Late sequelae of gastric acid injury

Sham Feeding Induced Gastric Acid Secretion in Patients with Caustic Induced Esophageal Stricture

Caustic ingestion can lead to structural changes in the upper gastro-intestinal tract. However, there is limited data on the effect of caustic ingestion on gastric secretion. This study was planned to determine changes in gastric acid output after sham feeding in patients with caustic induced esophageal stricture and to compare it with healthy controls. It was a prospective study done at tertiary care center in North India. Consecutive patients with caustic induced esophageal stricture were evaluated for the study. Gastric secretory function was estimated in the basal state and after modified sham feeding. These results were compared with age-matched controls. The mean age of the included patients (n = 18) was 30.11 ± 9.19 years and 13 patients were male. 16 (88%) patients had history of acid ingestion. Patients with caustic sequelae had significantly lower basal and stimulated acid secretion compared to controls (n = 10) (5.84 ± 2.44 mmol/hr; p < 0.01 and 17.16 ± 7.53 mmol/hr; p < 0.01; respectively). Patients with lower esophageal stricture (n = 8) had significantly lower increase in acid output compared to patients with stricture elsewhere in esophagus (0.20 ± 0.3 vs. 2.31 ± 1.74 mmol/hr, p < 0.01). Patients with lower esophageal involvement had significantly lower stimulated acid secretion and increase in acid secretion compared to controls (4.74 ± 4.67 vs. 17.16 ± 7.53 mmol/hr; p < 0.01 and 20 ± 0.3 vs. 2.09 ± 0.88 mmol/hr; p < 0.01; respectively).

Gastric secretion in patients with caustic ingestion: A prospective study

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic Diamond Antroduodenostomy for Postcorrosive Pyloric Cicatrization: A Novel Approach

BACKGROUND

Traditionally, Billroth I procedure or bypass gastrojejunostomy were the recommended approaches for management of postcorrosive complete gastric outlet obstruction (GOO), whereas Heineke Mickulicz pyloroplasty was recommended for moderate mucosal injury with partial cicatrization. In this study, laparoscopic diamond antroduodenostomy was carried out as an alternative minimally invasive approach for cases with pyloric cicatricial obstruction.

PATIENTS AND METHODS

Between January and December 2017, children who were referred to Pediatric Surgery Department, Cairo University Hospital, with GOO as a consequence of caustic liquid ingestions were included in this study. Laparoscopic diamond antroduodenostomy was performed for the presented cases.

RESULTS

Through the year 2017, 5 cases were approached with laparoscopic diamond antroduodenostomy. Isolated pyloric cicatrization was evident in 4 cases, whereas synchronous insult to thoracic esophagus and pylorus was manifest in the fifth case. Laparoscopic feeding jejunostomy completed the procedure for the case with esophageal stricture. Contrast study-24 hour postoperatively-assured no radiological leaks in the presented cases, where enteral feeding was gradually commenced, and patients discharged home a day later. After a mean follow-up of 13.5 months, neither recurrence of obstructive symptoms nor dumping was displayed. Cosmetic outlook inherent to the minimally invasive approach was appreciated by the parents.

CONCLUSION

Laparoscopic diamond antroduodenostomy is a feasible approach for management of postcorrosive pyloric obstruction. It allowed early enteral feeding, with no dumping symptoms, in addition to the fundamental advantages of minimally invasive surgery. A bigger series and longer follow-up is recommended to verify the reported results.

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).

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.

Predicting the progress of caustic injury to complicated gastric outlet obstruction and esophageal stricture, using modified endoscopic mucosal injury grading scale

Severe caustic injury to the gastrointestinal tract carries a high risk of luminal strictures. The aim of this retrospective study was to identify predicting factors for progress of caustic injury to gastric outlet obstruction (GOO) and esophageal strictures (ES), using modified endoscopic mucosal injury grading scale. We retrospectively reviewed medical records of patients with caustic injuries to the gastrointestinal tract in our hospital in the past 7 years. We enrolled 108 patients (49 male, 59 female, mean age 50.1 years, range 18–86) after applying strict exclusion criteria. All patients received early upper gastrointestinal endoscopy within 24 hours of ingestion. Grade III stomach injuries were found in 58 patients (53.7%); 43 (39.8%) esophageal, and 13 (12%) duodenal. Of the 108 patients, 10 (9.3%) died during the acute stage. Age over 60 years (OR 4.725, P = 0.029) was an independent risk factor of mortality for patients after corrosive injury. Among the 98 survivors, 36 developed luminal strictures (37.1%): ES in 18 patients (18.6%), GOO in 7 (7.2%), and both ES and GOO in 11 (11.3%). Grade III esophageal (OR 3.079, P = 0.039) or stomach (OR 18.972, P = 0.007) injuries were independent risk factors for obstructions. Age ≥60 years was the independent risk factor for mortality after corrosive injury of GI tract. Grade III injury of esophagus was the independent risk factor for development of ES. Grade III injury of stomach was the independent risk factor for development of GOO.

Surgical treatment of caustic esophageal strictures in adults

BACKGROUND AND AIMS

Caustic esophageal injury is a rare clinical condition in adult patients. Although dilatation, or the conservative approach, is the primary treatment method, some patients require surgical intervention. Because of the rarity of such cases, standard surgical treatment algorithms cannot be utilized. In this article, we present our surgical experience and discuss the challenges in the surgical management of corrosive injury of the esophagus in adults.

METHODS

A retrospective review was conducted of 28 patients who suffered from a corrosive esophageal injury between 1996 and 2011. Patient demographics, history of corrosive material ingestion, preoperative findings, treatment strategy, operative technique, postoperative course, requirements for further treatment, and the current status of the patients were investigated.

RESULTS

All patients underwent a transhiatal esophagectomy in addition to a gastric pull-up with a cervical esophagogastrostomy. The mean follow-up time was 62 (12-140) months. One patient developed a deep surgical infection; anastomotic stenosis was noted and treated with dilatation in 13 patients. The mean time period between the operation and the first dilatation for 12 patients was 81 (45-161) days. The mean dilatation count for the patients was 3 (1-10).

CONCLUSION

Although it comes with high anastomotic stenosis rates, transhiatal esophagectomy and gastric pull-up with cervical anastomosis is a safe procedure, which can be performed for the treatment of corrosive esophageal stricture.

Self-expandable metal stenting of refractory upper gut corrosive strictures: a new role for endoscopy?

Caustic strictures of the gastrointestinal tract are often difficult to treat, since relapses are frequent after medical or endoscopic treatment. Thus, novel approaches are needed. We report here our experience with self-expandable metallic stents (SEMS) as a new endoscopic approach in three patients with corrosive strictures of the upper gastrointestinal tract.

Isolated corrosive pyloric stenosis without oesophageal involvement: an experience of 21 years

BACKGROUND AND STUDY AIMS

Corrosive ingestion is common in Asia and it is a frequent cause of morbidity secondary to intense fibrotic reaction and stricture formation of the oesophagus. Isolated corrosive pyloric stenosis without oesophageal involvement is an uncommon phenomenon.

PATIENTS AND METHODS

All consecutive patients, with corrosive ingestion in the last two decades, were reviewed and analysed. Eleven out of 201 patients with corrosive ingestion had isolated gastric outlet obstruction.

RESULTS

Patients' age ranged from 11 to 29 years with a male:female ratio of 1.75:1. All patients developed pyloric stenosis following ingestion of solution of acids. Barium study revealed complete/near-complete gastric outlet obstruction in all patients. On laparotomy, there was gastric dilatation in 10 patients, who underwent posterior gastrojejunostomy, whereas the stomach was contracted in one patient, and hence anterior gastrojejunostomy was performed. Seven patients were completely relieved of their symptoms; persistent postprandial epigastric fullness and/or dyspepsia was observed in four patients whose gastrojejunostomy stoma was found adequate on barium study, suggestive of gastric motility disorder. We did not encounter gastrojejunostomy-related complication of stomal ulcer/stenosis in our patients.

CONCLUSION

Isolated corrosive pyloric stenosis is not as rare as is commonly thought. Gastrojejunostomy is effective, although a fair percentage of patients appear to develop gastric motility disorder secondary to corrosive injury.

Pediatric gastric outlet obstruction following corrosive ingestion

PURPOSE

Corrosive substance ingestion is still a major medical and social problem for children. Gastric injury after corrosive ingestion is relatively uncommon as compared with esophageal injury. Gastric outlet obstruction (GOO) is a significant complication of corrosive ingestion.

METHODS

Medical records of 20 consecutive patients with GOO due to corrosive ingestion during an 8-year period between 2002 and 2009 were retrospectively reviewed.

RESULTS

There were 10 boys and 10 girls with a mean age of 5.1 years (1.5-15 years). Ingested material was acid in all the patients. Two patients had associated esophageal stricture. The mean time between the ingestion and the development of GOO was 27.8 days (range 21-45 days) and all the patients presented with postprandial epigastric distension, nonbilious vomiting and weight loss. Surgical treatment included gastroduodenostomy (n = 8), Billroth I (n = 7), pyloroplasty (n = 5), and gastrojejunostomy (n = 2) procedures for GOO. Anastomotic stricture requiring a second operation developed in two patients. There was no surgical mortality. The mean follow-up is 3.3 years and all patients are free of symptoms.

CONCLUSION

GOO is one of the most common gastric complications of corrosive ingestion that may require surgical treatment. Prevention of corrosive ingestion has great importance to avoid such complications.

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.

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.

Delayed gastric emptying in patients with caustic ingestion

INTRODUCTION

Patients with caustic ingestion may develop esophageal and/or gastric cicatrization.

OBJECTIVE

Scintigraphic assessment of liquid gastric emptying time in patients with caustic ingestion.

MATERIALS AND METHODS

Consecutive patients with caustic-induced esophageal cicatrization attending the gastroenterology clinic of our institute were studied (patients with age >or=60 years, earlier gastric surgery, vagotomy, peptic ulcer disease, diabetes, systemic sclerosis, and those on gastrointestinal motility-altering drugs were excluded). Gastric emptying time was assessed by radionuclide scintigraphy (ingestion of 200 ml mango juice containing of 18.5 MBq 99mTc sulfur colloid after an overnight fast by static imaging in anterior and posterior projections in supine posture at 10 min intervals each for 1 h). A time-activity curve was generated and gastric half-emptying time (GET 1/2) was calculated. Results were compared with GET 1/2 values estimated for normal individuals in our laboratory (mean+/-2 SD). The emptying study protocol for normal individuals was the same as in patients.

RESULTS

Twenty patients (males 10) median age 32 years, 16 with acid ingestion and four with alkali ingestion, were studied. No patient had symptoms suggestive of gastric outlet obstruction or gastroparesis. Eight patients had evidence of gastric cicatrization in the form of straightening of the lesser curvature and pulling of incisura and duodenal bulb medially and loss of parallelism between the fundus and left dome of diaphragm. Gastric distensibility was however normal in them. As compared with values for normal controls (25+/-9 min), GET 1/2 was significantly prolonged in the study group as a whole (53.2+/-27.77 min, P=0.000). No significant difference was observed between different age groups, sex, or type of caustic agent consumed. GET 1/2 differed in patients (n=10) with stricture involving lower-third of esophagus (72.2+/-27.67 min) when compared with those (n=10) who had a stricture involving upper and/or middle-third of esophagus (34.3+/-8.02 min, P=0.000). In the former, GET 1/2 was maximally prolonged in patients (n=6) with involvement of the lower esophagus and reduced stomach capacity (84.6+/-27.03 min), followed by patients (n=4) with lower esophageal involvement with normal stomach capacity (53.7+/-17.41 min), but the difference did not reach statistical significance (P=0.078). Patients (n=10) without lower esophageal involvement did not have statistically significant altered GET 1/2 compared with normal controls (P>0.05).

CONCLUSION

Our results show that patients with caustic ingestion have prolonged liquid gastric emptying even in the absence of any gastric symptoms.

Corrosive injury to upper gastrointestinal tract: Still a major surgical dilemma

In the developed and developing countries, corrosive injury to the gastrointestinal system as a consequence of either accidental ingestion or as a result of self-harm has become a less common phenomenon compared to decades ago. This could partly be attributed to the tighter legislation imposed by the government in these countries on detergents and other corrosive products and general public awareness. Most busy upper gastrointestinal surgical units in these countries, especially in the developed countries will only encounter a small number of cases per year. Up to date knowledge on the best management approach is lacking. In this article, we present our experience of two contrasting cases of corrosive injury to the upper gastrointestinal tract in our thoracic unit in the last 2 years and an up-to-date Medline literature search has been carried out to highlight the areas of controversies in the management of corrosive injuries of the upper gastrointestinal tract. We concluded that the main principle in managing such patients requires a good understanding of the pathophysiology of corrosive injury in order to plan both acute and future management. Each patient must be evaluated individually as the clinical picture varies widely. Signs and symptoms alone are an unreliable guide to injury.

Augmentation gastroplasty using a segment of transverse colon for corrosive gastric stricture

BACKGROUND AND AIMS

Diffuse corrosive gastric stricture is a relatively rare entity, and gastric ablative procedures are traditionally recommended for it. We emphasize the importance of preservation of a cicatrized stomach and describe its augmentation using a segment of transverse colon.

CASE REPORT AND PROCEDURE

A young female with a history of corrosive acid ingestion presented to our surgical unit with nonbilious vomiting following meals, consistent weight loss and features of gastric outlet obstruction. A barium study revealed a small-capacity stomach with pyloric stricture. We planned to augment the stomach capacity by using a segment of transverse colon. After documentation of a normal colon by barium examination, a 15-cm segment of transverse colon was harvested based on middle colic artery. This vascularized patch of bowel was united with the stomach that was opened up by a longitudinal incision made along the body.

RESULT AND FINDING

A barium study on the tenth postoperative day revealed a good capacity and contour of the stomach and free entry of Barium into the small intestine. The patient is tolerating a normal meal and has no vomiting. At 3 months follow-up, the patient had a normal stomach radiologically and endoscopically, with a weight gain of 7 kg.

CONCLUSIONS

Augmentation of corrosive gastric stricture by a segment of transverse colon is an innovative, practical, and useful procedure, although long-term results are awaited.

Deaths due to corrosive ingestion: a 10-year retrospective study

OBJECTIVES

Evaluation of the substances used, macroscopic and microscopic autopsy findings, and the manner of corrosive ingestion deaths in Istanbul are aimed in this study.

METHODS

The autopsy records of the corrosive ingestion cases in Istanbul, Turkey, between 1992 and 2001 are investigated in our retrospective descriptive study.

RESULTS

The cause of death was determined as "corrosive injury" in 23 (0.089%) cases among 25,763 autopsy cases. Among these cases one was in the child age group and the corrosive substance ingestion was accidental, whereas all the other cases were adults and the ingestion was for suicidal intent. Sixteen (69.6%) of the cases were female. Nitric acid was the most frequent agent with 13 cases (56.5%). Necrosis of esophagus was determined in 19 cases (82.6%) and perforation of stomach in 11 cases (47.8%).

CONCLUSION

Guidance and education are important tools for prevention from corrosive injuries, but we believe that the best weapon is to restrict easy access to corrosive agents by prohibiting the free commercialization of these most potent agents.

Gastric outlet obstruction secondary to acid ingestion in children

BACKGROUND/PURPOSE

Gastric outlet obstruction (GOO) is a well-known complication of acid ingestion. However, most reports deal with adults. In this report, the authors present their experience with the treatment of acid-induced GOO in children.

METHODS

The records of patients admitted for unintentional ingestion of corrosive agents between 1980 and 2002 were reviewed retrospectively. Data concerning age at ingestion, type of ingested substance, time between ingestion and the first signs of GOO, weight loss, treatment, complications, duration of hospital stay, and long-term follow-up were reviewed.

RESULTS

GOO was not observed in any of the children admitted for alkaline ingestion, whereas GOO developed in 8 of 98 children (8.2%) in a mean period of 26.7 +/- 10 days after the ingestion of acid substances. Presenting symptoms were frequent nonbilious vomiting and marked weight loss. All had pyloric obstructions in the upper gastrointestinal series and required surgical intervention. Gastrojejunostomy was the operation of choice for all patients. Oral feedings were started on the third postoperative day. The complications were wound infection in 1 and upper gastrointestinal bleeding in another in the early postoperative period. Mean follow-up is 8.33 +/- 4.45 (4.8-18.7) years. No late complications such as marginal ulcus or stricture at the anastomosis site were observed in the series.

CONCLUSIONS

Treatment of GOO with gastrojejunostomy gives good long-term results in children. This procedure is safe and causes minimal morbidity particularly in patients without extensive gastric damage.

Corrosive ingestion in adults

Ingestion of a corrosive substance can produce severe injury to the gastrointestinal tract and can even result in death. The degree and extent of damage depends on several factors like the type of substance, the morphologic form of the agent, the quantity, and the intent. In the acute stage, perforation and necrosis may occur. Long-term complications include stricture formation in the esophagus, antral stenosis and the development of esophageal carcinoma. Endoscopy should be attempted and can be safely performed in most cases to assess the extent of damage. Procedure-related perforation is rare. Stricture formation is more common in patients with second and third degree burns. Corticosteroids may help prevent stricture formation. Esophageal carcinoma may develop beginning 30 to 40 years after the time of injury.

Corrosive injury-induced gastric outlet obstruction: a changing spectrum of agents and treatment

METHODS

During the last 5 years, 61 children were admitted to the authors' hospital because of corrosive substance ingestion, and among them 6 patients were seen with gastric outlet obstruction. Two of them had ingested acid substances, and the other 4 had ingested alkali corrosives. The mean age was 2.9 years (range, 1.5 to 3). Their common complaint was postprandial vomiting, which had begun 3 weeks after the event (range, 1 week to 10 weeks). Endoscopic evaluation and barium contrast radiographies were performed at admission. Four patients had a pyloric stricture, 1 had an antral stricture, and another had an antropyloric stricture. Balloon dilatation of the pylorus (in 1 patient), pyloroplasty (in 3 patients), and Billroth I procedures (in 2 patients) were performed. The mean follow-up period was 22 months (range, 6 weeks to 48 months). One patient, who had undergone a Billroth I procedure, underwent reoperation because of intestinal obstruction 3 months later. On follow-up they are all free of symptoms.

CONCLUSIONS

The treatment of gastric outlet obstruction caused by corrosive ingestion should be treated surgically. Although endoscopic and radiologic evaluation helps to determine the time and necessity, once the diagnosis is confirmed, early definitive surgical intervention should be performed, and the type of the surgery depends mostly on the findings of the surgeon at laparotomy. Endoscopic balloon dilatation of the pylorus maybe attempted in suitable cases. Special care should be given to prevent children from accidental corrosive ingestion.

Tracheoesophageal fistula secondary to muriatic acid ingestion

Acid ingestion may result in a variety of early and late complications. A patient is presented with severe sequelae from muriatic acid ingestion, including a tracheoesophageal fistula which is a previously unreported complication of acid ingestion injury. Recommendations are made for diagnosis and prevention of this potentially lethal complication.