Updates on the Evaluation and Management of Caustic Exposures

A Caustic Hydrochloric Acid Enema: A Case Report

Rectitis caused by the administration of a caustic enema is uncommonly encountered in routine clinical practice. The reasons given for the application of caustic enemas are diverse, including but not limited to suicide attempts, murder attempts, iatrogenic causes and simple mistakes. When caustic enemas do occur the consequences can be dire, resulting in extensive injury. These injuries often prove fatal in the short term, but if the patient survives the initial injuries, they may subsequently cause severe disability. Treatment can be conservative but commonly involves surgery, with a significant proportion of patients not surviving the intervention or succumbing to complications thereafter. We present the case of a patient with a history of alcoholism, depression and a recent recurrence of oesophageal cancer who self-administered a hydrochloric acid enema in an attempted suicide. The patient subsequently suffered a stenosis of the lower bowel, resulting in diarrhoea. A colostomy was performed in order to alleviate the patient's symptoms and improve their comfort.

Utilization of chest tube as an esophagus stent in pediatric caustic injuries: A retrospective study

BACKGROUND

The management of caustic esophageal burns in the pediatric population has changed over the years, while the most optimal management with regards to effectiveness, availability, and cost-beneficent stays controvertible.

AIM

To describe how to utilize a chest tube for esophageal stenting in pediatrics.

METHODS

Data regarding the etiology, treatment, and complications of caustic injury in pediatrics over 10 years was collected retrospectively. Furthermore, data regarding the patient's follow-up who underwent esophageal chest tube (ECT) were collected. The ECT was prepared by carving a narrowed section in the chest tube while maintaining the radiopaque section. The ECT will then be positioned from the cricopharyngeal and exited through the nostril and fixed on the patient's cheek.

RESULTS

During the period of our study, data from 57 patients with an average age of 2.5 years (range 1-12; SD = 1.7) were obtained. The results showed that 89% of esophageal injury was due to alkaline and 9.4% were caused by acidic agents. The treatment methods showed that 29 patients (50.8%) recovered with dilatation alone. In 16 patients (28.06%), the esophageal repair was performed by using the colon, and in 5 patients (8.7%), other surgical methods were used and in 7 patients (12.2%), the ECT stents were used. ECT was inserted in 7 cases with a mean age of 2 (range: 1.5-3) years who were classified as grade IIB or III. Grading was performed by endoscopy assessment on the first day. Antibiotics and corticosteroids were administrated as initial medical management for all patients. ECT implantation was done during the first 8 d for 5 out of 7 cases (mean: 3.8 d). For the 2 patients, ECT was used after 27 (patient 6) d and 83 (patient 7) d. The reason for late stenting in these patients was a postponed referral to our center, in which patient 7 even received 4 dilation episodes before visiting our center. ECT was removed after an average of 44 d in the first 5 patients, while in the other 2 patients (6 and 7) was 2 and 1 wk, respectively. There was no complication related to, or failure of, stent placement. It is worth mentioning that none of the 7 ECT cases required gastrostomy or jejunostomy.

CONCLUSION

The ECT method introduced in our study can be used as a broadly available, economic, and easy-use facility for esophageal stenting, particularly in developing countries and emergency departments which have limited access to modern equipment. Further multicenter studies with higher volume patients are required for further deployment of this method.

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.

pH and specific gravity of corrosive agents as indicators in caustic injuries

BACKGROUND

Video endoscopy, which remains the diagnostic gold standard after ingestion of a corrosive substance, is performed under general anesthesia in children, requires advanced technology, and is costly. Simple and accessible methods are therefore needed to determine the need for endoscopy. The aim of this study was to evaluate the role of the pH and specific gravity of ingested substance in determining endoscopy indications after corrosive ingestion.

METHODS

This prospective study included pediatric patients who presented after ingesting a corrosive substance from June 2018 to June 2019. Relationships between the extent of damage detected by endoscopy and the patient's age, physical examination findings, and the pH and specific gravity of the causative substance were evaluated.

RESULTS

The degree of damage detected on endoscopy was significantly milder for corrosive substances with a pH between 2 and 12 (P = 0.003). In addition, pH values between 2 and 12 were significantly more common among patients without physical examination findings (P = 0.029). Specific gravity less than 1,005 was associated with mild injury detected by video-endoscopy (P = 0.011). Patients in whom severe injury was detected by endoscopy had marked findings on physical examination (P < 0.001). There was no significant relationship between physical examination findings and the specific gravity of the substance involved (P = 0.087).

CONCLUSIONS

The results of this study suggest that conservative treatment options can be used without performing endoscopy in patients who have no physical examination finding after corrosive ingestion and where the pH of the substances is between 2 and 12 and the specific gravity of the substances is less than 1,005.

Household cleaning products poisoning in a pediatric emergency center: A 10- year cross-sectional study and literature review

BACKGROUND

Poisoning by household cleaning products(HCPs) is common in children. Some HCPs are toxic and may cause severe complications. We assessed HCP poisonings treated in a pediatric emergency department(PED).

METHODS

This was a retrospective study of patients aged under 18 years with HCP poisoning admitted to the largest PED in Taiwan from 2011 to 2020 were recruited.

RESULTS

The records over a 10-year period from 103 children admitted to the PED because of HCP poisoning(70 boys [68%] and 33 girls [32%]), mean age 3.54 years(standard deviation [SD] = 3.15 years) were evaluated. Most poisonings were unintentional(99%, n = 102) and occurred at home(96%, n = 99). The HCPs included alkaline(74%, n = 76), acidic(25%, n = 26), and neutral(1%, n = 1) agents. Most were orally ingested(86%, n = 89). Panendoscopy was performed in 25 patients(24%), and the endoscopic(Zargar) grade was used to determine the severity of injury. Medications(steroids [9%, n = 9], antibiotics [10%, n = 10], or antacids [30%, n = 23]) were prescribed. Alkaline HCP ingestion induced severe esophageal injury(p = 0.04) and esophageal stricture(p = 0.04). Five patients(5%) exhibited esophageal strictures and required balloon dilation. On multivariate analysis, alkaline HCP ingestion(p = 0.04), severe esophageal caustic injury(Zargar grade ≥ 3) (p < 0.001), and medications(steroids [p < 0.001], antibiotics [p < 0.001], and antacids [p = 0.001]) were associated with esophageal stricture.

CONCLUSION

Alkaline HCP ingestion and severe esophageal caustic injury(Zargar grade ≥ 3) were associated with esophageal stricture. Physicians tended to prescribe medications(steroids, antibiotics, or antacids) for patients with severe esophageal injuries to reduce the risk of esophageal stricture. The usefulness of these medications requires further study.

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.

Conservative treatment of caustic oesophageal injuries in children: 15 years of experience in a tertiary care paediatric centre

INTRODUCTION

Endoscopic dilatation is good choice of conservative treatment for caustic digestive tract injuries in children.

AIM

To set up a strategy of management of caustic digestive tract injury based on our experience and literature review.

MATERIAL AND METHODS

We retrospectively analysed medical records of 34 paediatric patients who were admitted to the Centre of Paediatric Surgery of the Children's Hospital between 2000 and 2017. Age at presentation, gender, anatomic location, circumstances and distribution of injury, early and late complications, clinical signs, and the first aid were analysed. Upper gastrointestinal (GI) endoscopy was performed within 12-24 h after ingestion in all cases. The Zargar classification system was used to grade the severity of the injury. Fisher's exact test was used for statistical analysis, with p < 0.05 considered as the limit of statistical significance.

RESULTS

The upper GI endoscopy revealed caustic injuries in 5 (15%) and 8 (23%) patients were classified as grade IIa and IIb, respectively. Oesophageal and ventricle caustic injuries in 3 (9%) and 2 (6%) patients were classified as grade IIIa and IIIb, respectively. Thirteen patients with grade IIa and IIIb injuries suffered permanent damage and required repeated dilatation. All patients underwent stricture treatment using late or early endoscopic dilatation of the oesophagus. An average of 15 dilatation procedures were required to achieve a satisfactory lumen.

CONCLUSIONS

Our experience of 34 children revealed that endoscopic dilatation may be required as a primary treatment for oesophageal strictures.

Corrosive injury of the trachea in children

The secondary injury may present weeks to months after the initial insult and repeat bronchoscopy, and long-term follow-up is required for the respiratory complications of CSI.Ingestion of caustic fluid may cause severe tracheal stenosis. Repeated airway dilatation may be a lifesaving intervention until such point that surgery can be performed.

Caustic Agents Ingestion in Children: A 51-Year Retrospective Cohort Study

OBJECTIVES

Children experience serious gastrointestinal tract injuries due to consumption of caustic agents more often than adults. The aim of the study was to analyze diagnostic methods and treatment of children with esophageal burns according to the degree of the injury.

METHODS

Our one-center population-based retrospective cohort study included 150 children admitted between 1967 and 2018 to Clinic of Pediatric Otolaryngology, Phoniatrics and Audiology of University Children's Hospital in Lublin, Poland, due to the chemical burn of the mouth, throat, larynx, and esophagus. Each patient underwent a thorough laryngological examination and endoscopy to assess the place and degree of injury.

RESULTS

Of 150 patients, 65.3% were male and 34.7% female. The median age was 4 years and 3 months. Salivation, dysphagia, burning sensation, edema, and whitish coating on the oral mucosa, palate, and throat were the most common clinical symptoms. In addition, dyspnea and chest pain were observed in 30% of patients. Esophagus endoscopy results were: Zargar grade I burn (84.7%), grade IIA (8%), grade IIB (2.6%), grade III (0%), and grade 0 (4.7%). Treatment included antibiotics, proton pump inhibitors, analgesics, and intravenous fluid therapy. Late sequelae (scarred esophageal strictures) developed in 20 (13.3%) patients.

CONCLUSIONS

Accidental intake of caustic agents is observed in young children, especially younger than the age of 5. Early esophagus endoscopy should be performed in all patients to assess the grade of injury, plan initial treatment, and predict the risk of developing complications. Early diagnosis and immediate pharmacological treatment reduce the number of late sequelae.

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.

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.

The Challenges of Dysphagia Management and Rehabilitation in Two Complex Cases Post Chemical Ingestion Injury

PURPOSE

Dysphagia is common sequelae of chemical ingestion injury, resulting from damage to critical swallowing structures. From a speech-language pathology perspective, this study outlines the physiological deficits in 2 individuals with severe injury (1 woman, acid; 1 man, alkali) and the pattern of dysphagia rehabilitation and recovery.

METHOD

A retrospective chart review of clinical and instrumental assessments was conducted to examine swallow characteristics and speech-language pathology management (compensatory and rehabilitation strategies) at multiple time points.

RESULTS

Chemical ingestion injury resulted in severe pharyngeal dysphagia for both participants, warranting speech-language pathology management. Dysphagia was characterized by poor base of tongue mobility and reduced laryngeal excursion. Decreased airway patency and protection, secondary to mucosal sloughing, widespread edema, and structural deficits necessitated tracheostomy. Recovery was complicated by physical alterations of pharyngeal and laryngeal structures (e.g., interarytenoid adhesions) and esophageal strictures. Participant 1 was discharged (Day 135) consuming a texture-modified diet; Participant 2 remained nil by mouth (Day 329).

CONCLUSIONS

Dysphagia recovery subsequent to chemical ingestion is protracted and complex. Clinical outcomes may be improved through individualized and intensive rehabilitation by speech-language pathologists.

Current and Upcoming Therapies for Ocular Surface Chemical Injuries

Chemical injuries frequently result in vision loss, disfigurement, and challenging ocular surface complications. Acute interventions are directed at decreasing the extent of the injury, suppressing inflammation, and promoting ocular surface re-epithelialization. Chronically, management involves controlling inflammation along with rehabilitation and reconstruction of the ocular surface. Future therapies aimed at inhibiting neovascularization and promoting ocular surface regeneration should provide more effective treatment options for the management of ocular chemical injuries.

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.

[Caustic injury of upper gastrointestinal tract: 20 year experience at a tertiary referral center]

BACKGROUND/AIMS

Caustic ingestion can cause severe injury to upper gastrointestinal tract. There were few studies about clinical characteristics and treatments of caustic injury in Korea. We investigated the changes in clinical features of caustic injury over the past 20 years including pattern of endoscopic mucosal injury and treatment modality.

METHODS

This study was a retrospective review of medical records from patients with caustic injury from September 1993 through December 2012. Patients were classified into two groups based on the year when caustic ingestion occurred: patients who visited the hospital from 1993 to 2002 (early group) and patients who visited the hospital from 2003 to 2012 (late group).

RESULTS

A total 140 patients were included (early group [n=50] vs. late group [n=90]). Annual number of caustic ingestions did not show decreasing tendency over the past 20 years. Alkali ingestion increased (20.0% vs. 65.6%, p<0.001) and cases with more than grade 2b of esophageal mucosal injury decreased (41.3% vs. 20.7%, p=0.012) in late group. There were no differences between two groups in sex, age, proportion of accidental ingestion, and systemic/gastrointestinal complications. Use of gastric lavage (p<0.01) and broad spectrum antibiotics (p=0.03) decreased in late group. However, there was no difference in use of steroid between two groups.

CONCLUSIONS

In this study, overall caustic ingestion did not decrease and ingestion of alkali agents increased over the past 20 years. Tighter legislation on caustic agents is required and we need to be alert to the best management of caustic injury.

Case Report

Accidental caustic ingestion occurs mainly in the 2- to 3-year-old age group. Up to 33% of patients develop long-term complications that principally involve the gastroesophageal tract, whereas their occurrence at the level of pharyngeal and laryngeal structures is less frequent. When present, strictures are the main disorders that can be observed. In this pathological situation, surgery is the treatment of choice, and several procedures have been described. We report the history of a 3-year-old boy affected by pharyngolaryngeal stenosis due to accidental caustic ingestion. After careful diagnosis, the child underwent surgery by transoral CO2laser. The patient had immediate improvement and restarted oral feeding 1 day after the surgical procedure. An analysis of diagnosis and treatment of this long-term complication is also presented.

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.

The ocular surface chemical burns

Ocular chemical burns are common and serious ocular emergencies that require immediate and intensive evaluation and care. The victims of such incidents are usually young, and therefore loss of vision and disfigurement could dramatically affect their lives. The clinical course can be divided into immediate, acute, early, and late reparative phases. The degree of limbal, corneal, and conjunctival involvement at the time of injury is critically associated with prognosis. The treatment starts with simple but vision saving steps and is continued with complicated surgical procedures later in the course of the disease. The goal of treatment is to restore the normal ocular surface anatomy and function. Limbal stem cell transplantation, amniotic membrane transplantation, and ultimately keratoprosthesis may be indicated depending on the patients' needs.

Evaluation and management of caustic injuries from ingestion of Acid or alkaline substances

Although the numbers have decreased compared with in the past, cases of patients who ingest caustic substances and visit the emergency room are not rare. However, well-summarized data about caustic injuries are insufficient. Therefore, in this article, I will discuss the etiologic causative agents, injury mechanism, and clinical characteristics, as well as the endoscopic evaluation of the degree of injury and proper management of the patient, in gastrointestinal caustic injury.

High doses of methylprednisolone in the management of caustic esophageal burns

OBJECTIVE

Caustic substance ingestion in childhood is a public health issue in developing countries, and several management protocols have been proposed to prevent the resulting esophageal strictures. The role of corticosteroids in preventing corrosive-induced strictures is controversial. Our aim was to study the influence of high doses of corticosteroids in preventing esophageal strictures.

METHODS

Eighty-three children with a mean age of 4.10 6 2.63 years and with grade IIb esophageal burns (an esophagogastroscopy was performed within 24–48 hours of injury) due to corrosive substance ingestion were enrolled in our study between 2005 and 2008. Forty-two children (study group) received methylprednisolone (1 g/1.73 m2 per day for 3 days), ranitidine, ceftriaxone, and total parenteral nutrition. Forty-one children (control group) were administered the same regimen excluding methylprednisolone. Stricture development was compared between groups based on endoscopic and radiologic findings.

RESULTS

During the endoscopic examination, stricture development was observed in 4 patients (10.8%) in the study group and in 12 patients (30%) in the control group. The difference was statistically significant (P = .038). The stricture development rate in the upper gastrointestinal system with barium meal was 14.3% and 45.0% in the study and control groups, respectively. The difference was statistically significant (P = .004). The duration of total parenteral nutrition was shorter in the study group compared with the control group (P = .001). High doses of methylprednisolone were well tolerated in the study group without any side effects.

CONCLUSIONS

High doses of methylprednisolone used for the management of grade IIb esophageal burns may reduce stricture development.

Management of acute severe upper airway obstruction in children

There are many causes of acute severe upper airway obstruction (UAO) in children. The timing of symptom onset and the presence of fever will help to distinguish infectious from non-infectious conditions. Signs and symptoms from congenital malformations often present at birth but may also develop over time. The most common cause of UAO in children is croup. Choking on a foreign body also occurs relatively frequently. Evaluation of the child with UAO starts with a detailed history followed by a thorough physical examination, including an assessment of severity. Severe airway obstruction will result in respiratory failure. This situation requires an immediate response. A child with partial airway obstruction may initially have an adequate airway. However, this situation can deteriorate rapidly. Therefore, providing supportive care and mobilizing resources for definitive airway management may be the most appropriate interventions.

(99m)Tc-pertechnetate scintigraphy and endoscopy in assessment of caustic-induced gastric mucosal injury

Endoscopy is the gold standard for evaluating caustic-induced gastric mucosal injury. Injuries ≥ 2b (confluent ulceration or charring) are associated with perforation and cicatrisation. Grade 1-2a injuries recover without intervention. Grade 2b and 3 injuries require observation and may need intervention. (99m)Tc-pertechnetate imaging can assess gastric viability after caustic injury. We correlated (99m)Tc-pertechnetate SPECT/CT with endoscopic findings in 4 patients with increasing grades of caustic-induced gastric mucosal 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.

Salicylic acid ingestion leading to esophageal stricture

Accidental ingestion of caustic substances (acid and alkali) occurs more frequently in children than in adults. The subsequent injury varies from minimal to severe, with perforation and even death as potential complications. Several factors have been shown to mediate the severity of injury, including the pH, concentration and physical state of the ingested substance, tissue contact time, and quantity (volume) of the ingested material. Liquids with a pH of less than 2 (acidic) or a pH of greater than 12 (alkali) are considered to be extremely corrosive and hold the greatest risk for injury. Esophageal injury after caustic ingestion is endoscopically graded with a score of 0 for no injury to IIIb for significant circumferential injury with ulcers and necrosis. Ingestion of either a strong alkali or acid has been documented to result in esophageal necrosis and ulcers (grade IIIb). Alkali ingestions occur more frequently because of their presence in daily life (detergents, degreasers) and therefore have more reports of injury. Despite more than 8200 documented cases of topical salicylic acid ingestions annually in US children younger than 19 years, there are no reported cases of salicylic acid resulting in gastrointestinal pathology. We report 2 cases of salicylic acid ingestion resulting in esophageal strictures. Both patients had more significant injury than anticipated given their initial clinical presentations. Given our recent experience, we recommend close follow-up and evaluation for strictures in patients with exposure to salicylic acid.

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.

Caustic ingestions in children

PURPOSE OF REVIEW

The purpose of this review is to outline the current epidemiology, mechanism of injury, clinical manifestations, management and long-term complications of caustic ingestions in pediatric patients.

RECENT FINDINGS

Recent data suggest that more than 200 000 exposures to household or industrial cleaning products occur annually in the United States. It is difficult to determine what fraction of these exposures represents caustic ingestions. Caustic ingestions occur most commonly in children less than age 6 years. Because of the accidental nature of the ingestions, the case fatality rate for pediatric patients is significantly less than that of adolescents and adults. Despite laws to limit the concentration of household cleaning products, farm and industrial products and products stored in nonoriginal containers represent a significant source of caustic agents. Endoscopy remains the preferred method of staging injury. In children the absence of symptoms does not predict lack of relevant injury. However, the presence of three or more symptoms is associated with a high likelihood of significant injury. Long-term complications in pediatric patients may be severe and include esophageal cancer.

SUMMARY

Caustic ingestions remain a significant cause of pediatric morbidity in the United States and abroad. Endoscopy is the primary method of staging injury following a caustic ingestion. Extent of injury at initial evaluation remains the best predictor of morbidity and mortality in pediatric patients following an accidental caustic ingestion.

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.

Chemical, thermal, and biological ocular exposures

Chemical or radiant energy injuries to the eyes are considered ocular burns. The majority of these injuries are occupation-related. Chemical burns are by far more common and represent a true emergency. Thermal and UV injuries are associated with severe pain, but often result in less long-term sequelae than chemical injuries do. The term "biologic exposure" refers to an exposure to human blood or other body fluid. This article describes patterns of these injuries and exposures, with particular emphasis on emergent management and including acute diagnostic and treatment considerations.