Clinical evaluation and management of caustic injury in the upper gastrointestinal tract in 95 adult patients in an urban medical center. Surg Endosc. 2008;22:1119-1125. [PMID: 17965918 DOI: 10.1007/s00464-007-9620-2]

Classification of the oesophageal perforation

OBJECTIVES

Esophageal perforations are a complex clinical scenario that have been poorly studied. To date, there is no grading of esophageal perforations, the reason being that the outcome is very heterogeneous, because the perforation is very heterogeneous. A grading of the severity of the perforation may guide treatment, and could ultimately affect morbidity and mortality.

METHODS

The observation period of the study was four years. All patients with a perforation of the esophagus aged 18 to 90 years were included. All anastomotic insufficiencies or fistulas after surgery of the esophagus were excluded. The cause of the injury and the time interval between the event and the start of therapy were analyzed. The severity of each perforation was classified based on the results of a diagnostic CT scan, gastroscopy as well as clinical and laboratory findings. Therapy and signs of infection were evaluated. Endpoints of the study were patient recovery or death. The study was conducted as a retrospective single-center study at a university hospital of Düsseldorf. The study has been approved by the review board. Patients gave their informed consent before data collection. All data were analyzed using SPSS 29 (IBM SPSS Statistics software).

RESULTS

Age, gender and cause of the esophageal perforation did not impact significantly on overall survival. The duration of injury > 24 h (p = 0.01), presence of mediastinitis (p = 0.01) and necrosis of the esophagus (p = 0.02) were associated with an unfavorable outcome. The correlation of the clinical grading of the severity of the perforation based on the endoscopic, radiological and clinical findings with the overall survival of patients was significant. Patients categorized into the four grades of severity (I-IV) had an overall survival of 100%, 100%, 70% and 50%, respectively.

CONCLUSION

The severity of esophageal perforations can be systematically rated grades I to IV based on the radiological, endoscopic and clinical findings at diagnosis. Due to the grading and its correlation to the overall survival, a comparison of patients, their treatment and outcome becomes possible. In future, the grade of a perforation may guide treatment, and therefore affect morbidity and mortality.

[Results of emergency management of esophageal lesions related to caustic ingestion in children in the emergency department of the General Reference Hospital of Niamey (Niger)]

Introduction

Caustic ingestion in children is a public health problem; it is mainly due to domestic accidents due to improper packaging and storage of caustic products. It is a medical and surgical emergency whose management is multidisciplinary. The lesions caused by the accidental ingestion of caustics can affect the functional and vital prognosis in 10% of cases.

Methodology

A retrospective, descriptive study from January 2020 to December 2022 (2 years), carried out in the emergency department of the General Reference Hospital of Niamey (Niger). The study included patients less than 15 years old admitted for ingesting a caustic product.

Results

Our study included 17 patients. The average age was 5 years, with age extremes of 2 to 11 years. We noted a male predominance with a sex ratio (M/F) of 2.4. Ingestion of caustic products was accidental in all cases. The caustic product was caustic soda in 59%. The average quantity of product ingested was 5 ml (2 ml to 20 ml). The average consultation time was 3 days (3 hours to 15 days). Clinically, dysphagia was the most functional sign, represented by 13 cases, or 76%. Regarding general signs, 3 patients (18%) were admitted with fever; blood pressure was normal in 15 patients (88%); and 2 patients (18%) were admitted in a state of shock. The respiratory rate was normal in 14 patients (82%). Four patients (24%) were admitted in a state of deterioration in the general condition associated with severe malnutrition and dehydration. On physical examination, 2 patients (12%) presented with abdominal defense at the epigastric level. Examination of the ENT sphere revealed benign buccopharyngeal ulcerations in 2 patients (12%). Esogastroduodenal fibroscopy was performed in 4 patients (24%). The caustic lesions observed in the esophagus were: Zargar stage I at 25%, stage Ila at 50%, and stage Illb at 25%. In the stomach, the lesions were Zargar stage I in 75% of cases and stage III in 25% of cases. An injected thoracic-abdominopelvic computed tomography (CT) was performed in 3 patients (18%). It revealed a lack of enhancement of the esophageal wall compatible with esophageal necrosis in one patient. An esophagogastroduodenal transit was performed in 8 patients (47%) admitted more than 72 hours after ingestion of the caustic. They showed esophageal stenoses longer than 3 cm in 3 patients, multiple esophageal stenoses in 2 patients, a single esophageal stenosis in 2 patients, and a single antropyloric stenosis in 1 patient. Therapeutically, all patients benefited from antiemetics to avoid vomiting and proton pump inhibitors. Intravenous antibiotic prophylaxis with third-generation cephalosporin was administered to 12 patients (71%). Corticosteroid therapy based on IV prednisolone at a dose of 1 g/1.73 m2 per day was used to limit or prevent stenoses in 9 patients (53%). Parenteral nutrition was administered to 7 patients (41%). Endoscopic dilations were performed in 2 patients (12%). Emergency surgical treatment was performed in 7 patients (41%): 3 patients underwent transitional feeding gastrostomies; in 3 others, esophagoplasties by colon transplant were performed, and 1 patient was treated by stripping of the esophagus associated with total gastrectomy. The postoperative course was marked by a leak of esocolic anastomosis in one patient for whom conservative treatment was performed with good progress. The average length of hospital stay was 5 days (1-32 days).

Conclusion

Accidental caustic ingestions can have serious consequences. Preventing these accidents relies on raising public awareness of the dangers associated with improper storage of these products.

Poly(l-Histidine)-Mediated On-Demand Therapeutic Delivery of Roughened Ceria Nanocages for Treatment of Chemical Eye Injury

Development of topical bioactive formulations capable of overcoming the low bioavailability of conventional eye drops is critically important for efficient management of ocular chemical burns. Herein, a nanomedicine strategy is presented to harness the surface roughness-controlled ceria nanocages (SRCNs) and poly(l-histidine) surface coatings for triggering multiple bioactive roles of intrinsically therapeutic nanocarriers and promoting transport across corneal epithelial barriers as well as achieving on-demand release of dual drugs [acetylcholine chloride (ACh) and SB431542] at the lesion site. Specifically, the high surface roughness helps improve cellular uptake and therapeutic activity of SRCNs while exerting a negligible impact on good ocular biocompatibility of the nanomaterials. Moreover, the high poly(l-histidine) coating amount can endow the SRCNs with an ≈24-fold enhancement in corneal penetration and an effective smart release of ACh and SB431542 in response to endogenous pH changes caused by tissue injury/inflammation. In a rat model of alkali burn, topical single-dose nanoformulation can efficaciously reduce corneal wound areas (19-fold improvement as compared to a marketed eye drops), attenuate ≈93% abnormal blood vessels, and restore corneal transparency to almost normal at 4 days post-administration, suggesting great promise for designing multifunctional metallic nanotherapeutics for ocular pharmacology and tissue regenerative medicine.

Assessment and management after corrosive ingestion: when is specialist centre referral needed? A 10-year UK experience

BACKGROUND

Corrosive ingestion injuries are rare but clinically significant events, potentially associated with high morbidity and mortality. The low volume of cases limits guideline development. We report a 10-year experience of our tertiary centre focusing on cases requiring specialist care.

METHODS

All adults treated following corrosive ingestion between 2010 and 2020 were included. Blood results, imaging and endoscopic findings were reviewed. Patients were stratified based on endoscopic findings. Emergency and delayed management was analysed along with short and long-term outcomes. Predictive value of early outcome indicators was investigated.

RESULTS

Eighty-one patients were included, with an average follow-up of 5 years. Patients with injuries ≤ Zargar 2A (n = 15) had long-term outcomes similar to the ones with negative endoscopic findings (n = 51). All fifteen patients suffering injuries Zargar ≥ 2B required ITU and four died (26.6%). All deaths occurred within 50 days of ingestion, had Zargar grade ≥ 3 and airway involvement. Five patients (33%) required emergency operations, two of which died. All Zargar ≥ 2B injury survivors (n = 11) developed strictures and/or tracheo-esophageal fistulae (18%), required multiple admissions and prolonged nutritional support; five required delayed resections. Zargar grade ≥ 2B, airway damage, and increased CRP on admission correlated with unfavourable outcomes.

CONCLUSION

Corrosive ingestion injuries up to Zargar 2A do not cause long-term sequelae and can be managed locally. Injuries > 2B bear high mortality and will cause sequelae. Early identification of severe injuries and transfer to specialist centres with multidisciplinary ITU, OG, thoracic and ENT expertise is recommended.

Evaluation of Pediatric Early Warning System and Drooling Reluctance Oropharynx Others Leukocytosis scores as prognostic tools for pediatric caustic ingestion: a two-center, cross-sectional study

Caustic chemicals are widely distributed in our environment. Exposure to caustic agents is a lifelong problem associated with severe tissue and mucous membrane injuries. In pediatrics, corrosive exposure is the most common cause of nonpharmaceutical exposure presenting to poison control centers. Therefore, this study evaluated the role of the Pediatric Early Warning System (PEWS) and Drooling Reluctance Oropharynx Others Leukocytosis (DROOL) scores as early in-hospital outcome predictors following corrosive ingestion. The current study was a two-center, retrospective, cross-sectional study carried out among pediatric patients diagnosed with acute caustic ingestion during the past 4 years. Most exposure occurred accidentally among boys (59.4%) living in rural areas (51.9%) of preschool age (50% were 2-4 years old). Residence, body temperature, respiratory rate, vomiting, skin and mucosal burns, retrosternal pain, respiratory distress, Oxygen (O2) saturation, Glasgow Coma Scale score, HCO₃ level, total bilirubin level, anemia, leukocytosis, and presence of free peritoneal fluid were significant predictors of esophageal injuries (p < 0.05). DROOL and PEWS scoring were the most significant predictors of esophageal injuries with worthy predictive power, where odds ratio (95% confidence interval (CI)) was 1.76 (0.97-3.17) and 0.47 (0.21-0.99) for PEWS and DROOL, respectively. At a cutoff of < 6.5, the DROOL score could predict esophageal injuries excellently, with AUC = 0.931; sensitivity, 91.7%; specificity, 72.5%; and overall accuracy, 91.3%. At a cutoff of > 6.5, PEWS could significantly predict unfavorable outcomes, with AUC = 0.893; sensitivity, 94.4%; specificity, 71.9%; and overall accuracy, 89.3%. However, PEWS better predicted the need for admittance to the intensive care unit (ICU). Pediatric Early Warning System (PEWS) and Drooling Reluctance Oropharynx Others Leukocytosis (DROOL) are potentially useful accurate scorings that could predict the esophageal injuries and ICU admission following corrosive ingestion in pediatrics.

Gastric Pneumatosis After Accidental Ingestion of Concentrated Hydrogen Peroxide: A Case Report

Introduction

Hydrogen peroxide is a common oxidizing agent that if ingested may cause injury to the gastrointestinal tract or embolic events. Although therapy is primarily supportive, gastric perforation is a rare but serious complication of corrosive ingestion that may require surgical treatment.

Case Report

We report the case of a 77-year-old male who presented for nausea and vomiting after accidentally ingesting approximately 150 milliliters of 35% hydrogen peroxide. Computed tomography revealed gastric pneumatosis and extensive portal venous air. The patient was admitted for observation with plans for endoscopy; however, due to the limitations of our small community hospital, he was transferred to a tertiary care center due to concern for a potential gastric perforation.

Conclusion

The presence of portal venous air as a result of peroxide ingestion may be treated conservatively depending on presenting symptoms; however, severe injury such as gastrointestinal perforation may necessitate surgical intervention.

Surgical management of esophageal stenosis due to ingestion of corrosive substances

BACKGROUND

Corrosive ingestion is a significant challenge for healthcare systems. Limited data are available regarding the best treatments, and there remains a lack of consensus about the optimal surgical approach and its outcomes. This study aims to review the current literature and show a single institution's experience regarding the surgical treatment of esophageal stenosis due to corrosive substance ingestion.

METHODS

A retrospective review that accounted for demographics, psychiatric profiles, surgical procedures, and outcomes was performed. A systematic review of the literature was performed using PubMed.

RESULTS

In total, 27 surgical procedures for esophageal stenosis due to corrosive substance ingestion were performed from 2010 to 2019. Depression and drug abuse were diagnosed in 30% and 22% of the included patients, respectively. Esophagectomies and esophageal bypasses were performed in 13 and 14 patients, respectively. No 30-day mortality was recorded.

CONCLUSION

Surgical intervention either by esophagectomy or esophageal bypass results in durable relief from dysphagia. However, successful clinical outcomes depend on a high-quality multidisciplinary network of esophageal and thoracic surgeons, intensivists, psychologists, psychiatrists, and nutritional teams.

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.

Endoscopic findings and outcome in caustic ingestion of acidic and alkaline agents in adults: A retrospective analysis

Caustic ingestion in adults is a rare but potentially life-threatening problem. It remains controversial whether endoscopic findings and mortality differ between acid and alkali ingestion. We compared ingestion of these agents and evaluated prediction parameters for survival and complications.Adult patients who presented with caustic ingestion were analyzed from 2005 to 2016. Mucosal injury was graded endoscopically by Zargar's score. Age, gender, intent of ingestion, caustic agents, comorbidities, management, complications, and mortality were examined.Thirty-one patients met inclusion criteria and were divided into acid (n = 10) and alkali group (n = 21). Ingestion of alkali resulted in higher grades (≥III) of esophageal (56% vs 24%, P = .01) and stomach injuries (43% vs 13%, P = .05) and was mostly done with suicidal intent (76% vs 30%, P = .003). Patients in the alkali group received more often surgical interventions, mechanical ventilation and tracheotomy. Overall complications including Zargar's-score ≥ grade III, mediastinitis, and aspiration pneumonia were higher in alkali group but all showed no statistical significance (P = .73). Mortality (acid: 1 (10%), alkali: 4 (19%), P = .52), age, gender, comorbidities, and intensive care management did not differ significantly between the groups. Chronic renal failure and mediastinitis were promising prediction parameters for mortality but did not reach statistical significance. No independent risk factors for the development of esophageal stenosis were identified.Alkaline agents caused a higher mucosal injury severity and were more often used in suicidal intent. Mediastinitis and chronic renal failure might be potential prediction parameters for survival but need to be evaluated in larger studies.

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.

Submucosal hematoma: a new distinctive sign during emergency upper digestive endoscopy for ammonia ingestion

Background

Submucosal hematoma has never been associated with caustic injuries. Long-term follow-up of patients who ingested ammonia is not well known and ammonia ingestion is rare.

Methods

In a Single-center observational study, prospective data were collected from 2009 to 2013, in patients over the age of 14 years old referred for ammonia ingestion. The emergency and follow-up endoscopic data and the outcome were reported.

Results

Ammonia ingestion occurred in 43 patients. Submucosal hematoma of the gastric wall was a distinctive endoscopic sign observed in 15 (34.8%) cases. Oropharyngeal lesions were present in 30 (69.8%) patients, which was associated with ingestion with suicidal intent in 18 cases. Mild and severe endoscopic lesions (grade IIB to IIIB) were found in 16 (37.2%) cases with 10 (23.3%) cases presenting submucosal hematoma at initial endoscopy. A complete spontaneous gastric healing was frequently observed in 36 (83.7%) cases. In 11 cases with submucosal hematoma, a favourable outcome was observed with a medical treatment, however 6 of these patients had severe endoscopic lesions initially.

Conclusions

Submucosal hematoma of the gastric wall is an endoscopic sign occurring frequently in ammonia ingestion. Submucosal hematoma should be distinguished from necrosis in order to avoid false misclassification in favour of more severe lesions, which would lead to an abusive surgery.

Electronic supplementary material

The online version of this article (10.1186/s12876-018-0809-8) contains supplementary material, which is available to authorized users.

Surgical management of corrosive-induced gastric injury in children: 10years' experience

AIM

The purpose of this study was to report surgical management and outcome of corrosive-induced gastric injuries in children at our institute over the last decade.

PATIENTS & METHOD

Medical records of patients admitted for corrosive-induced gastric injury at the Pediatric Surgery Department of Ain Shams University between January 2007 and January 2017 were retrospectively reviewed.

RESULTS

Twenty six cases (17 boys and 9 girls) were enrolled. Mean age was 3.61±1.29. Ingested agent was acid in all the patients. Main presenting symptom was gastric output obstruction in 22 cases. The interval between corrosive ingestion and presentation ranged from one to 135days (mean=43.9±34). Surgical procedure included total gastrectomy (n=2), partial gastrectomy (n=2), augmentation gastroplasty (n=1), Billroth I (n=2), antrectomy (n=2), antroplasty (n=3), gastrojejunostomy (n=2), Heineke-Mikulicz pyloroplasty (n=9), Finney pyloroplasty (n=5), and feeding jejunostomy (n=4). Anastomotic stricture requiring a second operation developed in one patient. There were three mortalities related to the associated esophageal strictures. The mean follow-up period is 3.5years. All patients are free of symptoms and gained adequate weight.

CONCLUSION

Surgery is the mainstay of management for corrosive-induced gastric injuries with good long-term results. Surgical procedure should be tailored according to the patient's general condition and extent of gastric injury.

LEVEL OF EVIDENCE

This is a case series with no comparison group (level IV).

Hydrogen peroxide ingestion with injury to upper gastrointestinal tract

Hydrogen peroxide is a common over-the-counter solution that has developed a growing body of literature regarding toxic ingestion. Intentional ingestion of high concentration hydrogen peroxide for health purposes has gained popularity in certain patient populations; purported benefits are due to the increased oxygen released into the blood stream. We present for evaluation one such case with associated imaging that presented to our urban medical center. A brief review of the literature was also performed noting current recommendations regarding both outcomes and indications for endoscopy as well as hyperbaric oxygen therapy following ingestion of hydrogen peroxide. Our patient was a 51-year-old white female who presented with foamy hematemesis after ingesting 10 drops of 35% hydrogen peroxide as part of a home remedy to cleanse her colon and improve blood oxygenation. In addition to hematemesis, she also reported diffuse abdominal pain with sore throat and hoarse voice. Her imaging demonstrated portal venous gas and gastric edema. She was admitted for hyperbaric oxygen therapy and underwent upper endoscopy demonstrating diffuse esophagitis and gastritis with white exudate and multiple petechiae. She was later discharged home in stable condition and was lost to follow-up.

Outcome of dilatation and predictors of failed dilatation in patients with acid-induced corrosive esophageal strictures

Outcome of endoscopic dilatation in acid-induced corrosive esophageal stricture is less known. This study aims to determine the outcome of dilatation and predictors of failed dilatation in patients with acid-induced corrosive esophageal stricture. Patients diagnosed of corrosive esophageal strictures were included. Endoscopic dilatation with graded Savary-Gilliard dilator was performed as the first line treatment. Outcome of dilatation was considered favorable when patients were able to swallow solid without intervention at least six months after successful dilatation. Failure of dilatation was defined as one of the following; complete luminal stenosis, inability to perform safe dilatation, perforation, and inability to maintain adequate luminal patency. Surgery or repeated dilatation was indicated in failed dilatations. There were 55 patients with corrosive esophageal strictures. Of 55 patients, 41 (75%) had failed dilatation (38 having esophageal replacement procedure, two continue repeated dilatation and one unfit for surgery). Of 323 sessions of dilatations, eight out of 55 patients (14.5%) had perforations. There was no dilatation-related mortality. Patients with concomitant pharyngeal stricture (p = 0.0001), long (≥ 10 cm) stricture length (p < 0.0001), number of dilatation >6 sessions per year (p = 0.01) and refractory stricture (inability to pass a larger than 11 mm dilator within three sessions) (p = 0.01) were more likely to have failed dilatation. Thirty-two of 38 patients with surgery had good swallow outcome with one operative mortality (2.6%). At the median follow-up of 61 months, overall favorable outcome was 84% after surgery and 25% for dilatation (p < 0.0001). Majority of patients with acid-induced corrosive esophageal stricture were refractory to dilatation. Esophageal dilatations were ultimately failed in three-fourth of the patients. Concomitant cricopharyngeal stricture, long stricture length, requiring frequent dilatation, and refractory to >11 mm dilatation were factors associated with failed dilatation.

Risk factors for symptomatic esophageal stricture after caustic ingestion-a retrospective cohort study

Esophageal stricture is a major secondary complication of ingesting caustic agents. We examined our experiences with caustic injuries with a view to finding clinical and biological risk factors of esophageal strictures secondary to caustic ingestion. Records were retrieved for 58 adults admitted consecutively to our intensive care unit for caustic ingestion. Fifty cases were managed conservatively and therefore retained for analyses. Patients were grouped according to whether they developed strictures or not during the follow-up period. Mucosal damage was assessed by emergency endoscopy. Eleven patients (22%) developed a stricture. At referral, dysphagia, epigastric pain, and hematemesis were associated with secondary stricture (respectively P = 0.047, P = 0.008, P = 0.02). A high Zargar endoscopic grade (above IIa; P = 0.02), the ingestion of strong acids or alkalis (P = 0.006), hyperleukocytosis (P = 0.02), and a low prothrombin ratio (P = 0.002) were associated with a higher risk of developing a stricture. The median delay of stricture diagnosis was 12 (8;16) days after ingestion, with extreme values from 4 to 26 days. Initial symptoms such as dysphagia or hematemesis, early endoscopy showing >IIa grade esophagitis, and certain laboratory results should draw the physician's attention to a high risk of esophageal stricture.

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.

Roux-en-Y augmented gastric advancement: An alternative technique for concurrent esophageal and pyloric stenosis secondary to corrosive intake

Select group of patients with concurrent esophageal and gastric stricturing secondary to corrosive intake requires colonic or free jejunal transfer. These technically demanding reconstructions are associated with significant complications and have up to 18% ischemic conduit necrosis. Following corrosive intake, up to 30% of such patients have stricturing at the pyloro-duodenal canal area only and rest of the stomach is available for rather less complex and better perfused gastrointestinal reconstruction. Here we describe an alternative technique where we utilize stomach following distal gastric resection along with Roux-en-Y reconstruction instead of colonic or jejunal interposition. This neo-conduit is potentially superior in terms of perfusion, lower risk of gastro-esophageal anastomotic leakage and technical ease as opposed to colonic and jejunal counterparts. We have utilized the said technique in three patients with acceptable postoperative outcome. In addition this technique offers a feasible reconstruction plan in patients where colon is not available for reconstruction due to concomitant pathology. Utility of this technique may also merit consideration for gastroesophageal junction tumors.

Approach to Patients with Epigastric Pain

Epigastric pain is an extremely common complaint in the emergency department and has an associated broad differential diagnosis. In the differential it is important to consider cardiac causes that may be mistaken for gastrointestinal disorders as well as various serious intra-abdominal causes. This article highlights the limitations in laboratory testing and guides providers through the appropriate considerations for advanced imaging. Special attention is focused on acute pancreatitis, esophageal emergencies, and peptic ulcer disease/gastritis and their associated complications.

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.

Caustic ingestion-a forensic overview

The ingestion of corrosive substances may produce severe burns to the upper aerodigestive tract and stomach, particularly if the pH is greater than 12 or less than two. There is a biphasic age grouping with adult cases most often involving self-harm and pediatric cases accidental ingestion. Three cases are reported to demonstrate characteristic features following the ingestion of potassium hydroxide, glacial acetic acid and Lysol(®) , respectively. All deaths were due to the effects of caustic burns to the upper aerodigestive tract, esophagus and stomach with perforation and/or hemorrhage. The extent of injuries in these cases depends on the nature, amount, and concentration of the agent and on the exposure time. A point to note at autopsy is that tissue damage may also occur from postmortem exposure. Typical injuries involve perioral, limb, and trunk burns, with extensive aerodigestive liquefactive/coagulative necrosis causing hemorrhage and perforation.

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

INTRODUCTION

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

METHODS

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

CONCLUSIONS

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

Computed tomography evaluation of high-grade esophageal necrosis after corrosive ingestion to avoid unnecessary esophagectomy

BACKGROUND

Esophagectomy is the standard of care for high-grade corrosive esophageal necrosis as assessed endoscopically. However, the inaccuracy of endoscopy in determining the depth of intramural necrosis may lead to unnecessary esophageal resection, with devastating consequences. Our aim was to evaluate the use of computed tomography (CT) for the emergency diagnostic workup of endoscopic high-grade corrosive esophageal necrosis.

METHODS

In a before (2000-2007)/after (2007-2012) study of patients with grade 3b endoscopic esophageal necrosis, we compared outcomes after routine emergency esophagectomy versus selection for emergency esophagectomy based on CT evidence of transmural necrosis, defined as at least two of the following: esophageal-wall blurring, periesophageal-fat blurring, and the absence of esophageal-wall enhancement. Survival estimated using the Kaplan-Meier method was the primary outcome.

RESULTS

Compared to the routine-esophagectomy group (n = 125), the CT group (n = 72) had better overall survival in the crude analysis (hazard ratio [HR], 0.43; 95 % confidence interval [95 %CI], 0.21-0.85; P = 0.015) and in the analysis matched on gender, age, and ingested agent (HR, 0.36; 95 %CI, 0.16-0.79; P = 0.011). No deaths occurred among patients managed without emergency esophagectomy based on CT findings, and one-third of CT-group patients had their functioning native esophagus at last follow-up. Self-sufficiency for eating and breathing was more common (84 % vs. 65 %; relative risk [RR], 1.27; 95 %CI, 1.04-1.55; P = 0.016) and repeat suicide less common (4 % vs. 15 %; RR, 0.27; 95 %CI, 0.09-0.82; P = 0.019) in the CT group.

CONCLUSION

The decision to perform emergency esophagectomy for endoscopic high-grade corrosive esophageal injury should rely on CT findings.

Esophageal plasmacytoma diagnosed in a patient presenting with cardiac symptoms: a novel case

Extramedullary plasmacytoma is the uncommon phenomenon of a plasma cell neoplasm occurring outside of the bone marrow. Primary plasmacytoma is a rare occurrence in the gastrointestinal tract and exceptional to originate in the esophagus. We present a novel case of a 62-year-old man who presented to our emergency department with chest pain. A cardiovascular workup was negative, and an endoscopy was subsequently performed. The endoscopy findings showed evidence of Grade IV esophagitis with ulcerations extending from 25 cm to 32 cm. Histopathological examination revealed marked acute and chronic inflammation, granulation tissue, and overlying necroinflammatory exudate. However, sheets of plasma cells, some with prominent nucleoli, were also seen. Immunohistochemically, the plasma cells expressed CD138 and MUM1 and were IgG kappa restricted. A bone marrow biopsy was performed which was negative for involvement. This is a novel case of esophageal plasmacytoma diagnosed on endoscopy in a patient presenting with acute chest pain.

The role of chest and abdominal computed tomography in assessing the severity of acute corrosive ingestion

CONTEXT

Corrosive substance ingestion is a toxicological emergency with relatively high mortality requiring rational surgical decisions.

OBJECTIVE

Evaluate the role of chest and abdominal computed tomography (CT) in assessing the severity of acute corrosive ingestion.

METHODS

A retrospective study of adults admitted due to corrosive ingestion, who underwent gastrointestinal endoscopy and CT within 48 h of admission. Endoscopy findings were graded as 0, 1, 2a, 2b, 3a, and 3b (Zargar's criteria), CT findings were graded as 0, 1, 2, and 3. For each patient endoscopy and CT grades were compared, and sensitivity and specificity for predicting mortality or emergency laparotomy were calculated.

RESULTS

Twenty-three patients were included, aged 18-87 years; seven underwent emergency laparotomy, five died. Endoscopy grading was higher than CT grading in 14 patients (66%). The sensitivities of endoscopy grades 2b and 3 to predict mortality and emergency laparotomy were 1 and 0.8, respectively; the specificities were 0.38 and 0.37, respectively. The sensitivities of CT grade 3 to predict mortality and emergency laparotomy were 0.4 and 0.28, respectively; the specificities were 0.94 and 0.93, respectively. Three patients had pulmonary infiltrates on CT but not on chest X-ray. DISCUSSION. CT tends to underestimate the severity of corrosive ingestion compared with endoscopy. It has lower sensitivity and higher specificity than endoscopy in predicting major outcome. CT can provide important information on lung injury, and when endoscopy cannot be completed.

CONCLUSION

CT should not be the only basis for surgical decisions during the initial phase of acute corrosive ingestions.

Conservative therapeutic approach to corrosive poisonings in adults

INTRODUCTION

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

METHODS

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

CONCLUSION

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

Pathology of diseases that cause upper gastrointestinal tract bleeding

Acute and chronic bleeding from the upper gastrointestinal tract is a common indication for endoscopy and hospitalization and is associated with significant morbidity and mortality. The causes of upper gastrointestinal bleeding are numerous and can result in both acute and chronic hemorrhage. The aim of this article is to examine the pathologic features of various diseases associated with upper gastrointestinal tract bleeding.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

The role of age in predicting the outcome of caustic ingestion in adults: a retrospective analysis

Background

Although the outcomes of caustic ingestion differ between children and adults, it is unclear whether such outcomes differ among adults as a function of their age. This retrospective study was performed to ascertain whether the clinical outcomes of caustic ingestion differ significantly between elderly and non-elderly adults.

Methods

Medical records of patients hospitalized for caustic ingestion between June 1999 and July 2009 were reviewed retrospectively. Three hundred eighty nine patients between the ages of 17 and 107 years were divided into two groups: non-elderly (< 65 years) and elderly (≥ 65 years). Mucosal damage was graded using esophagogastroduodenoscopy (EGD). Parameters examined in this study included gender, intent of ingestion, substance ingested, systemic and gastrointestinal complications, psychological and systemic comorbidities, severity of mucosal injury, and time to expiration.

Results

The incidence of psychological comorbidities was higher for the non-elderly group. By contrast, the incidence of systemic comorbidities, the grade of severity of mucosal damage, and the incidence of systemic complications were higher for the elderly group. The percentages of ICU admissions and deaths in the ICU were higher and the cumulative survival rate was lower for the elderly group. Elderly subjects, those with systemic complications had the greatest mortality risk due to caustic ingestion.

Conclusions

Caustic ingestion by subjects ≥65 years of age is associated with poorer clinical outcomes as compared to subjects < 65 years of age; elderly subjects with systemic complications have the poorest clinical outcomes. The severity of gastrointestinal tract injury appears to have no impact on the survival of elderly subjects.

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.

Factors predicting the hospital mortality of patients with corrosive gastrointestinal injuries receiving esophagogastrectomy in the acute stage

OBJECTIVES

The aim of this study was to identify the preoperative factors that affect the survival of patients who undergo esophagogastrectomy after corrosive ingestion, using analysis of their physiological condition, associated diseases, physical examination, and laboratory data.

METHODS

Between January 1995 and December 2005, 71 consecutive patients who underwent esophagogastrectomy for corrosive ingestion injuries were retrospectively reviewed. Of them, 41 survived and 30 (42.3%) died during the perioperative period. Logistic regression analyses were used to model markers for postoperative mortality, including descriptive data, clinical symptoms/signs, and laboratory data.

RESULTS

There were 35 males and 36 females included in the study, with an average age of 54.7 +/- 14.9 years. After adjustments in the logistic regression model, age of over 65 years (p = 0.021), presence of gross hematuria (p = 0.016), twofold level of serum AST (p = 0.012), blood pH level below 7.2 (p = 0.017), and deficit of blood base over 16 (p = 0.007) were found to be independent risk factors for patient mortality.

CONCLUSIONS

We consider age over 65 years, preoperative pH < 7.2, base deficit >16, twofold level of serum AST, and presence of gross hematuria to be the important factors predicting postoperative hospital mortality in patients presenting with corrosive ingestion injuries who require emergency surgery.

Caustic injury: can CT grading system enable prediction of esophageal stricture?

BACKGROUND

The aim of this study was to test the utility of our computed tomography (CT) grading system, compared with endoscopy, for association with the development of esophageal stricture in patients with caustic ingestion.

METHODS

This retrospective case series involved 49 patients with caustic ingestion from 1998 to 2009. The degree of esophageal damage was graded using a scoring system based on the extent of esophageal wall edema and the damage in adjacent tissue as seen on thoracoabdominal CT scans. The presence of esophageal stricture was established by esophagography. Diagnostic performance was compared using receiver operating characteristic (ROC) analysis. Sensitivity and specificity were calculated for the grading system.

RESULTS

The CT grading score results showed that grade III was the most common injury (20 cases, 40.8%), followed by grade IV (14 cases, 28.6%), grade II (9 cases, 18.4%), and grade I (6 cases, 12.2%). In addition, damage to the esophagus was significantly correlated with esophageal stricture when the extent of damage approached grades III and IV (p < 0.001). The CT grading system for esophageal stricture resulted in a slightly larger area under the receiver operating characteristic curve (0.90) compared with endoscopic grading system (0.79). The sensitivity and specificity of CT grading system were moderately higher than those of endoscopic grading system.

CONCLUSION

Assessment of the degree of esophageal damage using CT, a noninvasive modality, in patients who visit the emergency department following caustic ingestion should be useful in estimating the occurrence of complications including esophageal stricture.

Corrosive injury to the GI tract in adults: a practical approach

Corrosive injury to the GI tract still poses great challenges with regards to the initial evaluation triage, as well as the optimization of medical management. Although relatively uncommon in the adult population, these injuries can cause significant morbidity and serious sequelae of complications, such as esophageal strictures and cancer. Prompt recognition of the process and aggressive measures towards the stabilization of the patient are key to a favorable outcome.

A complicated hospitalization following dilute ammonium chloride ingestion

INTRODUCTION

Unintentional ingestions of dilute (<7.5%) cleaning solutions containing ammonium chloride typically do not cause serious harm. We present a case of an intentional ingestion of a dilute ammonium chloride solution resulting in significant morbidity.

CASE REPORT

A 60-year-old woman with bipolar disorder presented one hour after an intentional ingestion of approximately 15 fluid ounces (500 mL) of an algae and odor humidifier treatment containing a total of 2.25% ethyl ammonium chloride. Initial complaints included nausea with a single episode of nonbilious, nonbloody emesis, mild shortness of breath, and chest and epigastric pain. Physical exam was remarkable for bilateral wheezing and epigastric tenderness. An emergent endoscopy demonstrated a Grade 2b caustic injury in the esophagus and a Grade 3b injury in the stomach. Due to persistent cough, copious oral secretions, and worsening hoarseness, the patient was intubated and admitted to the ICU. Her course was complicated by mild hypotension, nonanion gap metabolic acidosis, and oliguria treated successfully with intravenous (IV) fluids. She also developed bilateral pneumonias later in the hospital course. Bedside bronchoscopy showed laryngeal edema and mucosal injury to the segmental level. The patient underwent tracheostomy on hospital day 6. An upper GI swallow study revealed poor esophageal motility in the mid- to lower third of the esophagus. The patient gradually tolerated oral fluids and on hospital day 20 had her tracheostomy tube removed. The patient was subsequently transferred to the psychiatric ward on hospital day 22.

CONCLUSION

Intentional ingestions of dilute ammonium chloride solutions can cause serious injury to the gastrointestinal tract and pulmonary systems, which can result in a complicated and prolonged hospitalization.

What is new in esophageal injury (infection, drug-induced, caustic, stricture, perforation)?

PURPOSE OF REVIEW: We will focus separately on infectious, drug-induced and caustic injury of the esophagus and their possible complications such as stricture and perforation. RECENT FINDINGS: There has been a decrease in opportunistic esophageal infection in HIV-positive patients, in particular candidiasis, which remains an important cause of inpatient charges, length of stay and total hospital costs, and new antifungal therapy are currently explored. As far as drug-induced esophageal injury is concerned, more than 1000 cases of all cases due to nearly 100 different medications have been described during the last 10 years. However, the estimated case frequency is probably much higher and the related literature is of low quality, as cases are reported selectively and stimulated by clustering of cases, newly implicated pills or unusual complications. Finally, in the field of caustic ingestion-related injury, there has been greater understanding of geographical differences in prevalence and more frequently involved substances, choice of optimal timing for endoscopy, relationship between symptoms and severity of lesions and appropriate role of steroids and other therapies, such as the topical application of mytomicin C. SUMMARY: This update covers the most relevant papers published on the three areas of interest during the last year.

Surgical management of gastric cicatrisation resulting from corrosive ingestion

BACKGROUND

Caustic injury to the stomach can be complicated by gastric stenosis. We review our experience with surgical management of symptomatic gastric stenosis.

METHODS

This is a retrospective chart review of patients who underwent surgery for gastric stenosis within 6 weeks to 26 months following corrosive ingestion. The data analyzed included the extent of cicatrisation, surgical procedure performed and outcome. Preoperative evaluation in these patients included a barium contrast study and upper gastrointestinal endoscopy.

RESULTS

Main presenting symptoms were nonbilious vomiting, early satiety, dysphagia and significant weight loss. Antropyloric strictures were present in 28 (64%) patients, total gastric involvement was seen in 16 (36%) patients, associated esophageal stenosis was present in 18 (40.91%) patients. Surgical procedures performed included distal gastrectomy with Billroth1 reconstruction in 31.82%, distal gastrectomy with Roux-en-Y reconstruction in 20.45%, stricturoplasty in 11.36%, subtotal gastrectomy in 18.18% and total gastrectomy with pouch reconstruction in another 18.18% patients. Complications encountered were pneumonitis in 18.18%, wound infection in 11.36%, intra-abdominal infection, anastomotic breakdown, reactivation of pulmonary tuberculosis and dumping syndrome, each in 2.27% patients. One patient (2.27%) died.

CONCLUSION

Surgical procedure should be tailored according to the extent of gastric involvement. Surgical resection is feasible and safe. Our results suggest that satisfactory outcome could be expected with different therapeutic modalities based on degree of cicatrisation.

Strengthening the understandings on corrosive esophageal burn and prevention and management of corrosive esophageal stricture

Caustic esophageal injuries are corrosive burns of esophagus mostly caused by ingestion of chemical caustic substances such as strong acid or alkali. There is often "saddle" dysphagia following three pathologic phases after injury. In addition to early emergency treatment, it is very important to prevent corrosive esophageal stricture by medication, dilation, stenting and so on. Different surgical operations can be selected for those with cicatrix stricture of esophagus. In this paper, we comment on the causes, pathology, diagnosis of caustic esophageal injury and prevention and management of corrosive esophageal stricture.

Total gastrointestinal tract necrosis after ingesting a considerable amount of hydrochloric acid

BACKGROUND

It has not been reported that ingesting large amounts of strong acid resulted in total gastrointestinal tract necrosis. Here we describe a case of a man with total gastrointestinal tract necrosis after ingestion of a considerable amount of hydrochloric acid.

DISCUSSION

Computed tomography (CT) scan showed significant free air in the neck, lateral esophagus, and abdominal cavity, which indicated perforation of the esophagus and gastrointestinal tract. In addition, the abdominal CT image showed splenic subcapsular hematorna and swollen pancreatic head caused by strong acid causis. We found the entire gastrointestinal tract from stomach to rectum necrosis in the emergency exploratory laparotomy. Our case suggests that ingestion of a considerable amount (e.g., 500 mL) and concentration of strong acid could result in total gastrointestinal tract necrosis. Emergency laparotomy should be performed as early as possible to benefit this kind of patient.