Management of caustic ingestion in adults

Surgical management of catastrophic caustic ingestion in acute phase: A case report and review of the literature

INTRODUCTION

Caustic ingestion almost occurs accidentally in children and mostly intentionally in adults. The ingestion of caustic substances can cause various degrees of damage to the gastrointestinal tract. Depending on the severity of the injury, surgery may be a part of the treatment plan.

PRESENTATION OF CASE

A 32-year-old man was referred to our hospital after swallowing drain cleaner. Due to evidence of peritonitis and endoscopy results, he underwent emergency surgery. During the surgery, necrotic parts, including the esophagus, stomach, duodenum, head of the pancreas, and initial part of the jejunum, were resected. Then, after six months, colon interposition surgery was done to reconstruct the gastrointestinal tract.

DISCUSSION

Like trauma patients, managing patients with caustic injuries begins with an initial survey of the airway, breathing, and circulation status. In the first 48 h, early esophagoscopy is indicated to evaluate the amount of injury. Evidence of transmural necrosis or perforation is the most important indication for surgery, and surgical procedures are specific to each patient. Esophagogastrectomy is the most common surgery in cases of severe gastrointestinal injuries, but removing more abdominal organs may be needed in fewer cases.

CONCLUSION

This case report underscores the urgent need for further research and the development of evidence-based guidelines in managing caustic injury with extensive necrosis in the gastrointestinal tract. Our experience with this rare case highlights the importance of such guidelines in improving patient outcomes.

Exposure to ammonia solution due to substance use: a retrospective study from the French poison centres database (2009-2018)

INTRODUCTION

Ammonia solution (ammonium hydroxide) is used to convert cocaine hydrochloride to freebase cocaine. Due to its causticity, unintentional exposure to ammonia in a substance use context can result in injury. The objective of this study was to describe the characteristics of unintentional oral and buccal ammonia solution exposure in a substance use context.

METHODS

A retrospective study was conducted using the French poison centres database over a 10-year period (2009-2018).

RESULTS

A total of 1,546 files were extracted, and 263 substance users were included. There was a significant increase in the number of these exposures between 2009 and 2018. Unintentional ingestion of ammonia solution was linked to product decanting in 89 per cent of cases. Substance use prior to the exposure and a festive context, such as free parties or teknivals, were identified in 25 per cent and 21 per cent of cases, respectively. Patients received a hospital examination in 87 per cent of cases. The severity of intoxication in substance users was graded as moderate (33 per cent) or severe (15 per cent) using the Poisoning Severity Score.

DISCUSSION

The increased number of ammonia solution cases reported was consistent with an increase in the number of crack users in Europe in the same period. Ammonia solution exposure can suggest the possibility of substance use disorders. In such cases, patients can be referred to receive appropriate treatment and support. This study had some limitations, such as the lack of available information due to the retrospective nature of the study and the non-standardized questions asked by the poison centre during the medical phone interviews.

CONCLUSION

Oral and buccal ammonia solution exposure in known substance users in France increased between 2009 and 2018. These users were mostly young men. A festive context and decanting were frequent. Patients were mainly referred to emergency departments to receive clinical examination and care. The potential severity of oral or buccal ammonia solution exposure in substance users requires increased vigilance among all healthcare professionals involved in the management of these intoxication cases.

Aorto-oesophageal fistula after corrosive ingestion: A case report

BACKGROUND

Aorto-oesophageal fistula (AOF) are uncommon and exceedingly rare after corrosive ingestion. The authors report a case of AOF after corrosive ingestion that survived. A comprehensive literature review was performed to identify all cases of AOF after corrosive ingestion to determine the incidence of this condition, how it is best managed and what the outcomes are.

CASE SUMMARY

A previously healthy 30-year-old male, presented with a corrosive oesophageal injury after drain cleaner ingestion. He did not require acute surgical resection, but developed long-segment oesophageal stricturing, which was initially managed with cautious dilatation and later stenting. An AOF was suspected at endoscopy performed two months after the ingestion, when the patient represented with massive upper gastrointestinal bleeding. The fistula was confirmed on computerised tomographic angiography. The initial bleeding at endoscopy was temporised by oesophageal stenting; a second stent was placed when bleeding recurred later the same day. The stenting successfully achieved temporary bleeding control, but resulted in sudden respiratory distress, which was found to be due to left main bronchus compression caused by the overlapping oesophageal stents. Definitive bleeding control was achieved by endovascular aortic stent-grafting. A retrosternal gastroplasty was subsequently performed to achieve gastrointestinal diversion to reduce the risk of stent-graft sepsis. He was subsequently successfully discharged and remains well one year post injury.

CONCLUSION

AOF after corrosive ingestion is exceedingly rare, with a very high mortality. Most occur weeks to months after the initial corrosive ingestion. Conservative management is ill-advised.

Current practices in the management of corrosive ingestion in children: A questionnaire-based survey and recommendations

BACKGROUND AND AIM

Corrosive ingestion causes significant morbidity in children with no standard guidelines regarding management. This survey aimed to understand practices adopted by gastroenterologists, identify lacunae in evaluation and management and suggest a practical algorithm.

METHODS

Indian gastroenterologists participated in an online survey (65 questions) on managing corrosive ingestion. When ≥ 50% of respondents agreed on a management option, it was considered as 'agreement'.

RESULTS

Ninety-eight gastroenterologists (72 pediatric) who had managed a total of ~ 2600 corrosive ingestions in the last 5 years responded. The commonest age group affected was 2-5 years (61%). Majority of ingestion was accidental (89%) with 80% due to improper corrosive storage. Ingestion of alkali and acid was equally common (alkali 41%, acid 39%, unknown 20%). History of inducing-vomiting after ingestion by community physicians was present in 57%. There was an agreement on 77% of questions. The respondents agreed on endoscopy (70%) and chest X-ray (67%) in all, irrespective of symptoms. Endoscopy was considered safe on days 1-5 after ingestion (91%) and relatively contraindicated thereafter. The consensus was to use acid suppression, always (59%); steroids, never (68%) and antibiotics, if indicated (59%). Feeding was based on endoscopic findings: oral in mild injuries and nasogastric (NG) in others. Eighty percent placed a NG tube under endoscopic guidance. Stricture dilatation was considered safe after 4 weeks of ingestion. Agreement on duration of acid suppression and stricture management (dilatation protocol and refractory strictures) was lacking.

CONCLUSION

Corrosive ingestion mostly affects 2-5-year olds and is accidental in majority. It can be potentially prevented by proper storage and labelling of corrosives. An algorithm for management is proposed.

Corrosive substances ingestion: a review

Corrosive chemical substance ingestions are a major problem, especially in developing countries, but also in developed countries such as the United States, France, and Belgium. Ingestions may be deliberate as suicide attempts (mostly in adolescents and adults) or accidental (mostly in children). The results can be devastating in terms of individual suffering and disability, but also in terms of resource utilization and costs. In developing countries, outcomes may be worse because of limited medical/surgical resources. Common sequelae include gastrointestinal (GI) tract (esophagus, stomach, pylorus, and duodenum) stricture formation, GI tract perforation, and hemorrhage. Systemic effects may also occur, such as disseminated intravascular coagulation (DIC), multi-organ system failure, and sepsis. Various interventions in the acute phase to reduce the severity of injury have been attempted, but there are no large controlled clinical trials to demonstrate efficacy. Dilation therapy in various forms is commonly used for the treatment of strictures and a variety of surgical procedures including esophagectomy and delayed replacement may be required in severe corrosive injury cases.

Oral Chemical Burns Reported to the Poisons Information Centre in Erfurt, Germany, from 1997 to 2014

Devastating oral burns often followed by lifelong complications can result from ingestion of caustic substances. However, although being one of the most challenging situations in clinical practice, literature data on the epidemiology of oral burns are still scarce. Retrospective analysis of all cases of oral burns after ingestion of corrosive substances reported to the Poisons Information Centre in Erfurt, Germany, from 1997 to 2014 was performed. In total, 482 calls because of oral burns were registered, with no change in the numbers of cases during the years. In the majority of the instances (47%), toddlers were affected, followed by middle-aged adults (33%). In both age groups, the male sex prevailed. Ingestion of corrosive substances with babies, schoolchildren, adolescents, and elderly were much less frequent. In most cases (78%), the injury occurred accidentally and only in 5% of the instances in suicidal intent; 85% of the suicidal attempts were committed by middle-aged adults and 15% by elderly. Main agents involved in oral burns were cleansing agents (37%), remedies (12%), disinfectants (7%), acids or bases (6%), technical fluids (6%), cosmetics (5%), and foods (5%). Mostly, the calls came from emergency department doctors (58%), in 19% laymen were calling from home, and in 18% the calls came from a doctor's office. Most of the injuries occurred accidentally, in the domestic setting and in toddlers, and would have been preventable. Thus, a more comprehensive education of the population, especially of parents, regarding the dangers arising from household chemicals is still needed.

Perioperative Evaluation of Patient Outcomes after Severe Acid Corrosive Injury

We reviewed 64 patients with perforation or full-thickness injury of the alimentary tract after acid ingestion. Based on our classification of laparotomy findings, there were class I (n = 15); class II (n = 13); class III (n = 16); and class IV (n = 20). Study parameters were preoperative laboratory data, gastric perforation, associated visceral injury, and extension of the injury. End points of the study were the patients' mortality and length of hospital stay. All these patients underwent esophagogastrectomy with (n = 16) or without (n = 24) concomitant resection, esophagogastroduodenojejunectomy with (n = 4) or without (n = 13) concomitant resection, and laparotomy only (n = 7). Concomitant resections were performed on the spleen (n = 10), colon (n = 2), pancreas (n = 1), gall bladder (n = 1), skipped areas of jejunum (n = 4), and the first portion of the duodenum (n = 4). The study demonstrates five preoperative risk factors, female gender, shock status, shock index, pH value, and base deficit, and four intraoperative risk factors, gastric perforation, associated visceral injury, injury beyond the pylorus, and continuous involvement of the jejunum over a length of 50 cm. The overall mortality rate was 45.3%, which increased significantly with advancing class of corrosive injury.

Caustic ingestion management: world society of emergency surgery preliminary survey of expert opinion

Caustic material ingestion injuries (CMI) are uncommon. Only 5,000 cases are reported in the United States each year and most acute care healthcare facilities admit only a few cases annually. Accordingly, no single institution can claim extensive experience, and management protocols are most probably based on either expert opinion or literature reports.

In this study, we will attempt to review opinions and practices of representatives of the board members of the World Society of Emergency Surgery and compare them to the current literature.

Foregut caustic injuries: results of the world society of emergency surgery consensus conference

INTRODUCTION

Lesions of the upper digestive tract due to ingestion of caustic agents still represent a major medical and surgical emergency worldwide. The work-up of these patients is poorly defined and no clear therapeutic guidelines are available.

PURPOSE OF THE STUDY

The aim of this study was to provide an evidence-based international consensus on primary and secondary prevention, diagnosis, staging, and treatment of this life-threatening and potentially disabling condition.

METHODS

An extensive literature search was performed by an international panel of experts under the auspices of the World Society of Emergency Surgery (WSES). The level of evidence of the screened publications was graded using the Oxford 2011 criteria. The level of evidence of the literature and the main topics regarding foregut caustic injuries were discussed during a dedicated meeting in Milan, Italy (April 2015), and during the 3rd Annual Congress of the World Society of Emergency Surgery in Jerusalem, Israel (July 2015).

RESULTS

One-hundred-forty-seven full papers which addressed the relevant clinical questions of the research were admitted to the consensus conference. There was an unanimous consensus on the fact that the current literature on foregut caustic injuries lacks homogeneous classification systems and prospective methodology. Moreover, the non-standardized definition of technical and clinical success precludes any accurate comparison of therapeutic modalities. Key recommendations and algorithms based on expert opinions, retrospective studies and literature reviews were proposed and approved during the final consensus conference. The clinical practice guidelines resulting from the consensus conference were approved by the WSES council.

CONCLUSIONS

The recommendations emerging from this consensus conference, although based on a low level of evidence, have important clinical implications. A world registry of foregut caustic injuries could be useful to collect a homogeneous data-base for prospective clinical studies that may help improving the current clinical practice guidelines.

Influence of age on the survival and mortality rate in acute caustic poisonings

Objective:

Acute poisonings with caustic substances can cause severe chemical injuries to the upper gastrointestinal tract, which can be localized from the mouth to the small intestines. They are seen very often among young people in their most productive years. The aim of this study is to examine the influence of patient’s age on the mortality rate and survival of patients with acute caustic poisonings, and also to analyze their correlation.

Material and Methods:

We studied medical records from 415 patients, aged between 14 and 90 years, who were hospitalized and treated at the University Clinic for toxicology and urgent internal medicine, Skopje, Republic of Macedonia, in the period between 2007 and 2011.

Results:

In the survey we included 415 patients with acute corrosive poisonings, from which 295 (71.08%) were females and 120 (28. 92%) were males. 388 (93.49%) from the total number of patients ingested the corrosive agent with suicidal attempt and 27 (6.5%) ingested it accidentally.

Conclusion:

Unregulated production, import, packing and labeling of various caustic agents, due to inappropriate legislative, made them one of the most often abused substances in everyday life, especially in developing countries where the number of caustic poisonings rises.

Should computerised tomography replace endoscopy in the evaluation of symptomatic ingestion of corrosive substances?

INTRODUCTION

Corrosive ingestions are common, although most ingestions do not result in clinically significant effects. Limited guidance is available on the role of endoscopy and/or computerised tomography (CT) in the investigation of individuals with corrosive ingestion, and the present data regarding predictors of poor outcome are confusing. Furthermore, whilst there are many case series describing the use of endoscopy in corrosive ingestions, no clear ideal time frame has been established as to when it should be undertaken. More recently, CT has been used to grade injuries, but there are few studies on its role in managing corrosive injuries, and those studies that have been reported are conflicting in their results.

METHODS

A Medline search was performed with the terms 'Caustic ingestion' and 'Corrosive ingestion' and a second search by adding the words 'Endoscopy', 'CT', and 'Computerised tomography' as a subject term or keyword. These searches revealed a total of 277 reviews and papers, of which 33 original papers were relevant for analysis. Three further papers were identified during the analysis of these papers and a PubMed search of the same terms added one further paper, bringing the total to 37. There have been no prospective, randomised controlled trials directly comparing endoscopy and CT. Only two retrospective studies compared the use of CT and that of endoscopy. Thirty-five studies examined whether an endoscopy is always needed, and if so, within what time frame this should be done: CT or endoscopy? A review of these studies suggests that the data regarding the use of CT in these circumstances are not yet of sufficient weight to replace endoscopy as the first-line investigation in corrosive ingestion-related injury. Who needs investigation after corrosive ingestion? We believe that signs and symptoms indicate the likelihood of clinically significant injury in adults. Specifically, any evidence of oropharyngeal burns, drooling, vomiting, pain or dysphagia clearly indicates the need for an endoscopy. In children, it appears that an even greater degree of caution is needed. How soon after ingestion should investigation be performed? For whom an endoscopy is required, it is prudent to enable surgery and other specifics regarding management of corrosives to be decided quickly (< 12 h). There are many incidences where endoscopy has been done safely beyond 48 h although this is not needed frequently. Management recommendations Asymptomatic patients, particularly adults with a normal clinical examination and who can eat and drink normally, can be discharged safely without endoscopy. Endoscopy is preferred over CT in the assessment of risk in symptomatic patients with corrosive ingestion. If patients have any oropharyngeal injury and in particular symptoms of drooling, vomiting, dysphagia or pain (retrosternal or otherwise), the risk of having a high-grade injury is higher, and urgent endoscopy should be performed to grade the injury and determine whether surgical intervention is required. Patients who have non-specific symptoms, such as cough, should also undergo endoscopy, but this is less urgent.

CONCLUSIONS

Despite the lack of high-quality clinical trial data, the available evidence and clinical experience support the use of early endoscopy (< 12 h) in patients who are symptomatic after ingestion of a corrosive substance. We propose a clinical guideline that can be used to help plan management of corrosives.

Pulmonary patch repair of tracheobronchial necrosis with perforation secondary to caustic ingestion

Corrosive aerodigestive injury complicated by tracheobronchial necrosis is a rare complication after caustic ingestion that carries a high risk of mortality and morbidity. If left untreated, tracheobronchial necrosis results in perforation, mediastinitis, and death. Pulmonary patch repair is a safe, effective, and easily performed surgical technique for the treatment of tracheobronchial necrosis with perforation. Frequent endoscopic surveillance leads to early diagnosis and prompt operative management to prevent significant morbidity. We describe a pulmonary patch repair of a patient who had stage 3b necrosis of the esophagus and the stomach with tracheobronchial necrosis and perforation after caustic ingestion.

Foreign bodies and caustic lesions

Foreign body ingestions, food bolus impactions, and caustic agent injuries are frequent but specific situations. Although most foreign bodies will naturally pass through the digestive tract, practitioners should recognize specific situations were endoscopic management is required. In such cases, timing and adequate equipment are critical. Endoscopic treatment is successful in about 95% of patients. Severe complications (including oesophageal perforations) are rare. Underlying diseases (including eosinophilic oesophagitis) must be investigated after food bolus impaction. Accidental or suicidal ingestion of corrosive agents may result in severe upper gastrointestinal tract injuries requiring a multidisciplinary approach including gastroenterologists, surgeons, otorhynolaryngologists, anaesthesiologists and psychiatrists. Treatment includes conservative management of patients with mild injuries, while patients with severe injuries undergo emergency surgical exploration. At distance of the ingestion episode, oesophageal reconstruction is required in patients who underwent oesophageal resection and in patients who developed oesophageal strictures that failed dilatation.

Caustic injury of the upper gastrointestinal tract: A comprehensive review

Prevention has a paramount role in reducing the incidence of corrosive ingestion especially in children, yet this goal is far from being reached in developing countries, where such injuries are largely unreported and their true prevalence simply cannot be extrapolated from random articles or personal experience. The specific pathophysiologic mechanisms are becoming better understood and may have a role in the future management and prevention of long-term consequences, such as esophageal strictures. Whereas the mainstay of diagnosis is considered upper gastrointestinal endoscopy, computed tomography and ultrasound are gaining a more significant role, especially in addressing the need for emergency surgery, whose morbidity and mortality remains high even in the best hands. The need to perform emergency surgery has a persistent long-term negative impact both on survival and functional outcome. Medical or endoscopic prevention of stricture is debatable, yet esophageal stents, absorbable or not, show promising data. Dilatation is the first therapeutic option for strictures and bougies should be considered especially for long, multiple and tortuous narrowing. It is crucial to avoid malnutrition, especially in developing countries where management strategies are influenced by malnutrition and poor clinical conditions. Late reconstructive surgery, mainly using colon transposition, offers the best results in referral centers, either in children or adults, but such a difficult surgical procedure is often unavailable in developing countries. Possible late development of esophageal cancer, though probably overemphasized, entails careful and long-term endoscopic screening.

Conservative therapeutic approach to corrosive poisonings in adults

INTRODUCTION

In this study, we assess the effectiveness of a conservative therapeutic treatment of acute corrosive poisonings in adults, and we define therapeutic protocols based on clinical and endoscopic criteria.

METHODS

We analyzed clinical records of patients with acute corrosive poisonings who were hospitalized and treated at the Toxicology Clinic at the University of Skopje, Republic of Macedonia, during a 5-year period (2006-2010). A total of 481 patients' records with cases of acute corrosive poisonings were analyzed. There were 317 female (65.9 %) and 164 male (34.1 %) patients. The purpose of the therapy in the cases of acute corrosive poisonings is to prevent perforation as well as progressive fibrosis and stenosis of the esophagus and stomach. Therapeutic approach mainly consists of proton pump inhibitors, H(2) blockers, antibiotics, and intensive hyperalimentation. There are different opinions regarding conservative treatment of acute corrosive poisonings in adults.

CONCLUSION

Based on our study of corrosive poisonings of adults, we propose a list of optimal treatment recommendations.

Caustic injuries of the upper digestive tract: a population observational study

BACKGROUND

Both observational and aggressive surgical strategies have been advocated for the treatment of corrosive injuries of the upper gastrointestinal tract (UGT) but the optimal management is still a dilemma. The aim of this study was to report our experience with caustic UGT injuries in adult patients treated with a surgically aggressive, endoscopy-based therapeutic protocol over a 6-year period.

PATIENTS AND METHODS

Between January 2002 and December 2007, 315 patients (138 men, mean age = 40 ± 15.5 years) were referred for corrosive UGT injuries. Emergency endoscopy was performed in all patients at admission. Patients with mild injuries (grades I-IIIa) were offered nonoperative management, whereas emergency surgery was performed for severe injuries (grades IIIb and IV). Esophageal reconstruction was offered to psychologically stable patients after emergency esophageal resection and for esophageal strictures that failed endoscopic dilation. Functional failure was defined as the impossibility to remove the jejunostomy or/and the tracheotomy tube.

RESULTS

At endoscopy 73 (23%) patients did not have UGT injuries, 158 (50%) patients had mild injuries eligible for nonoperative management and 84 (27%) patients had severe injuries. Nonoperative management was successful in 93% of patients with mild injuries. Surgical exploration was eventually performed in 88 (28%) patients and resection was undertaken in 76 of them. Emergency mortality was 7% and all fatalities were patients with initial severe injuries. After a median follow-up of 6 days (range = 1 day-8.5 years), functional failure was recorded in 9 (3%) patients, all of whom had initial severe injuries.

CONCLUSION

Emergency endoscopic grading of caustic injuries is the main factor that conditions outcome after caustic ingestion.

Gastric perforation after corrosive ingestion

PURPOSE

To describe a series of children with gastric perforation (GP) after corrosive ingestion.

METHODS

Case notes of children treated for GP complicating corrosive ingestion between May 2001 and April 2010 were retrospectively reviewed.

RESULTS

Seventy-six children with corrosive ingestion were treated during the study period of which 5 (6.6%) developed GP. This complication was evident on admission in one case and developed within 48 h in the others. The major clinical findings were abdominal pain, tenderness, and distension with radiologic evidence of pneumoperitoneum. Associated pathology included necrosis of the abdominal esophagus in one case and duodenal perforation in another. Two cases have died during surgery while three survived with free of complications related to GP repair. Two patients developed gastric outlet obstruction (one with an esophageal stricture) on follow-up.

CONCLUSIONS

GP is a rare but major complication of corrosive ingestion. Children who swallow corrosives should be closely monitored and pediatric surgeons should be aware of this potential early complication. The possibility of associated pathology should be considered when undertaking surgical repair.

Acute corrosive injuries of the stomach: a single unit experience of thirty years

Introduction. The spectrum of gastric injury due to corrosives can vary. This paper presents a single center experience of over 30 years of corrosive gastric injuries of 39 patients with acute gastric injuries from 1977 till 2006. Patients and Methods. Two thirds of the patients in the acute injury group had a concomitant esophageal injury. The age of the patients ranged from 4 years to 65 years with a slight preponderance of males. (M : F ratio 22 : 17). Results. 36 out of 39 acute gastric injuries were due to ingestion of acids. Three patients had history of caustic soda ingestion. Oral hyperemia or ulcers of varying extent were seen in all patients. The stomach showed hyperemia in 10, extensive ulcers in 13, and mucosal necrosis in 10 patients. Fifteen patients (15/39, 38.5%) were managed conservatively. Twenty four patients (24/39, 61.5%) underwent laparotomy: one for frank peritonitis, 10 for gastric mucosal necrosis, and 13 others for extensive gastric ulcerations. Overall the mortality rate was 29.6 %. Conclusion. Although the mortality and morbidity of acute corrosive gastric injuries is high, the key to improve the survival is early identification of perforation, maintenance of nutrition and control of sepsis.

Pediatric gastric outlet obstruction following corrosive ingestion

PURPOSE

Corrosive substance ingestion is still a major medical and social problem for children. Gastric injury after corrosive ingestion is relatively uncommon as compared with esophageal injury. Gastric outlet obstruction (GOO) is a significant complication of corrosive ingestion.

METHODS

Medical records of 20 consecutive patients with GOO due to corrosive ingestion during an 8-year period between 2002 and 2009 were retrospectively reviewed.

RESULTS

There were 10 boys and 10 girls with a mean age of 5.1 years (1.5-15 years). Ingested material was acid in all the patients. Two patients had associated esophageal stricture. The mean time between the ingestion and the development of GOO was 27.8 days (range 21-45 days) and all the patients presented with postprandial epigastric distension, nonbilious vomiting and weight loss. Surgical treatment included gastroduodenostomy (n = 8), Billroth I (n = 7), pyloroplasty (n = 5), and gastrojejunostomy (n = 2) procedures for GOO. Anastomotic stricture requiring a second operation developed in two patients. There was no surgical mortality. The mean follow-up is 3.3 years and all patients are free of symptoms.

CONCLUSION

GOO is one of the most common gastric complications of corrosive ingestion that may require surgical treatment. Prevention of corrosive ingestion has great importance to avoid such complications.

Update on management of caustic and foreign body ingestion in children

The following recommendations for management of caustic and foreign body ingestion in children have been developed following a multicentre study performed by the Italian Society for Paediatric Gastroenterology, Hepatology and Nutrition (SIGENP). They are principally addressed to medical professionals involved in casualty. Because there is paucity of good quality clinical trials in children on this topic, many of the recommendations are currently extrapolated from adult experiences or based on experts opinions. The document represents a level 2 to 5 degree of evidence (according to the Oxford Centre for Evidence-based Medicine Levels of Evidence), gathered from clinical experience, recent studies, and expert reports discussed during a consensus conference of the Endoscopic Section of the Italian Society of Paediatric Gastroenterology Hepatology and Nutrition. This working group comprises paediatricians, endoscopists, paediatric surgeons, toxicologists, and ENT surgeons, who are all actively involved in the management of these children. Recommendations are intended to serve as an aid to clinical judgement, not to replace it and therefore do not provide answers to every clinical question; nor does adherence to them ensure a successful outcome in every case. The ultimate decision on the clinical management of an individual patient will always depend on the specific clinical circumstances of the patient, and on the clinical judgement of the health care team.

Catastrophic gastrointestinal injury due to battery acid ingestion

BACKGROUND

Acids account for 20% of all chemical exposures through various routes. Caustic acids such as hydrochloric and sulfuric acid are common ingredients in many household and industrial products. Due to the corrosive properties of these substances, tissue injury caused by oral exposure can lead to severe esophageal and gastrointestinal burns.

CASE REPORT

We report a case of a patient presenting with severe acidosis, who required multiple laparoscopic evaluations to assess various gastrointestinal tract injuries and who ultimately underwent total gastrectomy. The diagnosis was made primarily based on the arterial blood gas and esophagogastroduodenoscopy findings, as well as the pathological examinations of various biopsied and resected tissues showing hemorrhagic necrosis of the esophagus, stomach, and small bowel. This patient eventually admitted to having ingested an unspecified amount of battery acid.

CONCLUSIONS

Collaborative efforts by Emergency Medicine, Pathology, and General Surgery services are required for timely diagnosis, treatment, and management of patients after caustic acid exposures.

Laparoscopic transhiatal esophago-gastrectomy after corrosive injury

Esophago-gastric necrosis is a surgical emergency associated with high morbidity and mortality. We report a laparoscopic transhiatal esophago-gastrectomy performed on a 43-year-old male, presenting two hours after hydrochloric acid ingestion. A gastroscopy showed several oral mucosal ulcers, a significant edema of the pharynx and larynx, a necrosis of the middle and lower esophagus and of the gastric fundus and antrum. A conservative strategy with intensive care observation was initially followed. After a change of clinical signs, chest-abdominal computed tomography was realized and a pneumoperitoneum with free fluid in the left subphrenic space and bilateral pleural effusions was in evidence. A laparoscopic exploration was proposed to the patient, and confirmed the presence of free peritoneal fluid and necrosis with perforation of the upper part of the stomach. A laparoscopic total gastrectomy with subtotal esophagectomy was performed; the procedure finished with an esophagostomy on the left side of the neck and a laparoscopic feeding jejunostomy (video). Total operative time was 235 minutes. After six months a digestive reconstruction with esophagocoloplasty by laparotomy and cervicotomy was easily realized thanks to the advantages (few adhesions, bloodless, and simple colic mobilization) of the previous minimally invasive surgery.

Esophageal reconstruction after caustic injury: is there still a place for right coloplasty?

BACKGROUND

Through a systematic policy of using the right colon as an esophageal substitute, the authors analyze the reliability of this transplant for reconstruction after digestive caustic injury.

METHODS

From 1995 to 2005, a right coloplasty was attempted in 81 patients after total esophagogastrectomy (n = 57) or for esophageal stricture (n = 24).

RESULTS

The use of the right colon was not possible in 10 patients (12%) because of insufficient blood supply. In addition, postoperative right colic graft necrosis occurred in 5 patients. Cervical fistula occurred in 25 patients (31%). Opening of the thoracic inlet was associated with a lower rate of this complication (P = .04). At the end of the follow-up, 71 patients (88%) recovered oral feeding.

CONCLUSION

Attempt to use the right colon as an esophageal substitute failed in 18% of the patients. Despite high rates of cervical complications, in part linked to the peculiar setting of caustic injury, functional results remains satisfactory.

Steroids in second degree caustic burns of the esophagus: a systematic pooled analysis of fifty years of human data: 1956-2006

BACKGROUND AND OBJECTIVE

Although steroids are usually withheld in grades I and III esophageal burns, controversy continues regarding their use in grade II burns. Two analyses, including data from 1956-1991 and 1991-2003, respectively, disagreed in their therapeutic recommendations. Our objective is to re-evaluate the usefulness of steroids in grade II burns.

METHODS

The two previous analyses and their references were reviewed. Medline was searched for additional recent human reports. Inclusion criteria were endoscopically documented grade II burns and at least ten days of steroids or no steroids. Pooled data were evaluated by X(2) test with alpha set at 0.05.

RESULTS

Prior analyses identified 12 studies, and one additional study was found during the literature search for a total of 328 patients. 30/244 patients receiving steroids and 16/84 patients who did not receive steroids developed strictures, respectively. This difference was not statistically significant. Heterogeneity of the data prevented formal metanalysis.

CONCLUSION

Although methodologically limited, the existing data fail to support the use of steroids in patients with caustic-induced grade II esophageal burns.

Corrosive injury to upper gastrointestinal tract: Still a major surgical dilemma

In the developed and developing countries, corrosive injury to the gastrointestinal system as a consequence of either accidental ingestion or as a result of self-harm has become a less common phenomenon compared to decades ago. This could partly be attributed to the tighter legislation imposed by the government in these countries on detergents and other corrosive products and general public awareness. Most busy upper gastrointestinal surgical units in these countries, especially in the developed countries will only encounter a small number of cases per year. Up to date knowledge on the best management approach is lacking. In this article, we present our experience of two contrasting cases of corrosive injury to the upper gastrointestinal tract in our thoracic unit in the last 2 years and an up-to-date Medline literature search has been carried out to highlight the areas of controversies in the management of corrosive injuries of the upper gastrointestinal tract. We concluded that the main principle in managing such patients requires a good understanding of the pathophysiology of corrosive injury in order to plan both acute and future management. Each patient must be evaluated individually as the clinical picture varies widely. Signs and symptoms alone are an unreliable guide to injury.

Ingestion of caustic substances by adults

Caustic products are responsible for the most serious cases of poisoning, which are always emergency cases. In this paper, we review demographic features and endoscopic results of the patients admitted to a university emergency department with a history of caustic substance ingestion between January 2000 and June 2003. Thirty-seven patients were included in this study. Twenty-one of the patients were female and 16 were male. The mean age of the patients was 30.9 +/- 14.7 years. The agents included sodium hypochlorite in 24 patients and hydrochloric acid in 13 patients. All the patients ingested these agents orally. The mean interval time of admission to emergency department after ingestion of caustic agent was 5.4 +/- 5.6 hours. Endoscopy was attempted in 37 patients. Endoscopic results were as follows: grade 0 in 8 (21.6%) patients, grade 1 in 17 (45.9%) patients, grade 2a in 5 (13.5%) patients, and grade 2b in 7 (18.9%) patients. We believe that early signs and symptoms after caustic substance ingestion are not consistent with the extent of damage, and endoscopy is the only reliable method to assess injury. It is important that efforts should be made to educate the public about the dangers of caustic substances so that their threat may be diminished.

Endoscopic balloon dilatation of benign gastric outlet obstruction

BACKGROUND AND AIM

Endoscopic balloon dilatation (EBD) has been used for the treatment of gastric outlet obstruction (GOO). There are several reports on the utility and success of this non-surgical treatment option in peptic GOO, with variable results. However, there are only a few reports documenting the efficacy of this method for non-peptic GOO. The authors here report on experience with balloon dilatation in peptic and non-peptic GOO over a 3-year period.

METHODS

Twenty-three patients with benign GOO underwent EBD. Dilatation was carried out with through-the-scope balloon dilators after premedication. Dilatation was repeated every week and the response was documented on the basis of symptoms and endoscopic findings and barium studies. Helicobacter pylori was eradicated in patients with peptic GOO, when present.

RESULTS

The 23 patients with GOO included 11 with peptic ulcer as the etiology, eight with corrosive-induced and four with chronic pancreatitis (alcohol three, idiopathic one). Patients with peptic GOO required 1-3 sessions (mean 2.0 +/- 0.63) to achieve a diameter of 15 mm dilatation, with uniformly good response over a mean follow-up period of 14.04 +/- 9.79 months. Corrosive-induced GOO required a larger number of dilatation sessions (2-9, mean 5.63 +/- 2.88), but the response was equally good, with follow up of 12-30 months. Patients with pancreatitis-related GOO, however, failed to respond despite a mean of 5.50 (+/-0.58) dilatations, and continued to have symptoms. All these patients were subjected to surgical bypass. There were no major complications such as perforation.

CONCLUSIONS

A good response can be expected in the majority of patients with peptic and corrosive-related GOO after balloon dilatation; however, poor results are noted for chronic pancreatitis-related GOO.

Transhiatal esophageal resection for corrosive injury

OBJECTIVES

To analyze the feasibility and safety of transhiatal approach for resection of corrosively scarred esophagus. BACKGROUND SUMMARY DATA: The unrelenting corrosive strictures of esophagus merit esophageal substitution. Because of the risk of complications in the retained esophagus, such as malignancy, mucocele, gastroesophageal reflux, and bleeding, esophageal resection is deemed necessary. Transthoracic approach for esophageal resection is considered safe. The safety and feasibility of transhiatal resection of the esophagus is not established in corrosive injury of the esophagus.

PATIENTS AND METHODS

Transhiatal approach was used for resection of the scarred esophagus for all patients between January 1986 and December 2001. The intraoperative complications, indications for adding thoracotomy, and postoperative outcome were studied in 51 patients. Follow-up period varied from minimum of 6 months to 15 years.

RESULTS

Esophageal resection was achieved in 49 of 51 patients whereas thoracotomy was added in 2 patients. In 1 of the patients tracheal injury occurred whereas in other patient there were dense adhesions between tracheal membrane and esophagus. Gastric tube was used for esophageal substitution in 40 (78.4%) patients whereas colon was transplanted in 11 (21.6%) patients. Colon was used only when stomach was not available. One patient (1.9%) had tracheal membrane injury whereas 4 patients (7.8%) had recurrent laryngeal nerve palsy. One patient each had thoracic duct injury and intrathoracic gastric tube leak. There was no operative mortality. Anastomotic complications like leak were present in 19.6% and stricture in 58.8% patients. All the patients were able to resume their normal duties and swallow normal food within 6 months of the surgery.

CONCLUSION

One-stage transhiatal esophageal resection and reconstruction could be safely used for the extirpation of scarred esophagus. Use of gastric conduit was technically simple, quicker, and offered good functional outcome. Postoperative anastomotic stricture amenable to dilatations was the commonest complication.

Massive upper gastrointestinal bleeding after acid-corrosive injury

Our purpose was to delineate the characteristics and outcome of massive upper gastrointestinal bleeding (UGI) caused by acid-corrosive injury and to determine its management protocol. From June 1988 to June 2000, all patients with the history of acid-corrosive injury at our institution were reviewed. Patients with massive UGI bleeding (hematocrit level <25% or transfusion of three or more units of whole blood required to restore normal vital sign) were enrolled into this study. Altogether, 12 (3.2%) of 378 patients with acid-corrosive injury developed massive bleeding: 8 gastric bleeding, 2 duodenal bleeding, and 2 first gastric and then duodenal bleeding. Gastric bleedings started an average of 12.1 days after the initial injury (range 9-21 days). Duodenal bleeding usually occurred later, at 10.1 days (range 6-18 days) after a gastric or esophagogastric operation. Nine of the ten patients with gastric bleeding underwent surgery during the subacute stage: three esophagogastrectomy, three gastric mucosectomy with gastrostomy and jejunostomy, and three total or subtotal gastrectomy. Operative findings were hemorrhagic gastritis with diffuse mucosal bleeding. Two of four patients with duodenal bleeding underwent duodenotomy with suture-ligation of bleeding vessels, and the other two had conservative treatment. Nine patients (75%) had postoperative complications. One patient (8%) died from complications of surgery performed to stop duodenal bleeding. Massive UGI bleeding rarely occurs after acid-corrosive injury; but when it does, it occurs during the subacute stage. Aggressive surgical treatment is mandatory for gastric bleeding. How duodenal bleeding can be better managed requires further study.

[Extensive digestive caustic burns: what are the limits for resection? A series of 12 patients]

AIM OF THE STUDY

To report the results of oesogastric resections extended to surrounding organs following caustic ingestion, and to precise indications for resection and results of reconstruction.

PATIENTS AND METHODS

From 1988 to 2001, 12 patients underwent oesophago-gastrectomy, extended to duodenum and pancreatic head (n = 6), jejunum (n = 4), colon (n = 2), spleen (n = 2) or pancreatic body (n = 1). Early morbidity and mortality, specificities of reconstruction, and quality of oral feeding were assessed retrospectively.

RESULTS

Mean intensive care unit stay was 50 days (range: 16-152 days). All patients developed complications. Six patients were reoperated for secondary extension of caustic burns, mainly to colon (n = 4), small bowel (n = 2) and pancreas (n = 2). Three patients died on postoperative days 17, 20, and 130. Secondarily, eight patients (75%) underwent a substernal right ileocoloplasty. Six patients (50%) survived initial resection, and esophageal reconstruction. After a mean follow-up of 35 months (range: 7-87 months), four patients (33%) eat normally.

CONCLUSIONS

After caustic burn, oesogastric resections extended to surrounding organs are associated with high morbidity and mortality. However, return of normal oral feeding can be expected in 33% of cases. Secondary extension of caustic burns to adjacent organs is a common eventuality, and may lead to prompt reintervention. Massive injury to small bowel or colon may compromise digestive function or secondary esophageal reconstruction, and thus may be the reasonable limit for resection.

[Gastric conservation in severe caustic lesions of the digestive tract: is it legitimate?]

OBJECTIVE

To evaluate advantages and drawbacks of a controlled conservative management of patients with severe gastric caustic injuries.

METHODS

Among 40 patients with severe caustic gastric burns (> IIb), 28 with stade III lesions (mosaic necrosis: n = 10, extensive or circumferential necrosis: n = 18) were managed prospectively from 1990 to 1998. Twenty-two patients had associated stage III oesophageal lesions and 6 had stage III duodenal lesions. All patients were followed up by daily surgical examination. Total gastrectomy with esophageal exclusion or stripping was performed in case of perforation.

RESULTS

Five immediate and 7 secondary total gastrectomies, two associated esophagectomies and two jejunal resections were performed. Mortality rate was 18% (5/28). Sixteen gastric preservations (60%) were achieved, including 7 complete and 9 partial because of gastric stricture. Eighteen esophagoplasties for oesophageal strictures or after gastrectomy were performed without mortality.

CONCLUSION

Stage III caustic injuries of the stomach, when they are not immediately life-threatening, do not systematically require total gastrectomy. A strict conservative attitude can be done with significant morbidity and acceptable mortality and significantly raises the numbers of preserved stomach.

[Upper gastrointestinal tract injury caused by ingestion of caustic substances]

BACKGROUND

To determine the distribution, extension and severity of injuries produced by the ingestion of caustic substances in the upper gastrointestinal tract, and to assess the relationship of these factors with the type of caustic substance ingested, whether intake was accidental or deliberate and the appearance of strictures or death.

PATIENTS AND METHOD

Between 1993 and 1999, 138 patients (74 males and 84 females) who underwent upper gastrointestinal endoscopy in our unit within the first 24 hours after ingestion of caustic substances were included in the study. Mean age was 47 years (14-97 years). The severity of caustic injury was evaluated using the classification of Showkat et al.

RESULTS

The type of caustic substance ingested was as follows: lye in 84 patients (53%), nitric acid in 21 (13%), different caustic mixtures in 43 (27%) and unknown in 10 patients (6%). Lesions were grade I in 51 patients(32%), grade II in 33 (21%) and grade III in 20 (13%). No lesions were seen in 54 patients (34%). Of the 158 patients, gastric injury was found in 91 (57.5%), esophageal burn in 72 (45.5%) and duodenal injury in 28 (18%). Ingestion was accidental in 80 patients (51%) and voluntary in 62 (39%); the reasons for ingestion were unclear in 16 patients (10%). Voluntary ingestion and acid use were associated with greater severity of lesions (p < 0.0005). Eight patients (5.0%) died, 10 patients (6.3%) required emergency surgery, and 7 (4.4%) developed esophageal-gastric strictures that required surgery or endoscopic treatment.

CONCLUSIONS

The most common type of caustic substance ingested was lye. In 66% of the patients, lesions were absent or superficial. The more severe injuries, producing strictures and higher mortality, were related to voluntary and nitric acid ingestion. The part of the digestive tract most frequently affected after lye and acid ingestion was the stomach.

Extensive abdominal surgery after caustic ingestion

OBJECTIVE

To report the authors' experience in extensive abdominal surgery after caustic ingestion, and to clarify its indications.

SUMMARY BACKGROUND DATA

After caustic ingestion, extension of corrosive injuries beyond the esophagus and stomach to the duodenum, jejunum, or adjacent abdominal organs is an uncommon but severe complication. The limit to which resection of the damaged organs can be reasonably performed is not clearly defined.

METHODS

From 1988 to 1997, nine patients underwent esophagogastrectomy extended to the colon (n = 2), the small bowel (n = 2), the duodenopancreas (n = 4), the tail of the pancreas (n = 1), or the spleen (n = 1). Outcome was evaluated in terms of complications, death, and function after esophageal reconstruction.

RESULTS

Five patients required reintervention in the postoperative period for extension of the caustic lesions. There were two postoperative deaths. Seven patients had secondary esophageal reconstruction 4 to 8 months (median 6 months) after initial resection. Three additional patients died 8, 24, and 32 months after the initial resection. Three survivors eat normally, and one has unexplained dysphagia.

CONCLUSIONS

An aggressive surgical approach allows successful initial treatment of extended caustic injuries. Early surgical treatment is essential to improve the prognosis in these patients.

David R. Boyd lecture in trauma care and emergency medical systems: "The surgical complications of toxins."

Toxins have had major roles in our societies for thousands of years. Interactions between surgeons, both generalists and subspecialists, and those caring for poisoned patients have been extensive throughout history. The advancement of the science of toxicology, the development of regional poison control centers, the development of emergency medicine, and the development of the subspecialty of medical toxicology have led to more appropriate and creative interactions between medical toxicologists, emergency physicians, and surgeons. This article will review the diverse interfaces between the medical toxicologist and the surgeon.

Prediction of complications following unintentional caustic ingestion in children. Is endoscopy always necessary?

The records of 115 children hospitalized following caustic ingestion over an 18.5-year period from 1976 to 1994 were reviewed. The relationship between types of product ingested, signs and symptoms, degree of esophageal injury and complications was analyzed. All complications were the result of strong alkali ingestion (sensitivity = 1.0). Among the 102 incident patients, 36.8% of lye ingestions resulted in complications, whereas only 2.7% (one) of automatic dishwasher detergent (ADD) ingestions caused any complications (p < 0.01). Endoscopy 6 h to 4 days after injury was accurate in predicting or identifying complications in all types of strong alkali ingestions. In lye ingestions, endoscopy was not superior to the test, "one or more signs or symptoms" in predicting complications (predictivity = 1.0). Endoscopy is recommended to establish or confirm a prognosis, or to identify acute respiratory complications, in symptomatic ingestions of lye or ammonia water, in children with respiratory symptoms, and in rare cases of severe symptoms following ADD or strong acid ingestion. It is suggested that children who are non-symptomatic following unintentional ingestions are not at risk of complications and do not need endoscopic examination.

Prediction of complications following caustic ingestion in adults

The records of 86 adults admitted to hospital following caustic ingestion were reviewed. Eighteen patients (21%) developed complications; of these, six were fatal. Patients without symptoms or signs did not develop complications. Complications occurred only following lye ingestion, or intentional ingestion of hydrochloric acid or ammonia water. Of patients with such ingestion, and two signs or symptoms or more, 70% developed complications. Oesophagoscopy did not significantly improve the prediction of complications. There was a strong trend, however, for more severe complications with more severe submucosal, circumferential oesophageal injuries (P = 0.003). The study suggests that only adults with symptoms or signs following strong alkali or strong acid ingestion are at risk of complications. In adults who are symptomatic following ingestion of strong acid or alkali, oesophagoscopy is important to identify the potentially fatal transmural injuries.

Emergency management of caustic ingestion in adults

A study of 57 patients admitted to the Department of Emergency Surgery at the Ospedale Maggiore in Milan between 1980 and 1992 following the recent ingestion of a caustic substance is presented herein. Through this study, an aggressive diagnostic and therapeutic approach has been employed, including early surgery which plays a fundamental role in the prevention of acute hemorrhagic or perforative complications as well as in the development of scar tissue and neoplastic strictures over time. The criteria for early emergency surgery were the presence of endoscopic grade 3 and 4 lesions as well as those on the borderline between grades 2 and 3 with clinical symptoms. In 11 patients with lesions of moderate severity, the treatment of choice was medical therapy, which required subsequent surgical intervention for strictures in 5 patients. In 13 patients with severe lesions, an early surgical approach was performed with a mortality rate of 23%.

Caustic ingestion in adults--epidemiology and prevention

A 16 year retrospective review identified 179 patients hospitalized for ingestion of caustic products in Aarhus County, Denmark. Seventy-five were adults over 15 years of age and residents of Aarhus County. The average annual incidence rate of hospitalization for caustic injury in adults was 1/100,000 with an incidence of esophageal burns of 0.8/100,000/y. Of the adults 61% attempted suicide: of these 61% were women. The annual incidence rate for adult women attempting suicide had an increasing trend (p = 0.048). Changes of the incidence rate for unintentional ingestions and for male suicide attempts were not significant. More than half of the suicide attempts were by patients with a history of a psychiatric illness. Of the caustics ingested by adults 94% were liquids. Acids accounted for 55% of the ingested products. Suicidal ingestion of hydrochloric acid was fatal in 6 of 12 adults. The inavailability of liquid caustics in the homes of patients at suicidal risk might prevent impulsive ingestion.

Mid-colon oesophagocoloplasty for corrosive oesophageal strictures

Corrosive strictures of the oesophagus are common and being long and dense frequently require surgical replacement of the oesophagus. Presently available techniques of oesophagocoloplasty are associated with a significant mortality and major morbidity, such as a high rate of ischaemic necrosis of the colon, cervical salivary fistula or oesophagocolic stenosis. A method of mid-colon oesophagocoloplasty using an isoperistaltic colonic segment from the mid-ascending to the mid-descending colon is reported. The procedure was carried out in 33 patients. The conduit was placed retrosternally in 27 patients and subcutaneously in the rest. The essential steps of the procedure are simultaneous neck and abdominal dissection, near-total mobilization of the colon from the ileocaecal segment to the sigmoid colon and sequential clamping of ileocolic, right colic and usually the middle colic vessels leaving the left colic vessels as the major vascular pedicle. The divided ileum is used to pull the colon into position thus avoiding traumatization of the colon and leaving the whole length of the mobilized colon available for anastomosis. A wide side to side oesophagocolic anastomosis in the neck, resection and discarding of the bulky terminal ileocaecal segment after completion of the cervical anastomosis, closure of the terminal end of the colon and its placement adjacent to the hypopharynx and end to side cologastric anastomosis complete the procedure. There was no mortality and there was no instance of colonic necrosis. The procedure restored an ability to eat normal food in 93.9% of patients compared to only 39.2% of patients with bougienage.(ABSTRACT TRUNCATED AT 250 WORDS)

Battery acid burns of the upper gastro-intestinal tract

Strong acid ingestion produces distinctly different injuries from alkali burns. Alkali burns are well described but the lack of literature on the diagnosis and management of acid burns is apparent. This retrospective review of 18 patients with battery acid (30% sulphuric acid) ingestion showed no correlation between the severity of the symptomatology and the degree of injury. The quantity of acid needed to cause a significant upper GIT burn was more than 200 ml. Previous reports that acid spared the oesophagus due to rapid transit were disproved, since oesophageal involvement was found in 55% (10/18). Deep burns rather than circumferential burns resulted in stricture formation. The major injury site was the gastric antrum with 4 patients (23%) requiring surgical intervention to restore function.