure his airway ; supportive treatments: intravenous PPI, TPN for nutrition, steroids and broad- spectrum antibiotics for laryngeal edema and positive blood culture supportive treatments: intravenous PPI, TPN for nutrition, steroids and broad- spectrum antibiotics for laryngeal edema and positive blood culture Early endoscopy: inflammation and ulceration of the pharynx and esophagus Early endoscopy: inflammation and ulceration of the pharynx and esophagus

6. Endoscopy was repeated :Upper esophagus was relatively spared. Lower esophagus showed a circumferential burn with slough. Similar findings were noted on the mid-body of the stomach and the antrum Endoscopy was repeated :Upper esophagus was relatively spared. Lower esophagus showed a circumferential burn with slough. Similar findings were noted on the mid-body of the stomach and the antrum readmitted : gastric outlet obstruction readmitted : gastric outlet obstruction Endoscopy: a normal esophagus with an ulcerated and scarred gastric pylorus Endoscopy: a normal esophagus with an ulcerated and scarred gastric pylorus Roux-en-Y gastrojejunostomy was performed subsequently in order to bypass the stricture Roux-en-Y gastrojejunostomy was performed subsequently in order to bypass the stricture

7. DISCUSSION Failure to recognize the seriousness of the accident and to provide adequate therapy could result in serious morbidity and mortality Failure to recognize the seriousness of the accident and to provide adequate therapy could result in serious morbidity and mortality Children account for more than 80% Children account for more than 80% adult is more often of suicidal intent  tend to be more serious adult is more often of suicidal intent  tend to be more serious The mortality rate is between 10% to 20% and rises to 78% in cases of attempted suicide The mortality rate is between 10% to 20% and rises to 78% in cases of attempted suicide The extent of the injury depends on the type of agent, its concentration The extent of the injury depends on the type of agent, its concentration

8. Pathophysiology esophageal versus gastric injury in cases of acid and alkali ingestion esophageal versus gastric injury in cases of acid and alkali ingestion acid is said to “ lick the esophagus and bite the pyloric antrum(coagulation necrosis ) acid is said to “ lick the esophagus and bite the pyloric antrum(coagulation necrosis ) alkaline : more uniformly severe mucosal injury to the esophagus(liquefaction necrosis)  resulting in deeper tissue injury alkaline : more uniformly severe mucosal injury to the esophagus(liquefaction necrosis)  resulting in deeper tissue injury Our patient who ingested battery acid developed partial gastric outlet obstruction Our patient who ingested battery acid developed partial gastric outlet obstruction However, the distinction between the expected sites of gastrointestinal injury following acid versus alkali ingestion is not always clear. However, the distinction between the expected sites of gastrointestinal injury following acid versus alkali ingestion is not always clear.

9. Burn classification are classified in similar fashion to thermal burn of the skin are classified in similar fashion to thermal burn of the skin but at present, no definite measurements of the depth can be made, and is subjective. but at present, no definite measurements of the depth can be made, and is subjective. Endoscopic ultrasound may provide an answer Endoscopic ultrasound may provide an answer Oropharyngeal burns and clinical symptoms have a low predictive value for severity of esophageal injury Oropharyngeal burns and clinical symptoms have a low predictive value for severity of esophageal injury

10. Early versus late endoscopy Early endoscopy :most appropriate measure based on which clinical decisions are made Early endoscopy :most appropriate measure based on which clinical decisions are made to verify directly the healing state of the mucosa and may be of value in predicting which patients require further early intervention to verify directly the healing state of the mucosa and may be of value in predicting which patients require further early intervention early endoscopy in the hands of a less- experienced endoscopist could be hazardous early endoscopy in the hands of a less- experienced endoscopist could be hazardous difficult to assess the depth; difficult to assess the depth; in the upper third of the esophagus, the scope is not passed beyond this point. in the upper third of the esophagus, the scope is not passed beyond this point.

11. Complications of corrosive ingestion Severe complications,often life threatening are common : tracheobronchial fistula, severe haemorrhage secondary to gastric involvement, aortoenteric fistula or gastrocolic fistula, stricturesand perforation Severe complications,often life threatening are common : tracheobronchial fistula, severe haemorrhage secondary to gastric involvement, aortoenteric fistula or gastrocolic fistula, stricturesand perforation Stricture formation, by far, remains the main long-term complication of this injury Stricture formation, by far, remains the main long-term complication of this injury

12. Early use of steroids and antibiotic: Prevention of stricture formation Corticosteroids inhibit the transcription of certain matrix (for fibrosis) Corticosteroids inhibit the transcription of certain matrix (for fibrosis) Animal experiments have shown: stricture formation is reduced Animal experiments have shown: stricture formation is reduced Several authors have found corticosteroids ineffective Several authors have found corticosteroids ineffective Intra-lesional corticosteroid therapy has shown beneficial effects for refractory esophageal strictures Intra-lesional corticosteroid therapy has shown beneficial effects for refractory esophageal strictures

13. no convincing evidence supporting the use of antibiotics in reducing stricture formation no convincing evidence supporting the use of antibiotics in reducing stricture formation general consensus :antibiotic treatment should only be commenced when treated with steroids or there are signs of infection general consensus :antibiotic treatment should only be commenced when treated with steroids or there are signs of infection

14. Routine use of nasogastric (NG) tube significant lower incidence of stricture formation with routine use of NG tube for 15 day significant lower incidence of stricture formation with routine use of NG tube for 15 day long-term indwelling nasogastric insertion is known to cause long strictures of the esophagus long-term indwelling nasogastric insertion is known to cause long strictures of the esophagus We do not advocate the use of a NG tube We do not advocate the use of a NG tube

15. Experimental studies to prevent stenosis cytokines have been used successfully cytokines have been used successfully Epidermal growth factor (EGF) Epidermal growth factor (EGF) Interferon-g (IFN-g) Interferon-g (IFN-g) interferon-a-2b and octreotide interferon-a-2b and octreotide antioxidant, such as vitamin E and methylprednisolone antioxidant, such as vitamin E and methylprednisolone all these studies are only carried out on animals and these treatments have not been tested on humans. all these studies are only carried out on animals and these treatments have not been tested on humans.

16. Management The acute management: securing the airway, pain relief and adequate intravenous fluid The acute management: securing the airway, pain relief and adequate intravenous fluid nil by mouth nil by mouth plain chest radiograph: signs of perforation  diluted barium swallow plain chest radiograph: signs of perforation  diluted barium swallow antidote such as water or milk does not seem to prevent stenosis antidote such as water or milk does not seem to prevent stenosis Endoscopy is the diagnostic procedure of choice Endoscopy is the diagnostic procedure of choice

17. Patients with perforation require immediate surgery Patients with perforation require immediate surgery Gastric acid suppression with PPIs and H2- antagonists are often used Gastric acid suppression with PPIs and H2- antagonists are often used esophageal strictures was managed with frequently repeated dilatation (first patient) esophageal strictures was managed with frequently repeated dilatation (first patient) Early dilatation is not recommended due to associated high incidence of perforation (3 to 6 wk) Early dilatation is not recommended due to associated high incidence of perforation (3 to 6 wk) esophageal dilatation has proved to give good results in short strictures but might be dangerous for long and narrow esophageal strictures esophageal dilatation has proved to give good results in short strictures but might be dangerous for long and narrow esophageal strictures Complex strictures: fluoroscopic guidance Complex strictures: fluoroscopic guidance

18. intense PPI therapy and repeated dilatation will reduce the number of esophageal resection and reconstructive surgery intense PPI therapy and repeated dilatation will reduce the number of esophageal resection and reconstructive surgery steroid use is limited :severe laryngeal edema steroid use is limited :severe laryngeal edema pathophysiology of corrosive injury is important in planning both acute and on-going management. pathophysiology of corrosive injury is important in planning both acute and on-going management. Scar retraction begins as early as the end of the second week and lasts for 6 mo Scar retraction begins as early as the end of the second week and lasts for 6 mo esophagectomy : prior to the scar tissue maturation might increase the risk of anastomostic stenosis esophagectomy : prior to the scar tissue maturation might increase the risk of anastomostic stenosis delaying major reconstructive surgery for at least 6 month delaying major reconstructive surgery for at least 6 month Emergency: in cases of perforation and contamination of the mediastinum Emergency: in cases of perforation and contamination of the mediastinum

19. Risk of carcinoma The association of lye stricture and carcinoma of the esophagus has been known(at least 1000 times greater) The association of lye stricture and carcinoma of the esophagus has been known(at least 1000 times greater) The interval between lye ingestion and the development of carcinoma ranges between 25 to 40 years The interval between lye ingestion and the development of carcinoma ranges between 25 to 40 years operative risk may exceed the potential risk of cancer. operative risk may exceed the potential risk of cancer. The risk of gastric cancer is less known The risk of gastric cancer is less known

20. CONCLUSION treatment of patients with corrosive injuries is both controversial and inconclusive treatment of patients with corrosive injuries is both controversial and inconclusive each patient must be evaluated individually each patient must be evaluated individually The general consensus is that the initial treatment is supportive; ensuring the airway is patent and to establish haemodynamic stability. The general consensus is that the initial treatment is supportive; ensuring the airway is patent and to establish haemodynamic stability. Early endoscopy has a crucial role in both diagnosing the severity of the injury, as well as, in managing the patient. Early endoscopy has a crucial role in both diagnosing the severity of the injury, as well as, in managing the patient. Total parenteral nutrition is a useful adjunct. Total parenteral nutrition is a useful adjunct.

21. Operation :patients who have ingested large amounts of corrosive substance and in whom tissue necrosis is highly likely. Operation :patients who have ingested large amounts of corrosive substance and in whom tissue necrosis is highly likely. Immediate surgical intervention :extensive necrosis noted on endoscopy and with evidence of perforation Immediate surgical intervention :extensive necrosis noted on endoscopy and with evidence of perforation intractable esophageal strictures :dilatation is dangerous or impossible, surgical intervention may be unavoidable. intractable esophageal strictures :dilatation is dangerous or impossible, surgical intervention may be unavoidable. Diligent follow-up Diligent follow-up