A standardised protocol for the acute management of corrosive ingestion in children

Pediatric Esophageal Foreign Bodies and Caustic Ingestions

Foreign body ingestions commonly occur in children aged under 6 years. While serious complications of ingestions are rare, sharp objects, caustics, multiple magnets, and button batteries can be associated with poorer outcomes including gastrointestinal (GI) obstruction, perforation, necrosis, and fistula formation. Initial workup should include history, physical examination, and plain film radiographs that will identify radiopaque objects. Removal of the foreign body is typically warranted if the object is high risk, it is located higher up in the GI tract, the patient is symptomatic, or the object is retained for a prolonged amount of time.

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.

Caustic ingestion in children treated at a tertiary centre in South Africa: can upper endoscopy be omitted in asymptomatic patients?

PURPOSE

Considering that clinical presentation and gastrointestinal tract (GIT) injuries post-caustic ingestion vary in children, this study aims to establish whether a correlation exists between clinical presentation and endoscopic findings.

METHODS

This retrospective study comprised patients referred to a paediatric surgical unit between 2016 and 2018 within 72 h post-caustic ingestion. Data collected included caustic agents ingested, clinical presentation, endoscopic findings and management. Oesophageal injuries were graded according to the Zargar's endoscopic classification and gastric injuries classified as mild to severe.

RESULTS

Fifty patients with a mean age of 2.4 years were managed during the study period. Potassium permanganate (KMNO4) was the most frequently ingested substance in 27 (54%) patients. All 30 (60%) asymptomatic patients had no positive endoscopic findings regardless of clinical signs. Among the symptomatic patients (n = 20), 15 (75%) had oesophageal injuries (p = 0.01). Stridor was associated with a higher grade of oesophageal injury (p = 0.007).

CONCLUSIONS

Clinical signs and symptoms post-caustic ingestion correlated with endoscopic findings in our study. Endoscopy can be safely omitted in asymptomatic patients, including those with isolated staining secondary to KMNO4 ingestion. Symptomatic patients should have an endoscopy performed within 48-72 h of the insult to diagnose injuries.

Foreign Body and Caustic Substance Ingestion in Childhood

Foreign body and caustic substance ingestion in childhood are common and require accurate and timely diagnosis to provide appropriate management consistent with the ingested substance/foreign body and clinical presentation as well as the associated risk status to prevent significant complications and morbidity. The aim of this paper was to present foreign body and caustic ingestion in childhood in terms of epidemiology, pathophysiology, diagnostic work-up and appropriate management and potential complications in accordance with clinical presentation and the type of ingested substance/foreign body.

Acquired noncaustic esophageal strictures in children

BACKGROUND

Esophageal stricture (ES) is an uncommon clinic entity in pediatrics that may be congenital or acquired in childhood. Acquired noncaustic ES is very rare, and clinical features of affected patients are unknown.

PURPOSE

We aimed to evaluate the clinical findings, and outcomes of patients with acquired noncaustic ES to aid physicians in the early referral of patients to gastroenterologists.

METHODS

The medical data of patients with acquired noncaustic ES who were followed in our gastroenterology clinic between January 2009 and December 2019 were reviewed.

RESULTS

Acquired noncaustic ES was found in 12 of the 4,950 patients (0.24%) who underwent endoscopy during the study period. The main symptoms were dysphagia (58.3%), vomiting (33.3%), and chronic anemia (8.3%). Chronic malnutrition and underweight were found in 66.6% of the patients. The most common etiological factors were radiotherapy, peptic reflux, and achalasia (16.6%, each), while chemotherapy, squamous-cell carcinoma (SC) of the esophagus, eosinophilic esophagitis (EoE), esophageal web, epidermolysis bullosa, and esophageal diverticulum (8.2%, each) were the other etiological factors. Patients with EoE underwent endoscopic bougie dilation in addition to steroid use and elimination diet. Patients with epidermolysis bullosa and esophageal web underwent bougie dilation. Patients with peptic reflux-related ES were initially put on antireflux therapy, but during follow-up, one patient required esophageal replacement with colonic interposition. Patients with radiotherapy-related ES recovered with medical therapy. The patient with initially underwent surgical gastrostomy and tumoral mass excision. The patient then received chemotherapy and radiotherapy and underwent jejunal interposition. Patients with achalasia underwent surgical esophagomyotomy.

CONCLUSION

The presence of solid dysphagia, malnutrition, and an associated disease may alert physicians to the presence of ES.

Foreign body and caustic ingestions in children: A clinical practice guideline

Foreign body and caustic ingestions in children are usually the most common clinical challenges for emergency physicians, general pediatricians and pediatric gastroenterologists. Management of these conditions often requires different levels of expertise and competence. Endoscopy is often necessary but there is a high risk of misusing this tool with incorrect timing and indications. The imprecise clinical history frequently leaves clinicians uncertain about timing and nature of the ingestion. Few clinical guidelines regarding management of these ingestions in children have been published, none of which from the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP). An expert panel of Italian endoscopists was convened by the SIGENP Endoscopy Working Group to produce the present article that outlines practical clinical approaches to the pediatric patient with a variety of foreign body and caustic ingestions. The Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) has also endorsed the project since many adult endoscopists usually manage children with these conditions. Differently from the other published guidelines, the proposed one focuses on the role of the endoscopists (regardless of whether they are adult or pediatric gastroenterologists) in the diagnostic process of children with foreign body and caustic ingestions.

Protective Effects of Contractubex® on Stricture Formation after Experimental Corrosive Esophageal Burns in Rats

AIM/BACKGROUND

Although many agents have been tested as treatment options for caustic esophageal burn (CEB), none have successfully suppressed the formation of strictures. Thus,the purpose of this study was to determine the efficacy of Contractubex® gel (10% onion extract, 50 U/gr heparin, and 1% allantoin) in stricture preventing after CEB.

METHODS

In this study, 24 Wistar-albino rats were divided into 4 groups. CEB was initiated with an instillation of 1 mL of 10% NaOH solution into the an isolated esophageal segment for 3 min. Group C (control) was uninjured and untreated. In Group CEB, was initiated but no treatment was given. In Groups CTX¹ and CTX², the animals received 100 and 200 mg/kg/d, respectively, of Contractubex® for 4 weeks via gavage after CEB was initiated. The stenosis indices (SI), histopathologic damage scores, tissue hydroxyproline (HP) levels, and weights of the rats were taken before the experiment and 4 weeks after the experiment.

RESULTS

The Mean SI levels, HP levels, and histopathologic damage scores were statistically lower in Groups CTX¹ and CTX² when compared with Group CEB (p <0.05). The treatment groups increased in weight when compared to Group CEB. The results were similar between Group CTX¹ and Group CTX² (p >0,05); the efficacy of the treatment was not dose-dependent.

CONCLUSION

For the first time, Contractubex® was used for its antifibrotic, antioxidant, anti-inflammatory, and wound healing effects to treat caustic esophageal burn in rats. It was effective in reducing stricture formation by decreasing the HP levels and histopathologic damage as well as preventing stenosis and weight gain in the treatment groups.

Caustic Ingestion in Children: 1 Year Experience in 3 Italian Referral Centers

OBJECTIVES

Despite the efforts to reduce the exposure to corrosive household products, caustic ingestion in children is currently a significant medical problem. The aims of the present study were to evaluate the clinical consequences of caustic ingestion and to identify prognostic factors that could concur in driving both diagnostic and therapeutic management.

METHODS

All consecutive children referred for ingestion of a caustic substance from June 2017 to June 2018 were enrolled. Medical records, laboratory and endoscopic findings were reviewed and analyzed.

RESULTS

We enrolled 44 children with caustic ingestion. Alkaline agents were ingested by 26 of 44 (59.1%) patients, whereas acid agents were ingested by 18 of 44 patients (40.9%). Alkaline rather than acid agents were associated with a worse endoscopic score (r: 0.45) and a higher probability of early esophageal stricture occurrence (r: 0.38). The specific risk of the presence of severe esophageal lesions rose progressively with increasing number of symptoms whereas no esophageal injury was found in asymptomatic patients.

CONCLUSIONS

Our data suggest that endoscopic evaluation is mandatory in symptomatic patients to direct therapeutic management, but it could be avoided in asymptomatic patients after accidental ingestion, particularly if the ingestion is only suspected and patients have no oropharyngeal burns.

Endoscopic balloon dilatation is an effective management strategy for caustic-induced gastric outlet obstruction: a 15-year single center experience

Background and study aims  There is sparse data on the endoscopic management of caustic-induced gastric outlet obstruction (GOO). The present retrospective study aimed to define the response to endoscopic balloon dilatation (EBD) in such patients and their long-term outcome. Patients and methods  The data from symptomatic patients of caustic-induced GOO who underwent EBD at our tertiary care center between January 1999 and June 2014 were retrieved. EBD was performed using wire-guided balloons in an incremental manner. Procedural success and clinical success of EBD were evaluated, including complications and long-term outcome. Results  A total of 138 patients were evaluated of whom 111 underwent EBD (mean age: 30.79 ± 11.95 years; 65 male patients; 78 patients with isolated gastric stricture; 33 patients with both esophagus plus gastric stricture). The initial balloon diameter at the start of dilatation, and the last balloon diameter were 9.6 ± 2.06 mm (6 - 15 mm) and 14.5 ± 1.6 mm (6 - 15 mm), respectively. Procedural and clinical success was achieved in 95 (85.6 %) and 108 (97.3 %) patients, respectively, requiring a mean (SD) of 5.3 (2.6) and 7.21 (3.86) sessions, respectively. Patients with isolated gastric obstruction had a better response than those with combined esophagus and gastric stricture. Minor complications such as self-limited pain or bleeding were seen in 18 (16.2 %) and 16 (14.4 %), respectively. Perforation occurred in two patients. Over a follow-up period of 98 months, there were no recurrences. Conclusion  Caustic-induced GOO can be successfully managed using EBD with 97.3 % clinical success.

Long-Term Outcomes of Caustic Esophageal Stricture with Endoscopic Balloon Dilatation in Chinese Children

Caustic esophageal stricture (CES) in children still occurs frequently in developing countries. We aimed to evaluate the long-term outcomes of endoscopic balloon dilatation (EBD) in treating CES in children and the influencing factors associated with outcome. We retrospectively reviewed the data of all patients who had a diagnosis of CES and underwent EBD from August 1, 2005, to December 31, 2014. The primary outcome was EBD success, which was defined as the maintenance of dysphagia-free status for at least 12 months after the last EBD. The secondary outcome was to analyze influencing factors associated with EBD success. Forty-three patients were included for analysis (29 males; mean age at first dilatation 44 months with range 121 months). 26 (60.5%) patients had long segment (>2 cm) stricture. A total of 168 EBD procedures were performed. Twenty-six (60.5%) patients were considered EBD success. Seventeen (39.5%) patients failed EBD and required stent placement and/or surgery. Patients in the EBD success group had significantly shorter stricture segments when compared to the EBD failure group (t = 2.398, P = 0.018, OR = 3.206, 95% OR: 1.228-8.371). Seven (4.4%) esophageal perforations occurred in 6 patients after EBD. Stents were placed in 5 patients, and gastric tube esophagoplasty was performed in 14 patients. In conclusion, 26 (60.5%) of 43 children with CES had EBD success. Length of stricture was the main influencing factor associated with EBD treatment outcome.

Dysphagia and Speech-Language Pathology Involvement Following Chemical Ingestion Injury: A Review of 44 Cases Admitted to a Quaternary Australian Hospital (2008-2012)

PURPOSE

This study aimed to explore the clinical characteristics of an adult chemical ingestion population and examine the course of return to oral intake post injury and speech-language pathologist (SLP) involvement during the initial acute-care admission.

METHOD

A retrospective chart review of adults admitted to a quaternary hospital for the treatment of an acute chemical ingestion injury between 2008 and 2012 was conducted.

RESULTS

Forty-four adults (23 men, 21 women) were identified as receiving treatment for ingestion injury, of whom 18 (40.91%) required altered oral intake. Of those requiring altered oral intake, 50% were referred to SLPs. Individuals requiring altered oral intake were significantly (p < .05) older, more likely to be men, and present with more severe injuries requiring longer ICU and hospital admissions following intentional chemical ingestions than those who were able to commence a normal oral diet without any alteration or nonoral supplementation. By discharge, 15.91% (n = 7) of the total cohort had not resumed normal oral intake.

CONCLUSIONS

Return to oral intake post chemical ingestion injury can be protracted and complex. Referrals to SLPs were limited. These data may aid prognostic insight as well as provide (a) collateral information to assist discharge planning and follow-up and (b) background for evaluating the potential for SLP involvement.

Effect of polaprezinc on experimental corrosive esophageal burns in rats

Unconsciously caustic ingestion is one of the most common causes of serious esophageal strictures in children. The aim of this study is to determine the efficiency of polaprezinc in preventing stricture formation after corrosive esophageal burns (CEB); this was the first time it has been used to treat experimental CEB in rats. Twenty-four rats were divided into four groups, three of which received CEB by the instillation of 1 mL of 10% NaOH solution into their isolated esophageal segments for three minutes. Group C (control) was uninjured and untreated. Group B (esophageal burn) received CEB but were left untreated. Groups PT1 and PT2 had CEB and received 100 mg/kg/day and 200 mg/kg/day, respectively, of intraperitoneal polaprezinc treatment (PT) for the first two weeks, then oral PT for another two weeks. We assessed the treatment's efficiency of the treatment after the fourth week by evaluating the stenosis index (SI) and the histopathological damage score, determining tissue hydroxyproline content (HP), and measuring the weight of the rats before and after the experiment. Mean SI was statistically lower in the groups PT1 and PT2 when compared with Group B (p = 0.006, 0.004, respectively). HP levels were highest in Group B, but it was insignificant (P> 0.05). In terms of histopathological damage score, treatment groups demonstrated less collagen deposition, mucosal, and submucosal damage than both Group B (p = 0.01) and Group C (p = 0.02). Group PT1 and Group PT2 (P> 0.05) showed similar results, indicating the treatment's effectiveness was independent of dosage. Outside of Group C, weight gain was detected only in Group PT2, though it was statistically insignificant. In Group PT1, weight loss was lower than in Group B. Polaprezinc, with its antifibrotic, antioxidant, anti-inflammatory, wound-healing and antiapoptotic effects, was efficient in reducing stricture formation by decreasing HP levels and histopathologic damage, preventing stenosis, and weight gain in higher dosages in the treatment group.

Role of early endoscopic evaluation in decreasing morbidity, mortality, and cost after caustic ingestion: a retrospective nationwide database analysis

Caustic substance ingestion (CSI) is a serious medical problem with potentially devastating short- and long-term consequences. Early upper gastrointestinal endoscopy (EaEn) is recommended to evaluate the extent of injury and guide management but there has been controversy about the timing. There is no nationwide study evaluating adherence to EaEn and outcomes following CSI.Nationwide Inpatient Sample database 2003-2011 was used to identify all-age, nonreferral, urgent/emergent admissions with E-International Classification of Diseases Ninth Revision codes for CSI. We evaluated the association of undergoing late endoscopy (LaEn, >48 hours since admission) with poor clinical (death or systemic complications) and economic (cost for admission and length of stay above the 75th percentile) outcomes after controlling for other demographic and clinical factors using a multivariate analysis.We identified 21,682 patients with a median age of 37 years, 51% males, 43% Caucasians, with suicidal ingestion reported in 40%. Endoscopy was performed in 6011 patients (37%). The majority had EaEn (43% within 24, and 40% within 24-48 hours), whereas 17% had LaEn.Compared to EaEn group, the LaEn group was associated with a three-fold increase (OR = 2.7, P < 0.001) in the risk for poor clinical outcome: a fourfold increase (OR = 4.6, P < 0.001) in high cost admissions, and a fivefold increase (OR = 4.9, P < 0.001) in prolonged hospitalization. There was no significant difference in clinical outcomes based on endoscopy within 24, and 24-48 hours of admission.In this retrospective nationwide database analysis, undergoing LaEn was associated with both negative clinical and economic outcomes. More studies are needed to further examine the reasons for delaying endoscopy and subsequent management pathways based on the endoscopic findings. Early endoscopic evaluation could potentially improve the clinical outcomes and reduce costs of these admissions.

Caustic ingestion in children-A review

Various domestic or industrial chemicals may cause significant upper aerodigestive tract burns. Preventive measures should be up-scaled, especially in the developing world, to reduce the epidemic of accidental victims, largely unsupervised preschool children. External signs do not predict degree of injury. Non-invasive diagnostic screening includes radio-nuclear imaging, but early oesophago-gastroduodenoscopy remains the standard to predict stricture formation from circumferential submucosal scarring. Serial dilation is the mainstay of oesophageal stricture therapy, with oesophageal replacement reserved for severe refractory strictures. Intra-lesional steroid or mitomycin C may decrease the dilatations required for severe strictures, although long-term effects are unknown. Risk of secondary oesophageal carcinoma mandates long-term surveillance.

Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines

This guideline refers to infants, children, and adolescents ages 0 to 18 years. The areas covered include indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; corrosive ingestion and stricture/stenosis endoscopic management; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography; and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease has been dealt with in other guidelines and are therefore not mentioned in this guideline. Training and ongoing skill maintenance are to be dealt with in an imminent sister publication to this.

Caustic Ingestion in Children: a Systematic Review and Meta-Analysis

Introduction: Caustic ingestion that occurs accidently is one of the most common problems in children. Methods: This systematic review has been performed by searching the databases including Science Direct, ProQuest, Google Scholar, and PubMed. A strategic search was performed with keywords including caustic, corrosive, ingestion, and children, and was limited to articles in English and Persian. Data were analyzed using Comprehensive Meta-Analysis2 and PASW Statistics 18. Results: We selected 64 articles regarding caustic ingestion with a total sample of 11,345 cases. The data analysis indicated a higher consumption in young boys (age range 2.78 (2.02) years (OR=0.53 with a 95% confidence interval of 0.49-0.57 (P=0.08)). The most common caustic substances were household cleaning agents, particularly bleaches and cleaners. Esophageal cancer and death were reported as well as digestive and respiratory complications. Invasive and expensive techniques are frequently used for diagnosis, treatment and follow up. Conclusion: The results demonstrated that although caustic ingestion is a serious problem among children, it is a preventable and manageable issue. Therefore, appropriate efforts by families, government, factories, health team and media should be made to handle adequately this matter.

Caustic Esophageal Stenosis: A Case Report of Endoscopic Dilation With a Dynamic Stent

INTRODUCTION

The management of esophageal strictures has evolved from surgical treatment to the endoscopic dilation and, more recently, esophageal stenting.

CLINICAL CASE

We describe a case of a two-year-old boy with a double stenosis of the esophagus resulting from accidental ingestion of strong alkaline liquid. After several unsuccessful endoscopic dilations for three years and even topical mitomicin, it was decided to place a dynamic stent developed by the Digestive Surgery and Endoscopic Unit of the Bambino Gesù Hospital, Rome. The stent is a custom silicon device built coaxially on a nasogastric tube that is inserted after stricture dilations, by endoscopic guidance, and then fixed outside the nose. The device was removed after seven weeks with good clinical outcome (no dysphagia more than a year of follow-up).

CONCLUSION

This case confirms that the dynamic stent is a simple device that may avoid aggressive surgical substitution in cases of refractory strictures.

Evaluation of 968 children with corrosive substance ingestion

Background and Aims:

The aim of the study was to evaluate the etiology, treatment, and prognosis in children who had presented at our clinic with corrosive substance ingestion and comparison of our results with the literature.

Materials and Methods:

The patients were put on nil by mouth and broad-spectrum antibiotics were administered. Oral fluids were started for patients whose intraoral lesions resolved and who could swallow their saliva. Steroids were not given, a nasogastric catheter was not placed, and early endoscopy was not used.

Results:

A total of 968 children presented at our clinic for corrosive substance ingestion during the 22-year period. The stricture development rate was 13.5%. Alkali substance ingestion caused a stricture development rate of 23%. A total of 54 patients required 1–52 sessions (mean 15 ±12) of dilatation.

Conclusion:

We do not perform early endoscopy, administer steroids, or place a nasogastric catheter at our clinic for patients who had ingested a corrosive substance. This approach has provided results similar to other series. We feel that determining the burn with early esophagoscopy when factors that prevent or decrease the development of corrosive strictures will be very important.

Intercontinental comparison of caustic ingestion in children

Purpose

To investigate the caustic ingestion in children among different continents according to demographic characteristics (core purpose), main symptoms, common caustic agents, signs and symptoms, management, treatment and complications.

Methods

This systematic review was performed by searching the databases Science Direct, ProQuest, Google Scholar, and PubMed, electronically and manually. We included studies that were published from 1980 to 2013, at University of Medical Sciences of Tabriz, Iran. A strategic search was performed with keywords including caustic, corrosive, ingestion and children, and was limited to articles in English and Persian. Statistical analysis was performed by SPSS ver. 18.

Results

Of 63 selected articles of caustic ingestion with 9,888 samples, the proportion of Africa was 3 articles (4.8%) and 95 samples (1%), America 9 articles (14.3%) and 305 sample (3%), Asia 29 articles (46%) and 2,780 samples (28.1%), Europe 17 articles (27%) and 3,002 samples (30.4%), and Oceania 5 articles (7.9%) and 3,706 samples (37.5%). The average age was in the Africa 3.07±2.02 years, America 3.17±1.83 years, Asia 3.34±1.58 years, Europe 3.58±2.09 years and Oceania 3.52±2.02 years. Sex distribution was in Africa 76 males (0.91%) and 19 females (0.23%), America 49 males (0.58%) and 41 females (0.49%), Asia 1,575 males (18.76%) and 1,087 females (12.95%), Europe 1,018 males (12.13%) and 823 females (9.8%), and Oceania 1,918 males (22.85%) and 1,788 females (21.3%). Statistical analysis of the data indicated higher consumption in Europe and Oceania in the boys with higher average age of years.

Conclusion

The comparison of caustic ingestion indicated that the cause substances of caustic ingestion in children are different among continents, therefore prevention strategy and different treatment guidelines among continents will be needed.

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.

Topical mitomycin C versus intralesional triamcinolone in the management of esophageal stricture due to caustic ingestion

BACKGROUND

Esophageal stricture due to caustic ingestion is one of the most difficult problems to manage. Esophageal dilations are the usual treatment and they require a great number of sessions in the majority of cases. This implies time, risks for the patient, anguish for the relatives, and very often, frustration for the physician.

OBJECTIVES

To evaluate the efficacy of the application of topical mitomycin C and intralesional triamcinolone in the prevention of post-dilation esophageal stricture recurrence.

MATERIAL AND METHODS

A prospective, comparative, nonrandomized, and longitudinal study was conducted that compared a cohort of 16 patients treated with mitomycin C (2009-2012) with a retrospective cohort of 34 patients treated with triamcinolone (2002-2009).

RESULTS

The patients treated with intralesional triamcinolone had a median of 11 dilations (minimum 4 and maximum 24), whereas the median in the patients treated with topical mitomycin C was 4.5 (minimum 3 and maximum 8). The groups were compared using the Mann-Whitney U test, finding a statistically significant difference of a two-tailed P<.001. In the multiple linear regression model, the dependent variable was the number of dilations and the independent variables were the type of lesion and treatment. The result was an R(2) .676 with a significance level of P<.001, in which the regression coefficient for treatment was B -.682 (95% CI -8.286 to -5.025) and the lesion grade was B .435 (95% CI 2.043- 4.573). The ANOVA result was an F 49.08 and a P<.001 and showed that the independent variables of type of lesion and treatment had a linear relation with the number of dilations, reinforcing the fact that our results were not due to chance.

CONCLUSIONS

Topical mitomycin C considerably reduced the number of esophageal dilations compared with the use of intralesional triamcinolone to alleviate dysphagia, and therefore we suggest it as a treatment option in strictures due to caustic ingestion.

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.

Protective effect of glucagon-like peptide-2 in experimental corrosive esophagitis

Corrosive esophageal injuries are one of the life-threatening morbidities leading to esophageal stricture and perforation affecting all age groups but especially children due to accidental ingestions in this age group. Glucagon-like peptide-2 (GLP-2) is an intestinal polypeptide with potent anti-inflammatory effects. Its effects are studied in various studies but not in corrosive esophagitis. We aimed to investigate whether it has protective effect in experimental corrosive esophagitis, in the absence of existing studies into possible links. Twenty-four Wistar-albino rats, weighing 220-240 g, were randomized into three groups (n = 8 in each). First group is control, second one is sham operated, and the third one is treatment group. Median laparotomy was made in all groups. In sham and treatment groups, esophagus was loosened and suspended from 1 cm proximal to the esophageal junction. The esophagus segment between suspenders was exposed to 0.1 mL 5% NaOH for 10 seconds. In the treatment group, rats were given GLP-2 for 7 days intraperitoneally. After 7 days, all rats were sacrified and esophagi were totally removed. In the histopathologic examination, esophageal tissues were compared in terms of inflammation, muscularis mucosa injury, and collagen deposition of tunica muscularis. Histopathologic changes in the esophageal tissues of groups were compared. Histopathologic injury in the GLP-2 treated group was significantly less than sham group (P < 0.05). There was statistically significant healing in the GLP-2 treatment group. It is concluded that GLP-2 has a preventive effect on inflammation and collagen accumulation in an experimental corrosive esophagitis. In the light of the information that initial lesions in the early phase are predictors of complications, GLP-2 is a promising agent that has an anti-inflammatory effect in caustic injuries.

Corrosive substance ingestion in children

OBJECTIVES

To evaluate children who ingested corrosive substances, in terms of demographic features, nature of ingested substances, clinical findings, management and complications.

METHODS

A total of 1709 cases aged between 0 and 16 y who ingested corrosive substance were analyzed retrospectively by evaluating the medical records of the patients.

RESULTS

The mean age of the cases was 35.23 ± 30.65 mo and male:female ratio was 1.45. Forty one percent of corrosive substances causing intoxication contained NaOH. Thirty percent of the families consisted of 5 or more members. Fourteen percent of the mothers were illiterate. Stricture formation was observed in 29 (1.69 %) of the cases during follow-up. In 79.31 % of those cases alkaline substance ingestion was responsible for stricture development. It was found that stricture formation occurred more frequently among cases who were older than 5 y of age and this finding was statistically significant (p = 0.001).

CONCLUSIONS

The cases older than 5 y of age with the diagnosis of grade 2b esophagitis must be followed up closely for the stricture formation. In order to protect children from corrosive ingestion, importance must be given to preventive measures such as education of families, keeping and storing these agents out of the reach of children and providing safety caps for these products.

Modifications in endoscopic practice for pediatric patients

We recommend that endoscopy in children be performed by pediatric-trained endoscopists whenever possible. We recommend that adult-trained endoscopists coordinate their services with pediatricians and pediatric specialists when they are needed to perform endoscopic procedures in children. We recommend that endoscopy be performed within 24 hours in symptomatic pediatric patients with known or suspected ingestion of caustic substances. We recommend emergent foreign-body removal of esophageal button batteries, as well as 2 or more rare-earth neodymium magnets. We recommend that procedural and resuscitative equipment appropriate for pediatric use should be readily available during endoscopic procedures. We recommend that personnel trained specifically in pediatric life support and airway management be readily available during sedated procedures in children. We recommend the use of endoscopes smaller than 6 mm in diameter in infants and children weighing less than 10 kg. We recommend the use of standard adult duodenoscopes for performing ERCP in children who weigh at least 10 kg. We recommend the placement of 12F or 16F percutaneous endoscopic gastrostomy tubes in children who weigh less than 50 kg.

Emergent Treatment of Button Batteries in the Esophagus

Objectives:

The evolving epidemiology of pediatric button battery ingestion is alarming. Currently, assessment of the degree of damage relies heavily on the initial esophagoscopy in a manner similar to the management of caustic ingestion. We have noted that use of this classic approach may delay the return to normal oral intake. Using several cases treated at our institution, we illustrate the value of “close second-look esophagoscopy” (CSLE) in expediting a return to normal oral intake after button battery ingestion.

Methods:

We present a retrospective case series.

Results:

Five patients (11 to 18 months of age) with button batteries trapped in the cervical esophagus were recently managed at our institution. The batteries were lodged in the esophagus for durations ranging from 6 hours to 4 months. Three cases of initial grade III circumferential necrotic injury were downgraded to grade IIa after a CSLE performed 2 to 4 days after removal, and their management was appropriately changed.

Conclusions:

The injury and healing of cases of button batteries in the proximal esophagus appear to be variable; caustic injury, electrical mucosal damage, and direct pressure are thought to be several contributory factors. Performing a CSLE within 2 to 4 days after battery removal may provide more useful prognostic information. In certain cases, downgrading of the injury may facilitate an earlier return to an oral diet, use of fewer diagnostic tests, and a shorter hospital stay. The utility and timing of imaging, management of diet and medications, and acceptable follow-up plans are discussed within the context of guiding future research.

Predictability of outcome of caustic ingestion by esophagogastroduodenoscopy in children

AIM: To assess the necessity of esophagogastroduodenoscopy (EGD) to predict the outcome of caustic ingestion in children.

METHODS: The study included 206 children who underwent EGD because of ingestion of caustic substances between January 2005 and August 2010. Retrospective analysis of data of the patients was performed.

RESULTS: The male/female ratio was 1.6 and mean age was 38.1 ± 28.8 mo. The caustic substances were acidic in 72 (34.9%) cases, alkaline in 56 (27.2%), liquid household bleach in 62 (30.1%), and unknown in 16 (7.8%). Fifty-seven (27.7%) patients were symptom-free. Significant clinical findings were observed in 149 (72.3%) patients. Upper gastrointestinal endoscopy findings of esophageal injury were grade 0 in 86 (41.7%) patients, grade 1 in 49 (23.8%), grade 2a in 42 (20.4%), grade 2b in 28 (13.6%), and grade 3a in 1 (0.5%) patient. 35 patients with grade 2a, 2b, and 3a injuries underwent esophageal dilation at second week of ingestion. Esophageal stricture, which necessitated a regular dilation program developed in 13 of the aforementioned 35 patients. There is no statistically significant difference in the rate of development of esophageal stricture between the patients who ingested acidic (15.3%) and alkaline (8.9%) substances (P = 0.32). Severe gastric injury was detected in 38 (18.5%) patients. The rate of development of gastric injury was significantly higher in the acidic group (14%) than in the alkaline group (2.9%) (P = 0.001). Out of 149 patients with clinical findings, 49 (32.9%) patients had no esophageal injury and 117 (78.5%) patients had no gastric lesion. Esophageal and severe gastric injuries were detected in 20 (35.1%) and 8 (14%) of patients with no clinical findings respectively. Pyloric stenosis developed in 6 patients. Pyloric obstruction improved with balloon dilation in 2 patients. Mean hospitalization time were 1.2 ± 0.5 d for grade 0 and 2.3 ± 5 d for grade 1 and 6.3 ± 6.2 d for grade 2a and 15.8 ± 18.6 d for grade 2b. It was significantly longer for patients with grade 2a and 2b injuries (P = 0.000).

CONCLUSION: Endoscopy is an effective technique for determining the presence of esophageal and gastric damage and to avoid unnecessary treatment in patients with no or mild injury.

Caustic ingestion in children

Caustic ingestion continues to be a significant problem worldwide especially in developing countries. In 2008 over 200,000 exposures to caustic substances were reported to the National Poison Data System. The presence or absence of symptoms or oral lesions does not predict the existence or severity of lesions. The best predictor of morbidity and mortality is the extent of injury as assessed during initial evaluation. Upper endoscopy remains the mainstay diagnostic modality for the evaluation of patients with caustic ingestion. There is a pressing need for noninvasive diagnostic modalities and effective therapeutic options to evaluate and treat the complications associated with caustic ingestion.

[Caustic ingestion: current situation and review of updated recommendations]

BACKGROUND

Household product ingestion is the second cause of visiting an Emergency Department for poisoning in children. Among these products, caustics are of great interest because of their potential toxicity and risk of sequelae.

OBJECTIVES

To describe the epidemiological and clinical features of patients admitted to our hospital due to possible caustic ingestion. To analyse the risk factors associated with oesophageal or gastric injury. To review the latest treatment recommendations.

MATERIALS AND METHODS

Retrospective review of all patients admitted with suspicion of caustic ingestion between January 2005 and April 2010. Epidemiological, clinical and therapeutic aspects were recorded.

RESULTS

A total of 78 patients were admitted, 45 (57.7%) were male, with a median age of 2.2 years (range: 1-17.3 years). In 13 cases the product was kept in a container different than the original. In 36 children, the family had induced vomiting or had given a liquid to dilute the product. Fifty two patients were symptomatic, and 46 of them had some sign on physical examination. Thirty nine oesophagoscopies were performed, and 7 oesophageal or gastric lesions were observed. When patients with normal and abnormal endoscopic findings were compared, the factors associated with an increased risk of mucosal injury were vomiting (P=0.01), and two or more symptoms at admission (P=0.03). No complication was described in patients without endoscopy.

CONCLUSIONS

Family education about preventive and initial measures after caustic ingestion must be improved in an attempt to prevent wrong actions which can be harmful. Some patients might benefit from clinical observation without aggressive therapeutic measures.

Custom dynamic stent for esophageal strictures in children

BACKGROUND

Esophageal stenting represents a new strategy to avoid multiple dilations owing to stenosis relapse. Our custom stent improves esophageal motility unlike the widespread self-expandable plastic esophageal stents. The aim of the study was to confirm the efficacy of treatment with silicone custom stents in esophageal stenosis (ES) in pediatric patients.

METHODS

A silicone stent of 7-, 9-, or 12.7-mm external diameter is built coaxially on a nasogastric tube that guarantees the correct position. The 2 ends are tailored to allow food passage between stent and esophageal wall. All patients received dexamethasone (2 mg/kg per day) for 3 days and ranitidine/proton-pump inhibitors. Study approval was obtained from our ethical board.

RESULTS

From 1988 to 2010, 79 patients with ES, mean age 35.4 months (3-125 months), underwent esophageal hydrostatic/Savary dilations and custom-stent placement, left in place for at least 40 days. Stenting was effective in 70 (88.6%) of 79 patients. Fifty percent of the patients with effective treatment received only one dilation for stent placement. Fourteen patients received more stents successfully. There was one stent-related major complication.

CONCLUSION

Our custom stent improves treatment in ES. In caustic injuries, ES stenting represents the first option. In postsurgical ES, we stent after at least 5 dilations.

Conservative management of caustic substance ingestion in a pediatric department setting, short-term and long-term outcome

Patients with caustic substance ingestion are usually referred to surgery departments where endoscopic evaluation is the first step towards appropriate treatment. The aim of this study was to evaluate the safety and efficacy of conservative management of caustic substance ingestion in a pediatric department setting following a standard protocol including endoscopy in selected cases and conservative treatment based on clinical and endoscopy criteria. In this single center observational study, all children admitted for caustic substance ingestion to a pediatric department over an 8-year-period were managed according to a standard protocol that included endoscopy within 24 hours, if the endoscopy criteria were met, and conservative treatment as judged appropriate according to endoscopic classification. Patients were followed up for 8-10 years. Of the 24 patients (age 4/12 to 6 years) admitted, 14 met the endoscopy criteria. Grade II and III esophageal burns were found in 10/14 patients, and they were treated with H2-blockers, antibiotics, corticosteroids, and nutritional support (parenteral in 8/10). Patients with grade II or III esophageal burns necessitated prolonged hospitalization (x ± standard deviation, 23 ± 3 days; range, 21-30 days). Complications included esophageal strictures (n = 1), treated successfully with dilatations, and bleeding (n = 1) treated conservatively. During the 8- to 10-year follow-up all patients were recorded being well. Based on the study findings it is concluded that conservative management of children with caustic substance ingestion using a standard protocol, including endoscopy as indicated, is feasible within the pediatric department, and conservative treatment on demand is safe and effective in preventing short-term and long-term complications.

Protective effects of ibuprofen against caustic esophageal burn injury in rats

PURPOSE

The aim of this study was to investigate the efficacy of ibuprofen on the healing of esophagus and the prevention of stricture development after esophageal caustic injuries in rats.

MATERIALS AND METHODS

Rats were divided into three groups as: group 1(sham), group 2(esophageal burn injury), group 3(injury + ibuprofen). In groups 2 and 3, a standard esophageal burn injury was created by applying 10% NaOH solution to distal esophagus of about 3 cm. To rats in the sham group, isotonic solution was given instead of NaOH. Ibuprofen (90 mg/kg/day) was given via oral route to group 3 rats. Normal saline as placebo was given via the same route to rats in groups 1 and 2. 28 days later, all the live rats were killed. The distal esophageal segments of all rats were removed and divided into two equal parts for biochemical and histopathologic examination. In the tissue samples, biochemically hydroxyproline and histopathologically collagen content and stenosis indices were evaluated for efficacy of treatment.

RESULTS

The hydroxyproline level (microg/mg wet tissue) in the groups was 1.54 +/- 0.08, 4.82 +/- 0.60, and 3.28 +/- 0.27, respectively. The hydroxyproline level increased significantly in group 2 compared with group 1 (P < 0.01). Although the hydroxyproline level was significantly increased in group 3 compared with group 1, it decreased significantly in group 3 compared with group 2 (P < 0.05) by treatment of ibuprofen. In group 3, the collagen content score (1.50 +/- 0.26) was significantly lower than in group 2 (2.62 +/- 0.37) (P < 0.05). The stenosis index was found as 0.37 +/- 0.02 in group 1, 0.84 +/- 0.02 in group 2, and 0.67 +/- 0.03 in group 3. The stenosis index in group 2 was significantly higher than group 1 and group 3 (P < 0.01). Although the stenosis index was significantly higher than in group 1, a significant decrease in stenosis index was found in group 3 compared with group 2, by ibuprofen treatment (P < 0.01).

CONCLUSION

Based on these results, we concluded that the treatment with ibuprofen in acute phase esophageal burn injury has beneficial effects on healing of esophagus and may decrease the stricture formation. For these reasons, ibuprofen may effectively be used in the acute phase treatment of caustic esophagus injury and after esophageal dilatation procedures.

Minimally invasive management of children with caustic ingestion: less pain for patients

PURPOSE

Management of caustic ingestion in children is still controversial. In this study, we evaluate a minimally invasive management consisting of flexible endoscopy, balloon dilatation and intralesional steroid injection in children, with a history of caustic ingestion.

METHODS

Between April 2002 and January 2009, 350 (206 males and 144 females) children with a history of caustic ingestion were admitted. Enteral feeding was discontinued for 24 h. Parenteral feeding was started in patients with inadequate oral intake. No patient underwent an early esophagoscopy or gastrostomy. A contrast study of upper gastrointestinal tract was performed in all patients with persistent dysphagia within 3 weeks after injury. In case of an esophageal stricture, a dilatation program was initiated. For this purpose, a flexible esophagoscopy was performed. A guidewire was placed through the narrowed segment into the stomach and a balloon dilatator was inserted with the assistance of the guidewire. Balloon dilatations were performed every 1-3 weeks. In intractable strictures, triamcinolone acetonide (TAC) was injected into the narrowed segment via flexible endoscopy.

RESULTS

Seventeen patients (8 males, 9 females, median 3 years old) required esophageal dilatation. All of the patients completed dilatation program with complete relief of symptoms. None of the patients required any stent application nor esophageal replacement or gastrostomy. Ten patients underwent intralesional TAC injection. No patient had an esophageal perforation or any other complication related to dilatation. In all patients, the symptoms have been alleviated completely and no further dilatation was necessary after a median of five dilatation sessions (1-19 dilatations).

CONCLUSION

Minimally invasive management of caustic ingestion consisting of flexible endoscopy, guidewire-assisted esophageal balloon dilatation and intralesional TAC injection without any gastrostomy or esophageal stent/placement is effective and leads to relief of dysphagia in almost all patients. This method of dilatation is also safe and iatrogenic esophageal perforation is very unlikely.

Long-term management of corrosive esophageal stricture with balloon dilation in children

BACKGROUND AND PURPOSE

There are only a few studies focused on efficacy and safety of balloon dilation in corrosive esophageal stricture in children. The aim of this study is to assess the long-term clinical results of balloon dilation in the treatment of corrosive esophageal stricture in children.

MATERIALS AND METHODS

We retrospectively analyzed the management of 18 children (median age 3 years) who were treated with balloon dilation because of caustic esophageal stricture between January 2001 and December 2008.

RESULTS

A total of 295 sessions of balloon dilation were performed in all patients over an 8-year period. Technical success was achieved in all patients, whereas clinical success was achieved only in eight (44.4%) patients after first dilation. Eight (44.4%) of all patients showed recovery within the first year and another six (33.3%) patients recovered within 2 years. Esophageal perforation occurred in one (5%) patient, during one dilation session (0.33%). The average number of dilation sessions was 12.7, 2.8, and 1, respectively, in the first, second, and third year. There was significant difference between the mean number of dilation sessions in the first and second year, and second and third year (p < 0.01 and p = 0.043).

CONCLUSION

Short-segment esophageal strictures, improvement of food intake capacity, and increase in intervals of dilation sessions are good patient indicators. We suggest that esophageal balloon dilatation is a safe and effective method of treatment in caustic esophageal strictures and recommend that balloon dilation program be performed for at least 2 years before deciding that dilation has failed and preferring other treatment modalities which have higher risk of 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.

Is esophagoscopy necessary for corrosive ingestion in adults?

The aim of the study was to determine whether early esophagoscopy is really necessary for the patients who have ingested a corrosive agent. Patients who were followed up with the diagnosis of corrosive ingestion in our clinic between the years 1998 and 2008 were studied retrospectively. The data were collected through the medical records of the patients and from interviews with them. The analyzed parameters included age, gender, the nature and the amount of the ingested agent, whether the event was accidental or suicidal, diagnostic tools, treatment and the results of the treatment, and long-term follow up. Over a 10-year period, a total of 124 cases of corrosive ingestion cases were determined. Of these, 64 (51.6%) were male and 60 (48.4%) were female. The mean age was 38 +/- 17.5 years. The most commonly ingested corrosive agents were sodium hypochlorite in 50 (40.3%) patients and hydrochloric acid in 33 (26.6%) patients. The mean admission time for the emergency department after ingestion of the corrosive agent was 2.5 +/- 3.7 hours. Ingestion was accidental in 82% of the patients and as a result of a suicide attempt in 18%. The amount of ingested corrosive agent in the suicidal group (190 +/- 208.3 mL) was higher than that of accidental group (66 +/- 58.3 mL) (P= 0.012). Nine patients underwent esophagoscopy, six of which were performed in other clinical centers. Only three (2.4%) patients experienced esophageal stricture, which were treated with repeated dilatations. In the long-term follow up, we could get in touch with only 63 patients and none of them had complications due to corrosive ingestion. The follow-up period ranged from 1 to 120 months (median 45 +/- 29.2 months). Based on our study, early esophagoscopy appears to be unnecessary in adult patients who ingested the corrosive agent accidentally. A larger prospective study is needed to answer the question.

Caustic ingestion in children: is endoscopy always indicated? The results of an Italian multicenter observational study

BACKGROUND

The ingestion of caustic substances can represent a serious medical problem in children.

OBJECTIVE

Whether or not an urgent endoscopy should be performed is still a matter of debate, particularly in asymptomatic patients.

DESIGN

We conducted a multicenter observational study to investigate the predictive value of signs and symptoms in detecting severe esophageal lesions.

SETTING AND PATIENTS

The records of 162 children who presented with accidental caustic substance ingestion were analyzed.

INTERVENTIONS

Signs and symptoms were divided into minor (oral and/or oropharyngeal lesions and vomiting) and major (dyspnea, dysphagia, drooling, and hematemesis). An endoscopy was performed in all patients within 12 to 24 hours of the substance being ingested.

MAIN OUTCOME MEASUREMENTS

The types of substance ingested, signs and symptoms, age, sex, and severity of esophageal injury were correlated.

RESULTS

Mild esophageal lesions were identified in 143 of 162 patients (88.3%), and severe (third degree) esophageal lesions in 19 patients (11.7%). The risk of severe esophageal lesions without signs and/or symptoms was very low (odds ratio [OR] 0.13 [95% CI, 0.02-0.62], P = .002). Indeed, the presence of 3 or more symptoms is an important predictor of severe esophageal lesions (OR 11.97 [95% CI, 3.49-42.04], P = .0001). Multivariate analysis showed that the presence of symptoms is the most significant predictor of severe esophageal lesions (OR 2.3 [95% CI, 1.57-3.38], P = .001).

CONCLUSIONS

The results demonstrated that the incidence of patients with third-degree lesions without any early symptoms and/or signs is very low, and an endoscopy could be avoided. The risk of severe damage increases proportionally with the number of signs and symptoms, and an endoscopy is always mandatory in symptomatic patients.

Caustic ingestion in adults: the role of endoscopic classification in predicting outcome

BACKGROUND

The ingestion of caustic substances induces an extensive spectrum of injuries to the aerodigestive tract which include extensive necrosis and perforation of the esophagus and stomach. The gold standard of safely assessing depth, extent of injury, and appropriate therapeutic regimen is esophagogastroduodenoscopy (EGD). The objective of this study was to report our clinical experience and to evaluate the role of a 6-point EGD classification system of injury in predicting outcomes in adult patients diagnosed with caustic agent ingestion.

METHODS

The study was a retrospective medical chart review from 273 patients admitted to the Chang Gung Memorial Hospital in Tao-Yuan, Taiwan between June 1999 and July 2006 for treatment of caustic ingestion. The patients underwent EGD within 24 hours of admission and mucosal damage was graded using Zagar's modified endoscopic classification scheme. After treatment, patients were followed in the outpatient clinic for a minimum of 6 months.

RESULTS

A total of 273 patients were included for analysis. Grade 3b injury was the most common caustic injury (n = 82, 30.03%), followed by grade 2b injuries (n = 62, 22.71%). Stricture was the most common complication (n = 66, 24.18%), followed by aspiration pneumonia (n = 31, 11.36%), and respiratory failure (n = 21, 7.69%). Compared to grade 3a mucosal injury, grade 3b mucosal injuries were at greater risk of prolonged hospital stay (odds ratio [OR]: 2.44; 95% confidence interval [CI]: 1.25-4.80), ICU admission (OR: 10.82; 95% CI: 2.05-200.39), and gastrointestinal (OR: 4.15; 95% CI: 1.55-13.29) and systemic complications (OR: 4.07; 95% CI: 1.81-14.07).

CONCLUSION

In patients with caustic ingestion, EGD should be performed within 12 to 24 hours and categorized according to a 6-point scale. Patients with grade 3b burns identified on endoscopy have high rates of morbidity. The 6-point scale is useful for predicting immediate and long-term complications, and guiding appropriate therapy.

Clinical evaluation and management of caustic injury in the upper gastrointestinal tract in 95 adult patients in an urban medical center

BACKGROUND

Caustic ingestion causes a wide spectrum of injuries; appropriate treatment varies according to the severity and extent of the injury. This retrospective study of adult patients with caustic injury presents the endoscopic findings, treatment regimen, and clinical outcome.

METHODS

Over a 28-year period, 95 consecutive adult patients admitted to an urban emergency hospital for ingestion of caustic materials were studied. Each patient underwent early endoscopy and the injury was graded for severity. There were 61 men and 34 women with an average age of 37.2 years (range 17 to 81). Ingestion was due to a suicide attempt in 49 patients and accidental in 46 patients.

RESULTS

Ten patients showed no mucosal damage. The remaining 85 patients had grade I superficial injury in 47 patients, grade II moderate injury in 25 patients, and deep grade III injury in 13 patients. The ingestion of strong acid or strong alkali often produced deep grade III changes while bleach, detergent, ammonia or other substances usually caused grade I injury. Operative interventions were required for 11 patients with grade III injury and 6 patients with grade II injury. Endoscopic grading was predictive for the onset of complications including late esophageal stricture. There were no complications due to endoscopy; one patient with grade III and multiple comorbidities died from multiple organ failure.

CONCLUSION

Upper gastrointestinal endoscopy after caustic ingestion should be performed early to define the extent of injury and guide appropriate therapy. Grade I injuries heal spontaneously. Grade II injuries may be treated conservatively but repeat endoscopy helps define when intervention is needed. Grade III injuries ultimately require surgical intervention.