The Damage Pattern to the Gastrointestinal Tract Depends on the Nature of the Ingested Caustic Agent. World J Surg. 2016;40:1638-1644. [PMID: 26920407 DOI: 10.1007/s00268-016-3466-5]

Long-term outcomes of patients undergoing emergency surgery for corrosive injury of the upper digestive tract

PURPOSE

Emergency surgery can save patients' lives in cases of severe caustic injury. However, the long-term outcomes are not well understood.

METHODS

Patients who underwent emergency organ resection for severe corrosive acid injury were included. Subsequently, digestive tract reconstruction was performed to fit patients. Long-term outcomes were analyzed.

RESULTS

Fifty patients underwent emergency digestive tract resection. The operative mortality rate was 6% (of 3/50). One of the 50 patients underwent successful immediate reconstruction. Of the 46 survivors with digestive tract discontinuity, 32 (70%) underwent subsequent reconstructive surgery, 10 (22%) died while awaiting reconstruction due to deterioration in their psychiatric and nutritional status, and 4 (9%) were unfit for reconstructive surgery. No operative mortality occurred during reconstruction. Among the 32 patients who underwent reconstruction, 30 (94%) achieved nutritional autonomy. Nutritional independence was achieved in 62% of the patients (31/50). At a median duration of 58 months, the median survival time of the 50 patients was 158 months. Patients who underwent reconstruction had a significantly better overall survival than those who did not (p < 0.0001).

CONCLUSIONS

Emergency surgery remains the standard treatment for corrosive ingestion of complicated digestive tract injuries. However, only 60% of survivors can undergo subsequent digestive reconstruction and achieve long-term nutritional autonomy and a survival outcome.

Corrosive induced esophageal and gastric injury: Histopathological evaluation of surgically resected specimens over a decade in a tertiary care center

BACKGROUND

Caustic ingestion is associated with long-term sequelae like esophageal stricture, gastric cicatrization, and long-term risk of dysplasia or even carcinoma. However, only a few small studies have explored histopathological aspects of caustic-induced esophageal/gastric injury.

MATERIALS AND METHODS

We retrospectively evaluated specimens of patients undergoing surgery due to caustic ingestion-related complications from 2008 to 2020. Pathological examination was conducted by two independent gastro-pathologists to evaluate the extent and depth of the caustic injury, presence or absence of tissue necrosis, type and degree of inflammation, or presence of any dysplastic cells.

RESULTS

A total of 54 patients underwent surgical exploration during the inclusion period and complete details of 39 specimens could be retrieved. The mean age of the included patients was 28.66 ± 9.31 years and 25 (64.1%) were male. The majority of patients (30; 76.9%) had a history of caustic ingestion more than three months before the surgery and the presence of long or refractory stricture was the most common indication for the surgery (20; 51.28%). In the resected specimen, a majority of patients had superficial esophageal or gastric ulcer (90.6%; 60.0%), transmural inflammation (68.8%; 65.6%), transmural fibrosis (62.5%; 34.4%), and hypertrophied muscularis mucosa (78.13%; 53.3%). However, none of the patients had dysplasia in the resected esophageal or gastric specimens.

CONCLUSION

Caustic ingestion leads to mucosal ulceration, transmural inflammation, and transmural fibrosis which might be the reason for refractory stricture in such patients.

Can computed tomography-antral wall thickness predict response to endoscopic balloon dilation in patients with caustic-induced gastric outlet obstruction?

BACKGROUND

Caustic-induced gastric outlet obstruction (GOO) remains one of the important causes of long-term morbidity in patients with caustic ingestion. Though endoscopic balloon dilation is an effective modality, response to caustic GOO is poorer as compared to peptic stricture. Computed tomography (CT)-antral wall thickness (AWT) has not been previously explored to predict the procedural success in patients with caustic GOO.

METHODS

In a retrospective single-center study of prospectively maintained database, all patients with symptomatic caustic GOO who underwent CT scan prior to endoscopic balloon dilation were included. Gastric AWT was measured at the site of maximum visible thickness on CT scan. Details regarding caustic ingestion and endoscopic dilation were retrieved. Patients were divided into two groups, based on CT-AWT (< or ≥9 mm) and compared for outcome measures.

RESULTS

Mean age of included patients (n=35) was 33.51 ± 13.65 years and 22 were male. Procedural success was achieved in 29 (82.85%) patients. Number of mean dilation sessions required were 5.28 ± 2.96 for achieving procedural success. The mean CT-AWT was 10.73 ± 2.80 mm (range 4-18 mm). There was no significant association between the CT-AWT and the number of dilations and procedural success. On univariate analysis, size of the first balloon used was a predictor of refractory stricture (p=0.011). However, no other factors predicted either refractory stricture or procedural success.

CONCLUSION

There is no additional role of CT-AWT in predicting response to endoscopic balloon dilation or to predict refractory stricture in patients with caustic GOO.

Gastric secretion in patients with caustic ingestion: A prospective study

BACKGROUND

Caustic ingestion can lead to structural changes in the upper gastrointestinal tract. However, there are limited data on the effect of caustic ingestion on gastric secretion. This study was planned to determine the changes in gastric acid output in patients with caustic ingestion.

METHODS

It was a prospective study done at a tertiary care center in northern India. Twenty consecutive patients in chronic phase of caustic ingestion were evaluated for the study. The gastric secretory function was estimated in the basal state and following pentagastrin stimulation. These results were compared with normal values for our laboratory.

RESULTS

The mean age of the included patients (n = 20) was 27.35 ± 2.96 years and 14 patients were male. Sixteen (80%) patients had a history of acid ingestion. Patients with caustic ingestion had significantly lower mean gastric acid secretion (0.8 ± 0.4 mEq/h vs. 4 ± 0.4 mEq/h; p < 0.001) compared to controls. After pentagastrin stimulation, the mean gastric juice volume (31.8 ± 6 mL/h vs. 62.3 ± 11.7 mL/h; p < 0.01) and acidity (15.3 ± 5.1 mEq/L vs. 39.6 ± 9.3 mEq/L; p < 0.001) increased in patients with caustic ingestion, but were lower than those in control subjects. Patients with a lower esophageal stricture (n = 6) had decreased maximum acid output (0.62 ± 0.32 mEq/h vs. 6.05 ± 0.55 mEq/h; p < 0.05) compared to patients with stricture in the upper or middle esophagus.

CONCLUSION

Caustic ingestion is associated with reduced gastric juice volume and acid output. Patients with stricture in the lower one third of the esophagus are at a higher risk of hypochlorhydria compared to patients with stricture in either the upper or middle esophagus.

Caustic ingestion in children: A 6-year retrospective study

Some aspects of the management of caustic ingestion in children are still debated. We aimed to determine the predictive value of epidemiological and clinical features of caustic ingestion, and to define guidelines adherence. This is a retrospective study on children ≤18 years referred to our Emergency Department over 6 years because of caustic ingestion. Statistical significance at p<0.05. Overall, 107 caustic ingestions were identified, mainly accidental <5 years (87.85%). Bleach was the most common caustic (46.73%). Forty-six patients underwent endoscopy; 57.38% children who should have endoscopy on guidelines, actually did not (p<0.0001), but no complications were reported. No or minimal lesions were reported in asymptomatic children; ≥2 symptoms correlated with the severity of lesions (p<0.0002). Therapy of severe cases was correct; overtreatment was observed for minor injuries (p<0.0001). Asymptomatic children after caustic ingestion have a very low-probability of moderate-severe endoscopic lesions, and the risk of severe damage increases proportionally with ≥2 symptoms. Prospective studies are needed to evaluate the efficacy of intensive clinical observation versus EGD on low-risk children to identify those with clinically relevant esophageal lesions.

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.

Factors that affect mortality in local patients who ingested common household cleansing products and required intubation

Introduction:

Ingestion of common household cleansing products resulting in a need for intubation is not uncommon in Hong Kong. The objective of this study was to determine the factors that affect the mortality in this group of patients.

Methods:

This was a retrospective cohort study conducted in the Hong Kong Poison Information Centre, encompassing data from all Accident and Emergency Departments in Hong Kong over the period of 1 January 2008 to 31 January 2019. This study was conducted by recruiting all patients who had ingested common household cleansing products and required intubation in the same hospital admission. The outcome was death. The study aimed to look at risk factors associated with mortality.

Results:

Seventy-seven patients were included in the final analysis. The median age was 53 years. The mortality rate was 21%. Univariate analysis (at p < 0.05) indicated that (1) older age, (2) ingestion to intubation time more than 12 h, (3) not admitted to intensive care unit, (4) complication of chest infection, (5) complication of fast atrial fibrillation, and (6) complication of acute kidney injury were factors associated with higher mortality rate. Among these, older age and development of acute kidney injury were statistically significant (p < 0.05) on multivariate analysis.

Conclusion:

Among patients who ingested household cleansing products and required intubation, older age and development of acute kidney injury were factors strongly associated with mortality.

Role of endoscopy in caustic injury of the esophagus

Caustic injury of the esophagus is a problematic condition challenging endoscopists worldwide. Although the caustic agents and motives are different among countries and age groups, endoscopy still plays an invaluable role in diagnosis and treatment. Endoscopy can determine the severity of caustic ingestion which is of great importance in choosing appropriate treatment. However, some aspects of endoscopy in diagnosis of caustic injury remain controversial. Whether or not all patients need endoscopy, when to perform endoscopy and how to assess the severity are just some examples of these controversies. Due to lack of randomized controlled trials, many findings and suggestions are inconclusive. Computerized tomography scan of the chest and abdomen gains popularity in assessing the severity of caustic injury and avoiding unnecessary surgery. If esophageal stricture eventually develops, endoscopic dilatation is a mainstay. Maneuvers such as steroid injection and esophageal stent may be used in a refractory stricture. Nevertheless, some patients have to undergo surgery in spite of vigorous attempts with esophageal dilatation. To date, caustic injury remains a difficult situation. This article reviews all aspects of caustic injury of the esophagus focusing on endoscopic role. Pre-endoscopic management, endoscopy and its technique in acute and late phase of caustic injury including the endoscopic management of refractory stricture, and the treatment outcomes following each endoscopic intervention are thoroughly discussed. Finally, the role of endoscopy in the long term follow-up of patients with esophageal caustic injury is addressed.

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.