Caustic esophageal lesions in childhood: prevention of stricture formation

Foregut caustic injuries: results of the world society of emergency surgery consensus conference

INTRODUCTION

Lesions of the upper digestive tract due to ingestion of caustic agents still represent a major medical and surgical emergency worldwide. The work-up of these patients is poorly defined and no clear therapeutic guidelines are available.

PURPOSE OF THE STUDY

The aim of this study was to provide an evidence-based international consensus on primary and secondary prevention, diagnosis, staging, and treatment of this life-threatening and potentially disabling condition.

METHODS

An extensive literature search was performed by an international panel of experts under the auspices of the World Society of Emergency Surgery (WSES). The level of evidence of the screened publications was graded using the Oxford 2011 criteria. The level of evidence of the literature and the main topics regarding foregut caustic injuries were discussed during a dedicated meeting in Milan, Italy (April 2015), and during the 3rd Annual Congress of the World Society of Emergency Surgery in Jerusalem, Israel (July 2015).

RESULTS

One-hundred-forty-seven full papers which addressed the relevant clinical questions of the research were admitted to the consensus conference. There was an unanimous consensus on the fact that the current literature on foregut caustic injuries lacks homogeneous classification systems and prospective methodology. Moreover, the non-standardized definition of technical and clinical success precludes any accurate comparison of therapeutic modalities. Key recommendations and algorithms based on expert opinions, retrospective studies and literature reviews were proposed and approved during the final consensus conference. The clinical practice guidelines resulting from the consensus conference were approved by the WSES council.

CONCLUSIONS

The recommendations emerging from this consensus conference, although based on a low level of evidence, have important clinical implications. A world registry of foregut caustic injuries could be useful to collect a homogeneous data-base for prospective clinical studies that may help improving the current clinical practice guidelines.

Protective effect of early placement of nasogastric tube with solid dilator on tissue damage and stricture formation after caustic esophageal burns in rabbits

BACKGROUND

The ingestion of caustic substances remains an important public health issue worldwide. Children represent 80% of the ingestion injury population globally. Accidental alkaline material accounts for most caustic ingestions. There is no conclusive evidence of tissue damage and stricture protection of a nasogastric-tube with a solid dilator in the literature, therefore it was hypothesized that early intraesophageal tube placement does not cause additional histopathologic damage and prevents strictures.

METHODS

An exploratory study on experimental caustic esophageal burns in a rabbit model was designed. In the treated group a silicone tube was placed immediately after causing the burns, while the untreated group followed the natural course of the burn. On the twenty-secondday, an esophagectomy was performed on all animals for microscopic (Histopathologic Damage Score and Stenosis Index) and macroscopic analysis.

RESULTS

Forty animals were randomly divided into two groups. The Histopathologic Damage Score was 3.7±1.1 in the treated group versus 3.9±1.2 in the untreated group (p=.9690). The Stenosis Index was 0.6±0.1 in treated rabbits versus 2.3±0.2 in untreated (p<.0001).

CONCLUSION

The early placement of an intraesophageal tube with solid dilator prevents stenosis formation and does not produce greater tissue damage.

Efficacy of keratinocyte growth factor (palifermin) for the treatment of caustic esophageal burns

Current treatment strategies against the development of corrosive esophageal strictures remain unsatisfactory. Thus, the aim of the present study was to investigate the efficacy of keratinocyte growth factor, in the form of palifermin, for the prevention of stricture development following esophageal caustic injuries in a rat model. A total of 32 female Wistar albino rats were divided into four groups, which included the control (C), burn (B), steroid (S) and steroid plus palifermin (S/P) groups. An experimental corrosive esophageal burn model was established in the B, S and S/P groups. Weight gain was recorded and histopathological evaluation was performed for each group. Weight gain in the S and B groups was compared with the control group and statistically significant differences were observed. In addition, statistically significant differences in weight gain were observed between the S/P group and the B group. Histopathologically, statistically significant differences were identified with regard to submucosal collagen deposition, muscularis mucosa and tunica muscularis damage when comparing the B group with the C group. In addition, statistically significant differences were observed when comparing the S and S/P groups with the B group. Furthermore, significant submucosal collagen deposition and tunica muscularis damage were observed in the S group when compared with the S/P group. The stenosis indexes in the C and S groups were significantly lower compared with the B group. In addition, the stenosis index in the S/P group was significantly lower compared with the S group. To the best of our knowledge, the present study is the first to investigate the effect of palifermin on corrosive esophageal burns. The addition of palifermin to the corrosive esophageal burn standard treatment regimen was found to reduce the degree of fibrosis and ameliorate histopathological damage in an experimental model of corrosive esophagitis in rats.

Esophageal stents for severe strictures in young children: experience, benefits, and risk

The use of esophageal stents has been commonplace in adults for many years and for a variety of indications, including palliative care for malignant lesions involving the esophagus. The use of esophageal stents in the pediatric population, however, was limited by the inability to remove them and the implications this has for the growing child, especially for primarily benign esophageal lesions. With the advent of removable, covered stents, the potential uses for stents in children expanded to include treatment of a wide variety of congenital and acquired esophageal strictures. Stenting offers tremendous potential advantage over more traditional pneumatic or bougie dilation in its ability to provide continuous, radially oriented dilation pressure sustained over a period of time. This review examines the published pediatric literature on stents, discusses the indications for their use, outlines the types of stents available, offers technical guidance for proper placement, and reviews subsequent management and complications.

Battery ingestion in children

INTRODUCTION

Ingestion of batteries by children became more frequent in recent years, due to the increasing accessibility of electronic toys and devices to children. Due to their electrochemical composition, impacted batteries in the esophagus may cause an extensive damage. Following the removal of a battery, the post-esophagoscopy management is still controversial.

CASE PRESENTATION

An otherwise healthy 8 year-old boy presented to the pediatric emergency room 3h after the unintentional swallowing of a lithium battery. On examination, the patient was diaphoretic and tachypneic. Plain PA chest film revealed a 2.5 cm diameter radiopaque round object in the upper esophagus. The patient was scheduled for an urgent rigid esophagoscopy which was performed 2h after admission. Esophagoscopy findings included an impacted lithium battery in an advanced emptying process at a level of 17 cm from the incisor teeth, with a 3rd degree ulcerative esophagitis. It was not possible to visualize either the distal esophagus or the stomach. A nasogastric tube was not inserted because of a significant risk for esophageal perforation if bluntly passed. Post-operative medical therapy included fasting, administration of intravenous antibiotic therapy, antacids, and steroids. Flexible esophagoscopy superior to the level of the mucosal injury performed one day later, revealed erosive esophagitis, without evidence of perforation. Upper digestive tract gastrografin swallow test performed 2 days after esophagoscopy did not demonstrate a leak from the esophagus, and oral feeding was carefully re-initiated. Treatment was discontinued the following day. Follow up on days 10 and 14 revealed a healthy child with normal swallowing.

DISCUSSION

Battery ingestion-related injury results from direct pressure necrosis, local electrical currents and alkali leakage. Signs and symptoms of ingested battery are related to impaction duration, size of battery, battery content and peristaltic waves of the esophagus. Appropriate imaging studies should be performed to maximize identification of the foreign body before esophagoscopy. Esophageal stenting and adjuvant medical therapy (steroid therapy, antibiotic therapy and anti-reflux therapy) have a low evidence level of clinical benefit following caustic injuries from impacted batteries and spillage of their content to the esophagus. A judicious management should be tailored in each patient. Increased public and health personnel awareness is necessary to diminish the incidence of battery ingestion.

Clinical characteristics and complications in oral caustic ingestion in children

The aim of this study is to evaluate the prevalence of gastrointestinal symptoms in caustic ingestion, the severity of lesions and the role of early conducted endoscopy in prediction of outcome. In a cross-sectional study all children hospitalized for caustic ingestion during two years, aged 12 years and younger were evaluated for clinical history, endoscopic findings, method of treatment and observed complications. Out of 51 children, 8 consumed acidic and 43 alkaline materials. The mean age of the children was 35.9 +/- 18 months. Thirty four (66.7%) patients were male and 17 (33.3%) were female. In endoscopic survey, 38% had grade 1 and 62% had a burning intensity of grade 2 or higher. During the follow-up, esophageal structure developed in 5 cases and Gastric Outlet Obstruction (GOO) in 1 case. Two of 5 patients with stricture were treated by endoscopic dilatation and 3 of them underwent colon transposition surgery. Gastrectomy was done for the patient with GOO. Esophageal structure as a complication had a more incidence in acid ingestion. Gastric Otlet Obstruction (GOO) occurred in a case of acid ingestion. One of the patients died. Positive statistical relation between early endoscopic findings and complications found in control endoscopy suggest that early endoscopy probably is safe and provides important prognostic information. The role of prevention as a comprehensive strategy promoted by medical councils and the mass media is imperative.

A new endoscopic technique for suspension of esophageal prosthesis for refractory caustic esophageal strictures

There is no clear consensus concerning the best endoscopic treatment of benign refractory esophageal strictures due to caustic ingestion. Different procedures are currently used: frequent multiple dilations, retrievable self-expanding stent, nasogastric intubation and surgery. We describe a new technique to fix a suspended esophageal silicone prosthesis to the neck in benign esophageal strictures; this permits us to avoid the frequent risk of migration of the expandable metallic or plastic stents. Under general anesthesia a rigid esophagoscope was placed in the patient's hypopharynx. Using transillumination from the optical device, the patient's neck was pierced with a needle. A n.0 monofilament surgical wire was pushed into the needle, grasped by a standard foreign body forceps through the esophagoscope and pulled out of the mouth (as in percutaneous endoscopic gastrostomy procedure). After tying the proximal end of the silicone prosthesis with the wire, it was placed through the strictures under endoscopic view. This procedure was successfully utilized in four patients suffering from benign refractory esophageal strictures due to caustic ingestion. The prosthesis and its suspension from the neck were well-tolerated until removal (mean duration 4 months). A postoperative transitory myositis was diagnosed in only one patient. One of the most frequent complications of esophageal prostheses in refractory esophageal strictures due to caustic ingestion is distal migration. Different solutions were proposed. For example the suspension of a wire coming from the nose and then fixed behind the ear. This solution is not considered optimal because of patient complaints and moreover the aesthetic aspect is compromised. The procedure we utilized in four patients utilized the setting of a silicone tube hanging from the neck in a way similar to that of endoscopic pharyngostomy. This solution is a valid alternative both for quality of life and for functional results.

Caustic gastroesophageal lesions in childhood: an analysis of 473 cases

Ingested corrosive agents produce oropharyngeal and gastroesophageal injuries ranging from minor burns to severe necrosis, depending on the agent amount, concentration, and duration of exposure. The aim of this study was to present our patients with corrosive ingestion retrospectively. Four hundred seventy-three children younger than 16 years of age (mean age, 3.7+/-0.1 years) who were admitted to our hospital for suspected corrosive ingestion between the years 1995 and 2003 were studied. Two hundred eighty-six (60.5%) of 473 patients were males. Household bleaches (36.6%) and oven cleaners (23%) were the most frequently encountered corrosive agents. During endoscopy, lesions in the esophagus were recorded in 379 children. Eighty-one of the cases had gastric lesions. During the follow-up, esophageal stricture, esophageal perforation, and gastric outlet obstruction (GOO) developed in 11 cases, 1 case, and 2 cases, respectively. Caustic ingestion of alkali substances such as oven cleaner seem to cause more severe injuries. Early admission to the hospital with clinical and endoscopic evaluation and early surgery when required may reduce morbidity and mortality.

The effectiveness of sucralfate against stricture formation in experimental corrosive esophageal burns

PURPOSE

In this study, the effectiveness of sucralfate against stricture formation in experimental corrosive esophageal burn is reported.

METHODS

Sixty-four Swiss albino adult male rats were divided into three groups, group A (control; n, 7), group B (esophageal burn induced but not treated; n, 25), and group C (esophageal burn induced and treated with sucralfate, n, 32). Groups B and C were further subdivided into subgroups for evaluation on days 2, 7, and 28. A standard esophageal burn was performed by the method of Gehanno, using 50% NaOH. Oral sucralfate treatment was given to group C at a dosage of 50 mg/100 g twice daily. The rats were then killed after 2, 7, or 28 days. Levels of tissue hydroxyproline were measured in excised abdominal esophageal segments, and a histopathological evaluation was performed with hematoxylin-eosin and Masson's trichrome staining.

RESULTS

The tissue hydroxyproline levels were significantly lower in group C than in group B (P = 0.017). There was a significant difference in the stenosis index between groups B and C (P = 0.016). When compared with group B, the collagen deposition in the submucosa and tunica muscularis was significantly lower in group C (P = 0.02).

CONCLUSION

Sucralfate has an inhibitory effect on stricture formation in experimental corrosive burns and can be used in the treatment of corrosive esophageal burns to enhance mucosal healing and suppress stricture formation.

Early bougienage for relief of stricture formation following caustic esophageal burns

Accidental ingestion of corrosive substances remains a major health hazard in children. Most infants and children who ingest caustic substances present with very few symptoms or signs. Approximately 40% of caustic substance ingestions result in esophageal injury, but the optimal management of caustic esophageal burns remains controversial, with different treatment modalities in use. The aim of this study was to compare the results of prophylactic early bougienage with dilatation that was begun after stricture development. We retrospectively analyzed the management of 125 pediatric cases of corrosive substance ingestion. For children seen primarily at our institution, initial management consisted of prompt endoscopy. Of 125 children admitted with a history of caustic substance ingestion, 54 were found to have esophageal burns, and 32 underwent treatment for stricture formation. Patients with severe injury were divided into two groups: In group A, consisting of 20 patients, prophylactic early dilatation had been done. In the eight patients in group B, dilatation had begun after stricture development. The strictures had resolved after 6 months of dilatation in patients initially treated with prophylactic early bougienage, whereas in patients in whom dilatation began after stricture development, stricture resolution did not occur for more than a year. The goal of initial treatment is to avoid stricture formation. Although early dilatations do not eliminate stricture formation completely, the stricture can resolve more easily with early bougienage.

Effects of hyperbaric oxygen therapy on caustic esophageal injury in rats

BACKGROUND/PURPOSE

Caustic esophageal burn is a serious problem in pediatric surgery. Even though many clinical and experimental studies had been performed, the complication rate could not be reduced to a satisfying level. In this study, the authors evaluated the effects of hyperbaric oxygen (HBO) therapy in caustic esophageal burn in rats.

METHODS

Rats were divided into 4 groups, and caustic burn at the distal esophagus was created by applying 50% NaOH for 3 minutes in all groups. The first and third groups did not receive HBO therapy. HBO therapy was applied to the second group for 2 days and to the fourth group for 28 days. To evaluate the effects of short-term HBO therapy, the first 2 groups were compared for ulceration, inflammation, and submucosal vascular thrombosis after 2 days. The third and fourth groups were compared for the long-term effects of HBO therapy. Rats in these groups were killed after 28 days and compared for the collagen content, weight, and mortality rate.

RESULTS

In the second group, which received 2 days of HBO therapy, ulcer depth and vascular thrombosis were significantly lower than these in the first group (P =.022 and P =.020, respectively). The fourth group, which received 4 weeks of HBO therapy, had a significantly reduced mortality rate, weight loss, and collagen score and hydroxyproline level if compared with the third group (P =.035; P =.016; P =.028; and P =.033, respectively).

CONCLUSIONS

These results indicate that HBO therapy is useful in caustic esophageal burn both in short-term and long-term use.

The application of vascular technology to esophageal and airway strictures

BACKGROUND/PURPOSE

Strictures of the esophagus and airway tract can be dilated if the strictures can be traversed and dilators passed. Unfortunately, using standard methods, not all strictures can be traversed. The authors set out to find a safe, expeditious, and reproducible way to traverse otherwise impassable strictures of the esophagus and airway.

METHODS

Eight patients (n = 8), over a 2-year period, with strictures were entered prospectively into the study. One patient (n = 1) had a main stem bronchial stricture, and 7 patients (n = 7) had esophageal strictures from the following etiologies: esophageal atresia/tracheoesophageal fistula (EA/TEF) repair, Lye ingestion (n = 2), EA/TEF with gastroesophageal reflux, esophageal atresia without fistula, lye ingestion with colon interposition (n = 2), and iron pill inhalation lodged in left main bronchus. None of the strictures could be passed with conventional maneuvers or instrumentation including endoscopy, guide wires, Fogarty catheters, and filliform and followers. Results of barium studies showed no flow into the stomach. In the bronchial case, no lumen could be identified at bronchoscopy.

RESULTS

Utilizing the "Vascular Surgery Glidewire/Berenstein Catheter System" under fluoroscopy and utilizing the "spinning top" dynamic maneuver intrinsic to this system, all of the strictures were traversed easily. The passage of the wire/catheter system thus allowed sequential dilation of the previously impassable strictures. The mean time to cross the strictures with the wire/catheter system was 1 minute, 10 seconds. (t = 70 seconds). All of the procedures were done in the operating room under general endotracheal anesthesia by the same 2 attending pediatric surgeons.

CONCLUSIONS

The use of vascular surgical technology in difficult, otherwise impassable strictures of the esophagus and upper airway proved to be an extremely effective, easy-to-perform, and reproducible method of therapy. This procedure may obviate the need for resectional surgery in this setting.

Effects of interferon-alpha-2b and octreotide on healing of esophageal corrosive burns

OBJECTIVE

The aim of this study was to investigate the effect of interferon-alpha to 2b and octreotide on the treatment of esophagus corrosive burns.

METHOD

The experimental study was performed on 63 rabbits. Burn was obtained by treating a segment, isolated in cervical esophagus, with NAOH. The rabbits were allocated into three groups (control, interferon, and octreotide). On the fourth, eighth, and 20th days, 7 rabbits randomly selected from each group were killed. Comparisons among the groups were made by taking histopathologic findings, stenosis index, and hydroxyproline production into consideration. Cross-tabulation and analysis of variance tests were used for statistical analysis.

RESULTS

There were no statistically significant differences among the groups in terms of epithelial changes, extension of inflammation, and severity of fibrosis. In terms of severity of inflammation, there was a statistically significant difference between the control and the other two groups. Also, a significant difference was found between the control group and the other two groups in terms of extension of fibrosis on the 20th day. The difference between the control and the two treatment groups was significant on the eighth day and the 20th day measurements. Comparison of the hydroxyproline values showed a statistically significant difference between the octreotide group and the other two groups on the eighth and 20th days.

CONCLUSION

Histopathologic and biochemical findings indicate that, by hindering fibrosis progress, octreotide (and interferon) might be new and promising alternatives in the treatment of corrosive burns of the esophagus.

Local corticosteroid treatment of caustic injuries of the esophagus. A preliminary report

So far, no therapy has been shown to reduce the incidence of strictures in the esophagus after ingestion of caustic agents. Two patients with pronounced caustic ingestion injuries were treated locally with solutions of corticosteroids normally used for inhalation therapy in lung diseases. Serious strictures did not appear, and their swallowing returned to normal. Further studies are needed.

Reactive oxygen radical levels in caustic esophageal burns

PURPOSE

This study was designed to determine the tissue levels of reactive oxygen radicals in caustic esophageal burns in a rat model.

METHODS

Forty rats were divided into four groups of 10 animals each. The control rats were uninjured in group A, and the others were injured rats in groups B, C, and D. Through a median laparatomy incision, a 1.5-cm abdominal esophageal segment was isolated and tied with 2-0 chromic sutures in all groups as described by Gehanno. One milliliter of 10% sodium hydroxide solution in groups B, C, and D and 0.9% saline solution in group A were instilled through the isolated segment via a no. 24 cannula for 3 minutes, then the esophagus was rinsed for 1 minute with distilled water. The studied 1.5 cm of the abdominal esophagus was removed from each animal 24 hours after caustic injury in group B, 48 hours after in group C, and 72 hours after in group D. In group A, studied uninjured segments were removed for biochemical investigation. Tissue malondialdehyde (MDA) and glutathione (GSH) levels were determined for each group.

RESULTS

The mean MDA levels in esophageal tissue were significantly higher in groups B, C, and D than in group A (P < .05). Moreover, the mean GSH levels in the same esophageal tissues were significantly lower in groups C and D than in groups A and B (P < .05).

CONCLUSION

The reactive oxygen radicals may be play an important role in early phase of caustic esophageal burns by increasing the tissue damage.

Caustic injury of the oesophagus. Sixteen years experience, and introduction of a new model oesophageal stent

Caustic ingestion can lead to oesophageal stenosis. We studied 251 patients, 205 of whom were children, in a sixteen-year period. Seventeen patients, of whom one was an adult, acquired deep burns in the oesophagus which had to be treated, to prevent the development of oesophageal strictures. These patients were treated with long-term stenting of the oesophagus with specially designed, silicone rubber stents, impregnated with silicone oil 20 cS, designed by one of us (R.N.P.B.) as the only treatment. Of all models, the twin-tube dilator was the most satisfactory. No corticosteroids were administered. Only one patient developed a mild stenosis. It is therefore our opinion that, when life-saving operations are not indicated, twin-tube stenting of the oesophagus is helpful in treating caustic lesions of the oesophagus and will prevent stricture formation. Corticosteroids were not given in this series, and should be abandoned in the treatment of caustic lesions.

Treatment of corrosive esophageal strictures by long-term stenting

From 1975 through 1992, 932 patients with caustic esophageal burns were admitted to the author's institution. Deep circumferential burns were diagnosed esophagoscopically in 241 children within the first 48 hours postburn. Initial treatment consisted of periodic anterograde and/or retrograde dilations of the injured and scarring esophagus (n = 172). In 1989, a long-term stenting technique was introduced, and a total of 69 patients have been treated in this manner. The healing rates of patients treated with traditional therapy were compared with those of patients who had stenting, and a significant difference was noted (33% v 68%; P <.01). Failure among the stented group was attributable to poor patient compliance and to gastroesophageal reflux resulting from shortening of the esophagus during scar formation.

The management of esophageal strictures in children

During a 10-year period from 1982 to 1992, 36 children and infants were treated for esophageal stricture. The severity of the stricture was indicated by the degree of feeding intolerance manifested by delays in growth and development and confirmed by fluoroscopy and endoscopy. Their ages ranged from one month to seven years. During the first eight years, the initial treatment was the conventional use of Savory dilators. Balloon dilatation was applied in all patients with esophageal stricture during the last two years. According to the etiology of the stricture, patients were divided into three groups. Group A: (seven patients) due to peptic esophagitis following persistent gastroesophageal reflux (GER). Group B: (15 patients) following ingestion of corrosive material. All had severe strictures; two had stomach outlet obstruction in addition. Group C: (14 patients) following repair of esophageal atresia. There was no mortality; however, overall morbidity was 5.5%, as one patient had esophageal perforation during the initial esophageal dilatation and one patient developed anastomotic leak.

Consequences of caustic ingestions in children

A retrospective analysis of 98 patients, less than 15 years of age, treated for caustic ingestion during 1976-1990 was performed to evaluate the modern consequences of caustic ingestion in children and to set indications for esophagoscopies and radiographic and laboratory examinations. Dishwasher detergents were ingested by 56 children. There were no lye ingestions, since lye has not been freely available in Finland since 1969. Household acetic acid (vinegar) was the most commonly (12/23) ingested acid. Primary esophagoscopy was performed in 79 of the 98 cases (80.6%). Esophageal burns were found in 20 patients. Acids caused burns more often than alkalies (9/23 (39.1%) versus 11/75 (14.7%); p = 0.011; 95% confidence intervals (CI) for the difference 5.6-43.3%) and acid burns more often developed into scars (7.4% versus 4%; p = 0.029; 95% CI for the difference 1.4-25.4%). The only esophageal stricture developed after ingestion of a Clinitest tablet. The mean time for hospitalization as a result of acid ingestion was significantly longer than after alkaline ingestion (3.2 (SD 3.5) days, n = 23 versus 1.5 (1.6) days, n = 75; p < 0.05; 95% CI for the difference 0.7-2.8 days). Prolonged drooling and dysphagia (12-24 h) predicted esophageal scar formation with 100% sensitivity and 90.1% specificity, but signs and symptoms did not predict esophageal burns after primary esophagoscopy. Radiographic examinations and leukocyte counts were of no value in predicting esophageal burns and scars. The panorama of caustic ingestion appears to have changed, probably due in part to the law banning sale of lye products since 1969. This type of law should be encouraged elsewhere. Acids cause even more caustic burns than alkalies. Vinegar should be regarded as a potent caustic substance and distributed in baby-safe bottles with appropriate information on its caustic nature. As severe esophageal lesions after accidental ingestion of caustic substances are now rare in children, primary esophagoscopies and hospitalization of patients are not indicated routinely. The decision on esophagoscopy can be made on the basis of drooling and dysphagia during follow-up.

Ingestion of caustic cosmetic products

Twelve children over a 6-year period (1985 to 1991) underwent aerodigestive tract endoscopy after ingestion of lye-containing cosmetic products. All children were less than 2 years of age and had facial and/or oral cavity burns. Eleven of these patients ingested alkaline hair products such as "activators" or "relaxers." Endoscopy revealed pharyngeal burns in five patients but no laryngeal or esophageal burns in any patient. Erythema of the esophageal mucosa was seen in one patient. One patient ingested a solution used in fingernail decorating. This patient sustained extensive superficial burns of the pharynx, larynx, and esophagus and required intubation and admission to the intensive care unit. No long-term sequelae developed. Cosmetic products containing caustic chemicals represent a significant health risk to small children, especially because child-proof packaging is not standard for these products.

Initial symptoms as predictors of esophageal injury in alkaline corrosive ingestions

The predictive value of initial clinical evaluation in the management of alkaline corrosive ingestion remains unclear. This multicenter study was designed to determine if specific clinical signs and symptoms following ingestion of alkaline corrosives could predict significant esophageal injury. Alkaline corrosives were defined by a pH greater than or equal to 12. Signs and symptoms previously suggested as predictive of significant esophageal injury were documented on a standardized data form. Esophagoscopy reports were reviewed blinded to initial symptoms. Three hundred thirty-six alkaline-corrosive ingestions were analyzed. The mean number of symptoms reported in patients who did not have esophagoscopy was 1.2, in patients who had esophagoscopy was 3.0, and in patients that had visualized second or third degree esophageal burns was 4.8. Of 88 patients who had esophagoscopy, 63 (72%) had both the esophagoscopy report and initial symptom assessment available. Esophagoscopy was positive, defined as second or third degree esophageal burns, in 18 of 63 cases (29%). All patients with significant burns were symptomatic. No single or group of initially reported signs and symptoms could identify all patients with potentially serious esophageal burns.

A controlled trial of corticosteroids in children with corrosive injury of the esophagus

BACKGROUND

It is controversial whether treatment with corticosteroids reduces stricture formation in the esophagus after the ingestion of caustic material.

METHODS

We conducted a prospective study over an 18-year period in which 60 children (median age, 2 years) with esophageal injury from the ingestion of caustic material were assigned randomly to treatment either with or without corticosteroids. The corticosteroids were given initially as prednisolon (2 mg per kilogram of body weight per day intravenously) and then as prednisone orally to complete a three-week course. All patients were evaluated by esophagoscopy within 24 hours of the ingestion. Those with moderate or severe esophageal injury had repeat esophagoscopy and barium swallow at follow-up.

RESULTS

Esophageal strictures developed in 10 of the 31 children treated with corticosteroids and in 11 of the 29 controls (P not significant). Four children in the steroid group and seven in the control group eventually required esophageal replacement (P not significant). All but 1 of the 21 children with strictures had severe circumferential burns on initial esophagoscopy.

CONCLUSIONS

There appears to be no benefit from the use of steroids to treat children who have ingested a caustic substance. The development of esophageal stricture was related only to the severity of the corrosive injury.