Lye 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.

Pediatric caustic ingestion: 50 consecutive cases and a review of the literature

Caustic injury to the aerodigestive tract remains a significant medical and social concern despite various efforts to minimize hazards of caustic household products. Agents with a pH less than two or greater than 12 are extremely corrosive, causing damage that can range from mild to extensive, including esophageal perforation leading to mediastinitis and death at the extreme scale. Methods include retrospective case note review of all admissions to the otolaryngology unit with caustic injury that underwent esophagoscopy to the Children's Hospital Westmead between 1990 and 2007. A protocol-based management system with antibiotics and steroids together with esophagoscopy at 48 hours was implemented. A total of 50 admissions were identified with an average follow-up of 5 years. There were a total of 28 males and 22 females with a median age of 22 months. Forty-nine cases (98%) were accidental. Thirty-eight cases (76%) occurred within the interiors of the family home with the kitchen being the common location. Another seven (14%) occurred within the external environment of the home, usually in the garage or pool shed. The causative agents were varied with 37 (74%) being alkali, three cases (6%) being acidic, and other agents, such as chlorine bleach, being the remainder. The most frequently ingested alkalis were dishwashing powder and disinfectants closely followed by degreasers. Twenty-five children (50%) drank directly from a container with the remainder ingesting granules or powder directly. At esophagoscopy, 17 cases (34%) had grade 1 injury and 10 (20%) had grade 2 injury. Fifty percent of patients of grade 2 injury subsequently developed strictures requiring multiple dilatations. Importantly, six cases (12%) had evidence of esophageal injury without oral injury. Caustic injuries continue to be a significant morbidity in the pediatric patient group. Most cases are still happening as a result of accidental ingestion from unmarked containers within reach of children at home. Oral injury is not always a useful marker of more significant distal injury. A protocol-based management can identify children at risk for long-term stricture earlier.

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.

Corrosive oesophagitis in Nigeria: clinical spectrums and implications

Ingested corrosive agents produce oropharyngeal and gastro-oesophageal injuries ranging from minor burns to severe necrosis, depending on the agent, amount, concentration and duration of exposure. A 10-year (1990-1999) study of 23 corrosive oesophagitis patients depicting the clinical spectrums and implications was done. There were 17 (74%) males and 6 (26%) females, with an average age of 16 years: 35% were in the first decade of life and 39% in the second, with an average occurrence of three new cases a year. The main corrosive agents were alkali (NaOH) 48% and sulphuric acid 39%. The factors that predisposed to corrosive ingestion included: accidental 43%; suicidal 35%; homicidal 13% and 'therapy' 9%. Of the accidental cases 60% were seen in children; 75% of suicide attempts were in the second decade of life. Eleven (48%) patients developed complications, namely laryngeal stenosis 4% and oesophageal strictures 44%. The hospital stay ranged from 2-4 weeks. Awareness of the dangers of corrosive ingestion should be extensively publicized. Government regulations permitting the sales and procurement of corrosive substances should be strictly enforced and, if not yet in place, should be enacted without further delay.

Corrosive esophagitis in children: a 30-year review

Caustic ingestion with resultant corrosive esophagitis in the pediatric population comprises a heterogeneous group in terms of offending agent, location of burn and the degree of damage. Consequently, the treatment of these injuries has also varied over the years and the optimal management remains controversial. Another area of concern that is seldom reported in the otolaryngology literature is the socioeconomic impact of such injuries both on the child and on the family. We report a 30-year retrospective review of aerodigestive tract caustic injuries at The Hospital for Sick Children. Eighty patients were identified with an age range from 1 month to 16 years. Early and late complications are reviewed including 23 patients (29%) that developed medical complications and 16 patients (20%) that developed severe esophageal strictures. Five of these children required repeat prograde dilatation, while 11 children required gastrostomy and stringing with subsequent retrograde dilatation. All the 11 children required esophageal replacement surgery. The economic and social consequences to the child and family were also noted with particular attention to hospital costs, parental absenteeism from work, and the need for job relocation. A partial cost analysis using a child with a severe injury is presented as an example. Psychological aspects such as attempted murder, jail terms and attempted suicides are also documented. We also present an analysis of those children requiring esophageal replacement surgery, and examine the possible role of esophageal stents in recalcitrant strictures.

Effects of estradiol and progesterone on the synthesis of collagen in corrosive esophageal burns in rats

The effects of sex hormones on the synthesis of collagen were investigated in rats with alkali-induced corrosive esophageal burns. In 75 rats, a standard esophageal burn was produced as described by Gehanno. The animals were then grouped as follows: controls (group A), animals with pure esophageal burns (group B), and animals with esophageal burns treated with estradiol and progesterone (group C). All animals were killed on the 28th day of the experiment. Hydroxyproline levels were determined, and histopathologic evaluation was performed for each group. The hydroxyproline levels were significantly lower in the rats treated with estradiol and progesterone. Histopathologically, collagen deposition in the submucosa and tunica muscularis was lower in the estradiol/progesterone group than in the group with pure esophageal burns. Based on the results, the authors believe that estradiol and progesterone inhibited new collagen synthesis, and therefore, alkali-induced esophageal stricture formation.

Epidemiology and prevention of caustic ingestion in children

A total of 102 children less than 16 years of age admitted for caustic ingestion in the period 1976-1991 were registered. The annual incidence rate of hospitalization was 10.8:100,000 for the city of Aarhus, Denmark. Esophageal burns occurred with a frequency of 5.0:100,000 per year. Ninety-four percent of the children were less than 5 years old. For this age group, the incidence rates of admission and esophageal burns were 34.6:100,000 and 15.8:100,000, respectively. All ingestions were accidental. The incidence rates of esophageal burns in children 0-4 years old (p = 0.019) decreased significantly during the period studied. The cause of this decrease is not clear, but a change in the spectrum of household products and the gradual introduction of child-proof caps are possible explanations. To minimize the frequency of accidents, an information campaign directed specifically at parents of toddlers is recommended. Information material should stress that caustics should always be inaccessible to children and stored separately, and should never be decanted.

Caustic ingestion in adults--epidemiology and prevention

A 16 year retrospective review identified 179 patients hospitalized for ingestion of caustic products in Aarhus County, Denmark. Seventy-five were adults over 15 years of age and residents of Aarhus County. The average annual incidence rate of hospitalization for caustic injury in adults was 1/100,000 with an incidence of esophageal burns of 0.8/100,000/y. Of the adults 61% attempted suicide: of these 61% were women. The annual incidence rate for adult women attempting suicide had an increasing trend (p = 0.048). Changes of the incidence rate for unintentional ingestions and for male suicide attempts were not significant. More than half of the suicide attempts were by patients with a history of a psychiatric illness. Of the caustics ingested by adults 94% were liquids. Acids accounted for 55% of the ingested products. Suicidal ingestion of hydrochloric acid was fatal in 6 of 12 adults. The inavailability of liquid caustics in the homes of patients at suicidal risk might prevent impulsive ingestion.

Conservative treatment of caustic esophageal strictures in children

The most common cause of esophageal stricture in children is the accidental ingestion of strong corrosive agents. During a 13-year period between 1976 and 1989, 202 patients were diagnosed as having caustic esophageal strictures at the Hacettepe University Children's Hospital Department of Pediatric Surgery. A retrospective clinical study was performed to find out the place and predictors of a successful outcome for conservative treatment in children who have caustic esophageal strictures. Two hundred two children, of whom 145 were male (71.7%) and 57 female (28.3%) with 168 (83.2%) being younger than 6 years of age, were evaluated retrospectively. Whereas only 49.3% of patients could be treated within a 12-month period, 50.7% needed more than 1 year, 32.9% needed more than 2 years, 26.7% needed more than 3 years, and 15.4% needed more than 4 years of periodic dilations in order to become swallowers through native esophaguses. The success of conservative treatment has been higher in patients younger than 8 years of age, and in strictures due to caustics other than lye involving upper third portion and less than five cm of an esophageal segment. Most caustic esophageal strictures could have been treated by conservative measures in children.

Colonic replacement for the treatment of caustic esophageal strictures in children

Caustic esophageal stricture is one of the most common indications for esophageal replacement in children. During a 13-year period between 1976 and 1989, colonic replacement was performed in 50 patients for the treatment of caustic esophageal strictures at the Department of Pediatric Surgery of Hacettepe University Children's Hospital. A retrospective clinical study was undertaken to discuss the indications and results of colonic replacement. The 50 children, 34 of whom were male (68%) and 16 of whom were female (32%) with 27 patients (54%) under 6 years of age, were evaluated retrospectively. Indications for operation included 21 (42%) who could not swallow saliva and had total or nearly total obliteration of lumen involving more than 3 cm of an esophageal segment at admittance, and 16 (32%) who had difficulty in swallowing within a 1-month period following the last dilation after completion of a 1-year dilation program. A further 13 (26%) had bleeding and difficulties during dilations, after experiencing an esophageal perforation. The right colon was used in 48 and the left in the remaining 2 patients. Patients were followed for at least 1 year following replacement. Growth was excellent in all but one patient who had redundant colon and showed growth retardation. There was one postoperative late death because of massive bleeding from ulceration of the transplanted colon. The other 49 patients were available for accurate follow-up. The results were good, 46 (92%) were able to eat everything, while occasional dysphagia in 3 (6%) required dilation after operation. Colon conduit provides an excellent substitute for esophagus in pediatric patients.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Gastric antral patch esophagoplasty for extensive corrosive stricture of the esophagus

A case is reported of a patient with a 9-cm stricture of the esophagus caused by ingestion of sodium hydroxide, who was treated by gastric antral patch esophagoplasty. In this procedure, a full-thickness pedicled patch of gastric antrum, based on the left gastroepiploic artery, was used to enlarge the esophageal lumen, thus allowing preservation of esophageal continuity and utilization of a functioning lower esophageal sphincter. The patient ate normally after the operation, and radiological, manometric, and esophageal pH monitoring studies indicated satisfactory esophageal function. Gastric antral patch esophagoplasty avoids the complications associated with esophageal bypass or resection. Previous long-term results of this procedure in patients with reflux-induced esophageal stricture have been good, and the technique merits consideration in the treatment of severe corrosive strictures.

Caustic intoxication

After a retrospective study of 17 cases of caustic intoxication in the intensive care unit, the epidemiologic, pathophysiologic, clinic and therapeutic aspects are reviewed. The following procedure is suggested: early endoscopies, abstention of any gastric lavage, corticosteroids and empiric antibiotic therapy and the most early possible introduction of a parenteral nutrition.

Endoscopic diagnosis and treatment of mucosal lesions of the esophagus

The rapid evolution of fiberoptic endoscopes over the past three decades has greatly enhanced our understanding of esophageal diseases and has stimulated significant improvements in their management. With the early endoscopic diagnosis of infectious and inflammatory lesions, specific medical or surgical treatment can be initiated promptly and the results monitored easily. Although the diagnosis of malignant lesions is still commonly delayed because of the absence of early symptoms, surveillance of Barrett's esophagus offers the hope of more definitive management in these patients. Endoscopy has assumed an increasingly important therapeutic role in patients with inoperable cancer because it provides access for new ablative techniques or the placement of palliative prosthetic devices. Continuing advances in the use of endoscopic ultrasound, the delivery of photodynamic therapy, and the adjunctive application of intraluminal irradiation promise to further broaden the scope of fiberoptic intervention.

Early evaluation and therapy for caustic esophageal injury

Forty-one patients with caustic ingestion were reviewed. Eighty-three percent were children, all of whom suffered accidental injury. Liquid drain cleaner was the agent in 57 percent and was responsible for all esophageal burns. Symptoms and physical findings were unreliable in predicting the extent of injury. Endoscopy was performed in most patients within 36 hours of ingestion and accurately estimated the risk of subsequent esophageal stricture formation. Steroid administration had no influence on the development of strictures. Esophageal strictures developed in 22 percent of the patients. One-third were successfully managed by periodic dilation, whereas the remaining two-thirds required esophagectomy and reconstruction. Early endoscopic evaluation was the best means of assessing the degree of injury after caustic ingestion. Routine steroid administration had no apparent clinical benefit.

Corrosive injury of the oesophagus in childhood

A 10-year retrospective review of 73 children who had ingested a corrosive agent was performed. Presentation, management, and eventual outcome were assessed, and comparisons were made between those who received early medical treatment and those who did not. Results suggested that immediate proper assessment of the oesophagus and institution of appropriate therapy may reduce the incidence of complications associated with treatment of subsequent stricture formation. The importance of oesophagoscopy in the direct visualization of the oesophagus within 24-48 h of the burn is stressed.

Management of caustic ingestion in adults

The treatment of 484 adults with caustic ingestion injury is discussed. Signs and symptoms are an unreliable guide to injury and a chest X-ray and fibreoptic endoscopy should be performed as soon as possible. All of the 250 patients who developed superficial lesions of the oesophagus, stomach or duodenum experienced healing without sequelae. Forty-four patients required emergency surgery of whom twenty-four died and oesophagectomy without thoracotomy is now advocated for this group, followed by interval surgery to restore continuity. The remaining 190 patients suffered gastric or oesophageal ulceration without necrosis: 92 recovered without complication, 3 succumbed to aorto-oesophageal fistula, 12 survived following delayed surgery for complications and 83 developed oesophageal and/or gastric stenosis which subsequently required endoscopic or surgical treatment.

Experience with esophageal stenting for caustic burns in children

Seven children with deep circumferential esophageal burns were treated with antibiotics, steroids, and intraluminal silastic stents. Strictures did not develop if the esophagus was healed at the time the stent was removed. However, strictures developed if healing was incomplete. Esophageal stenting needs to be continued until healing has been demonstrated endoscopically.

Caustic injuries to the esophagus in children

The ingestion of caustic chemical agents, usually accidentally by children, produces a wide range of injuries from minor mouth burns to necrosis of the esophagus and stomach. The type of agent, amount, concentration, and duration of exposure are the determining factors. The treatment for the average burn is fairly well standardized, but the serious injuries require prompt recognition of complications and appropriate therapy to prevent more serious complications.

Caustic ingestions. Pathophysiology, diagnosis, and treatment

More than 5,000 caustic ingestions are estimated to occur each year. Liquid lye is associated with the greatest morbidity. Endoscopy is the only method for evaluating the extent of the injury; clinical signs and symptoms (e.g., vomiting, dysphagia, abdominal pain, oral burns, leukocytosis) are not reliable. In less severe burns (involving only mucosal irritation or ulceration), current therapy with antibiotics and steroids results in a very favorable prognosis. Circumferential or very deep burns have a much poorer outcome, with a greatly increased risk of stricture formation and/or perforation. The risk of developing esophageal carcinoma may be 1,000 times greater for individuals who have had a lye burn than in the general population. It cannot be overemphasized that prevention is still the key to decreasing this morbidity.

Nasogastric Intubation as Sole Treatment of Caustic Esophageal Lesions

In this partly retrospective and partly prospective study, we examined 200 patients with suspected caustic ingestion. No steroids were administered to the patients involved. Lesions in the esophagus were found in 93 patients. Thirty-two patients with deep circular burns had nasogastric tubes inserted immediately. Of these patients, two developed esophageal strictures, but subsequent dilatation was successful. No stricture formation was observed in the group of patients with noncircular lesions. We feel that this low percentage of stricture formation is due to the use of nasogastric tubes. Since neither the presence nor the severity of esophageal burns is predictable, an endoscopy should be performed in all suspected cases. In the absence of severe pharyngeal lesions, the use of a flexible fiberoptic endoscope is preferable because it also allows examination of the stomach and proximal part of the duodenum.