Gastric perforation after corrosive ingestion

CT appearances of gastric injury due to caustic ingestion and associated findings (a study of 30 cases)

The mortality and morbidity of acute caustic gastric injuries are high. The spectrum of gastric injury due to caustic ingestion varies from hyperemia, erosion, and extensive ulcers to mucosal necrosis. Severe transmural necrosis can be associated with fistulous complications in the acute and subacute phases and stricture formation in the chronic phase. Due to these important clinical implications, timely diagnosis and appropriate management of gastric caustic injury are crucial, and endoscopy plays a pivotal role. However, critically ill patients or those with overt peritonitis and shock cannot undergo endoscopy. Thoraco-abdominal computed tomography (CT) is preferable to endoscopy as it avoids the risk of esophageal perforation and allows the evaluation of the entire gastrointestinal tract, as well as of the surrounding organs. With the advantage of not being invasive, CT scan has a promising role in the early evaluation of caustic injury. It has an increasing role in the emergency setting with good accuracy in identifying patients who are likely to benefit from surgery. In this pictorial essay, we present the CT spectrum of caustic injury of stomach and associated thoraco-abdominal injuries, with clinical follow-up.

Corrosive ingestion managements in children

Corrosive (caustic) material ingestion remains a major health issue, particularly in developing countries. The management strategy after corrosive ingestion should be planned according to the signs and symptoms. The management of corrosive ingestion based on endoscopic grading, nothing by mouth, and barium studies should be abandoned. With the new management protocol, esophageal stricture can be predicted with high accuracy using the simple new prognostic DROOL score (≤ 4) rather than endoscopic grading, reduced by immediate oral feeding as soon as the patient can swallow saliva instead of nothing by mouth, diagnosed earlier (10-14 days) by fluoro-endoscopic balloon-assisted esophageal examination for patients with persistent dysphagia instead of relying on a barium study (≥ 21 days), and adequately treated by initiating balloon dilation earlier during the same anesthesia procedure. Fluoroscopically guided balloon dilatation with large balloons (18-20 mm) seems to be safe, with a low frequency of complications and a high success rate. If dilatation fails after a few months, esophagectomy and replacement surgery using the stomach should be considered. The increased risk of developing esophageal carcinoma after ingestion of corrosive substances should be kept in mind.

Pediatric gastric perforation beyond neonatal period: 8-year experience with 20 patients

BACKGROUND

To describe the characteristics, treatments, and prognosis of pediatric gastric perforation patients beyond neonatal period.

METHODS

Twenty pediatric patients beyond neonatal period were included in this study. Medical records were reviewed and clinical characteristics were analyzed. According to the outcomes, patients were divided into the survival group and the death group. Death time was documented, and survival patients were followed up. The degree of severity was calculated using pediatric critical illness score (PCIS). Differences between the two groups were analyzed by the Student's t-test, Mann-Whitney test and Chi-square test appropriately.

RESULTS

Gastric perforation was diagnosed in 20 pediatric patients beyond neonatal period, including 6 males (30%) and 14 females (70%), with the age of 37.18 (15.90, 107.12) months, and the range was from 4.30 months to 14.17 years old. They had different manifestations, etiologies, sites of perforation and surgery procedures. Among the 20 cases, 14 (70%) survived and 6 (30%) died. Age, gender, length and number of perforation had no statistically difference between the two groups. However, PCIS, ischemia of gastrointestinal wall, and transmural necrosis of gastric wall were statistically different. For the survival group, during a follow-up period of 50 (36, 68) months, ranging from 2 months to 8 years and 7 months, one patient had a second-time perforation, another 3 patients had brain injury symptoms, and the rest 10 patients had good quality of lives.

CONCLUSIONS

Gastric perforation of pediatric patients beyond neonatal period causes a mortality of 30% on this study. Spontaneous great curvature of gastric wall perforation has the highest morbidity. Low PCIS predicts for unfavorable prognosis. Most of the survival patients have satisfactory living quality after operation.

Caustic Ingestion in the Elderly: Influence of Age on Clinical Outcome

Caustic poisonings are still associated with many fatalities. Studies focusing on the elderly are rare. The purpose of the present study was to compare the clinical outcomes of caustic ingestion injury in elderly and non-elderly adults with regard to gender, intent of exposure, substance ingested, severity of mucosal injury, complications, and mortality. Caustic substance exposures reported to the National Toxicological Information Centre in Slovakia during 1998–2015 were reviewed retrospectively. The patients were divided into two groups: the non-elderly (<60 years) and elderly adults (≥60 years). The mortality rate in the elderly was significantly higher (elderly 23.0% vs. non-elderly 11.3%; p = 0.041). The risk of fatal outcome in the elderly was increased by acid ingestion (OR = 7.822; p = 0.002), particularly hydrochloric acid (OR = 5.714, p = 0.006). The incidence of respiratory complications was almost two times higher in the elderly was 31.1% vs. 17.4% for the non-elderly (p = 0.037). Respiratory complications significantly correlated with an increased mortality rate (p = 0.001) in the elderly whereas there was no association between GI complications and mortality in the elderly (p = 0.480). Elderly patients with respiratory complications had the poorest clinical outcomes. The highest risk of complications and fatalities was observed in patients after hydrochloric acid ingestion.

Caustic ingestion

Corrosive ingestion is a rare but potentially devastating event and, despite the availability of effective preventive public health strategies, injuries continue to occur. Most clinicians have limited personal experience and rely on guidelines; however, uncertainty persists about best clinical practice. Ingestions range from mild cases with no injury to severe cases with full thickness necrosis of the oesophagus and stomach. CT scan is superior to traditional endoscopy for stratification of patients to emergency resection or observation. Oesophageal stricture is a common consequence of ingestion and newer stents show some promise; however, the place of endoscopic stenting for corrosive strictures is yet to be defined. We summarise the evidence to provide a plan for managing these potentially life-threatening injuries and discuss the areas where further research is required to improve outcomes.

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 oesophagitis in children: prevalence, the corrosive agents involved, and management from primary care through to surgery

PURPOSE OF REVIEW

Caustic substance ingestion (CSI) remains a major health issue, particularly in developing countries, where laws are not effectively enforced. This review offers a thorough analysis of the current epidemiology, clinical features, management, treatment, and long-term complications of CSI in children.

RECENT FINDINGS

Strong alkalis sold in liquid and granular forms, particularly crystalline grease cleaners (concentrated sodium hydroxide), are the principal causes of severe oesophageal damage. Currently, early endoscopy to assess the gastro-oesophageal mucosa is not considered necessary for all CSI cases. Oesophageal stricture is a major complication developing after CSI, and should be diagnosed and treated earlier, 10-14 days after CSI via commencement of a dilation program. Fluoroscopically guided oesophageal balloon dilatation seems to be safe, with a low frequency of complications and a high success rate. However, it should commence earlier than is currently the case, and should be performed gently, using balloons of gradually increasing diameter. If dilation fails after a few months, oesophageal replacement surgery should be performed.

SUMMARY

Unfortunately, neither dilatation treatment nor oesophageal bypass surgery can prevent the development of oesophageal carcinoma, the incidence of which is high after CSI. The continuing unacceptably high incidence of CSI accidents would be reduced if corrosive materials were sold in their original childproof containers, highlighting the need for preventive and adult education programmes.

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.

An unusual presentation of hydrochloric acid ingestion: a mystery unraveled

BACKGROUND

Unintentional acid ingestion is less commonly encountered than alkali ingestion. The injury develops for hours to days after ingestion and often results in progressively increasing difficulty in airway management. However, gastric perforation is rare.

CASE

A 3-year-old boy presented to us with an orotonsillopharyngeal membrane and severe upper airway obstruction. Subsequently, he was diagnosed with a case of gastric perforation due to unintentional hydrochloric acid ingestion. He was treated with partial gastrectomy and feeding jejunostomy, and the recovery was good.

CONCLUSIONS

Unintentional hydrochloric acid ingestion is rare in children. The manifestations masquerade many other clinical conditions, and the diagnosis is difficult in cases in which history of ingestion is not available. Treatment is symptomatic, and emergency surgery is indicated in case of gastrointestinal perforation.

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.

Spontaneous gastric perforation in 11-year-old boy with anorexia nervosa: rare presentation with right iliac fossa pain

Spontaneous gastric perforation is rare in children. It is usually associated with prematurity, foreign bodies and trauma. Anorexia nervosa (AN) can be an underlying condition although no cases are reported in the literature. We are reporting a rare case of 11-year-old boy with AN who presented with right iliac fossa pain mimicking acute appendicitis. Intraoperative findings proved a gastric perforation. Pathophysiology of this condition in AN is poorly understood. Gastric smooth muscle atrophy and ischaemia can be the possible underlying mechanisms. The case discussed here highlights the fact that any abdominal pain in patients with underlying eating disorders should raise suspicion of perforation as diagnosis can be far more complicated.

Spontaneous gastric perforation in an 11-year-old boy with anorexia nervosa: rare presentation with right iliac fossa pain

Spontaneous gastric perforation is rare in children. It is usually associated with prematurity, foreign bodies and trauma. Anorexia nervosa (AN) can be an underlying condition although no cases are reported in the literature. We are reporting a rare case of 1-year-old boy with AN who presented with right iliac fossa (RIF) pain mimicking acute appendicitis. Intraoperative findings proved a gastric perforation. Pathophysiology of this condition in AN is poorly understood. Gastric smooth muscle atrophy and ischaemia can be the possible underlying mechanisms. The case discussed here highlights the fact that any abdominal pain in patients with underlying eating disorders (EDs) should raise suspicion of perforation as diagnosis can be far more complicated.

Surgical management and outcomes of severe gastrointestinal injuries due to corrosive ingestion

AIM: To report our experience in the surgical management of severe injuries of the gastrointestinal tract due to corrosive ingestion.

METHODS: A retrospective review of patients who underwent emergency surgery for severe gastrointestinal injuries following corrosive ingestion between 1983 and 2010 was carried out. Data was extracted from a prospectively maintained esophageal disease database. Severe corrosive injuries were defined as full thickness necrosis with perforation of the esophagus or the stomach (with or without involvement of the adjacent viscera) with resultant mediastinitis or peritonitis.

RESULTS: Between 1983 and 2010, 209 patients with corrosive injury of the esophagus were managed. Of these, 13 (6.2%) patients underwent emergency surgery for severe corrosive injury. The median age of the patients was 22 years and the median interval between ingestion of the corrosive substance and surgery was 24 h. The surgical procedures done included esophagogastrectomy alone (n = 6), esophagogastrectomy with duodenectomy (n = 4), esophagogastrectomy with pancreaticoduodenectomy (n = 1), esophagogastrectomy with splenectomy (n = 1) and distal gastrectomy with duodenectomy (n = 1). Two patients died in the postoperative period and one after discharge awaiting the second surgery. The factors significantly predictive of mortality following such an injury included renal failure at the time of initial presentation, presence of metabolic acidosis, delay of more than 24 h between corrosive ingestion and surgery, and corrosive induced adjacent organ injury (pancreatic) (P < 0.001, 0.02, 0.005 and 0.015 respectively). Ten patients underwent subsequent surgery for restoration of the alimentary tract continuity with a colonic pull-up (n = 8) and gastrojejunostomy (n = 1). In one patient, the attempted colon pull-up failed due to extensive scarring of the mesocolon. The median follow up (following restoration of continuity of the gastrointestinal tract) was 36.5 mo. One patient developed dysphagia due to a stricture at the anastomotic site, which was successfully managed by dilatation. Another patient developed severe aspiration, necessitating laryngeal inlet closure and permanent tracheostomy, and 3 patients complained of occasional regurgitation.

CONCLUSION: Management of severe corrosive injury involves prompt resuscitation and urgent surgical debridement. Although the subsequent restoration of continuity may be complicated and may not always be possible, long term outcomes are acceptable in the majority.