Caustic injuries to the esophagus in children

Corrosive substances ingestion: a review

Corrosive chemical substance ingestions are a major problem, especially in developing countries, but also in developed countries such as the United States, France, and Belgium. Ingestions may be deliberate as suicide attempts (mostly in adolescents and adults) or accidental (mostly in children). The results can be devastating in terms of individual suffering and disability, but also in terms of resource utilization and costs. In developing countries, outcomes may be worse because of limited medical/surgical resources. Common sequelae include gastrointestinal (GI) tract (esophagus, stomach, pylorus, and duodenum) stricture formation, GI tract perforation, and hemorrhage. Systemic effects may also occur, such as disseminated intravascular coagulation (DIC), multi-organ system failure, and sepsis. Various interventions in the acute phase to reduce the severity of injury have been attempted, but there are no large controlled clinical trials to demonstrate efficacy. Dilation therapy in various forms is commonly used for the treatment of strictures and a variety of surgical procedures including esophagectomy and delayed replacement may be required in severe corrosive injury cases.

The effect of platelet-rich plasma on motility changes in experimental caustic esophageal burn

BACKGROUND

Besides stricture formation, diminished esophageal motility after caustic esophageal burns also plays a role in the deterioration of the clinical course. In this study, we aimed to investigate the effect of caustic burn on the esophageal contractions and the effect of platelet-rich plasma (PRP) on these changes.

METHODS

Twenty-one Wistar albino rats were divided into three groups [Sham operation (n = 8), caustic esophageal burn with NaOH (n = 6), PRP treatment after caustic burn (n = 7)]. After 3 weeks, esophagectomy was performed and contractions and EFS responses were evaluated in the organ bath.

RESULTS

KCl- and acetylcholine-induced responses were reduced in the Burn group, but increased in Sham and PRP groups (p < 0.05). EFS responses were higher in Burn group compared to the other groups. Response with L-arginine was increased in Burn group, but decreased in PRP group. There was more decrease in the contraction in Sham and PRP groups compared to the Burn group after SNP (sodium nitroprusside) incubation (p < 0.05). L-NAME (Nω-Nitro-L-arginine methyl ester) did not change the EFS responses in the Burn group, but EFS responses were decreased significantly in Sham and PRP groups (p < 0.05). EFS responses were decreased in all groups, but more in the Sham and PRP groups after Y-27632 (Rho-kinase inhibitor) incubation (p < 0.05).

CONCLUSIONS

For the first time, we demonstrated that both cholinergic and non-adrenergic non-cholinergic mechanisms are responsible for the altered motility in corrosive esophageal injury. Our results suggest that PRP treatment may be helpful in regulating the esophageal motility and decreasing altered contractions in corrosive burns. This effect may also contribute to the reduction of stricture formation, especially by reducing inappropriate contractions of the esophageal wall during the post-burn healing phase.

Esophageal replacement

This article focuses on esophageal replacement as a surgical option for pediatric patients with end-stage esophageal disease. While it is obvious that the patient׳s own esophagus is the best esophagus, persisting with attempts to retain a native esophagus with no function and at all costs are futile and usually detrimental to the overall well-being of the child. In such cases, the esophagus should be abandoned, and the appropriate esophageal replacement is chosen for definitive reconstruction. We review the various types of conduits used for esophageal replacement and discuss the unique advantages and disadvantages that are relevant for clinical decision-making.

The efficacy of mesenchymal stem cell transplantation in caustic esophagus injury: an experimental study

Introduction. Ingestion of corrosive substances may lead to stricture formation in esophagus as a late complication. Full thickness injury seems to exterminate tissue stem cells of esophagus. Mesenchymal stem cells (MSCs) can differentiate into specific cell lineages and have the capacity of homing in sites of injury. Aim and Methods. We aimed to investigate the efficacy of MSC transplantation, on prevention of esophageal damage and stricture formation after caustic esophagus injury in rats. 54 rats were allocated into four groups; 4 rats were sacrificed for MSC production. Group 1, untreated controls (n: 10). Group 2, membrane labeled MSCs-treated rats (n: 20). Group 3, biodistribution of fluorodeoxyglucose labeled MSCs via positron emission tomography (PET) imaging (n: 10). Group 4, sham operated (n: 10). Standard caustic esophageal burns were created and MSCs were transplanted 24 hours after. All rats were sacrificed at the 21st days. Results. PET scan images revealed the homing behavior of MSCs to the injury site. The histopathology damage score was not significantly different from controls. However, we demonstrated Dil labeled epithelial and muscle cells which were originating from transplanted MSCs. Conclusion. MSC transplantation after caustic esophageal injury may be a helpful treatment modality; however, probably repeated infusions are needed.

Efficacy of intralesional corticosteroid injection in endoscopic treatment of esophageal strictures

BACKGROUND

The present study was conducted to determine the effectiveness of intralesional triamcinolone to improve the results of endoscopic dilation in esophageal strictures.

METHODS

We treated 9 patients with complex strictures of different etiologies (2 postsurgery, 3 gastroesophageal reflux disease, and 4 caustic) with intralesional injections of triamcinolone followed by endoscopic dilations. Outcomes of triamcinolone-treated patients were compared with those of historical control. We injected triamcinolone before dilating the strictures. All the patients were followed up for 1 year. The interval between dilations, frequency of dilation, and refractory rates were calculated.

RESULTS

There was no difference between the control group and the patients with steroids regarding baseline characteristics (age and sex distribution of patients and stricture etiologies, length, and location). The patients in the triamcinolone group had a bigger improvement of their dysphagia and had a lower refractority rate than the patients in control group, these differences being statistically significant.

CONCLUSIONS

Intralesional triamcinolone presented a higher improvement of dysphagia and a lower refractority rate in patients with complex strictures with statistically significant differences.

A novel model approach for esophageal burns in rats

Background:

Corrosive esophageal injury causes serious clinical problems. We aimed to create a new experimental esophageal burn model using a single catheter without a surgical procedure.

Materials and methods:

We conducted the study with two groups of 12 male rats that fasted for 12 h before application. A modified Foley balloon catheter was inserted into the esophageal lumen. The control group was given 0.9% sodium chloride, while the experimental group was given 37.5% sodium hydroxide with the other part of the catheter. After 60s, esophagus was washed with distilled water. The killed rats were examined using histopathological methods after 28 days.

Results:

In comparison with the histopathological changes experienced by the study groups, the control groups were observed to have no pathological changes. Basal cell degeneration, dermal edema, and a slight increase in the keratin layer and collagen density of submucosa due to stenosis were all observed in the group subjected to esophageal corrosion.

Conclusion:

A new burn model can thus, we believe, be created without the involvement of invasive laparoscopic surgery and general anesthesia. The burn in our experiment was formed in both the distal and proximal esophagus, as in other models; it can also be formed optionally in the entire esophagus.

[Management of caustic esophagitis in children]

In children, caustic ingestion is due to accidents at home and inadequate storage of caustic agents. In emergency, it is useful to remove the soiled clothes, rinse the affected area, and prevent vomiting and feeding. Caustic ingestion (pH<2 or>12) induces burns of the upper gastrointestinal tract requiring esophagogastro-duodenoscopy between H12 and H24. Strong alkalis cause necrosis with liquefaction of the esophagus, penetrating deeply with a high-risk of perforation. Management of these children requires a specialized care center with an intensive care unit, endoscopic equipment, and a surgical team. Esophageal stricture is the main complication; no prophylactic treatment (steroids) is effective. Strictures occur after the 3rd week, and barium swallow should be performed by the end of the 1st month. Stricture are often multiple, long, and tortuous; endoscopic dilatation is difficult with a high-rate of perforation and a low-rate of success. In situ application of mitomycin C or injection of triamcinolone could reduce the recurrence rate of stricture. In recalcitrant or recurrent strictures, it is recommended to perform an esophageal replacement using a colonic interposition or a gastric tube. Endoscopy should also be performed 15-20years after caustic ingestion to screen for early neoplastic lesions. Prevention is very important for avoiding caustic ingestions. Information and education should be given specifically to the parents of toddlers; caustic products should be stored out of reach of children and they should not be kept with food.

The efficacy of single-dose 5-fluorouracil therapy in experimental caustic esophageal burn

INTRODUCTION

Accidental ingestion of caustic substances may cause serious problems in children. Approximately 20% of caustic ingestions result in esophageal stricture formation, resulting from excessive collagen synthesis to the extracellular matrix by fibroblasts. Recent studies showed that a single application of 5-fluorouracil (5-FU) is a very effective inhibitor of fibroblast proliferation and differentiation for prolonged periods. Using an experimental model, we investigated the efficacy of single-dose 5-FU on stricture formation after caustic esophageal burn.

MATERIALS AND METHODS

Forty Wistar-Albino rats were divided randomly into 4 equal groups: group 1 (sham-operated group), the esophagus was uninjured and untreated; group 2 (control group), the esophagus was injured and left untreated; group 3 (intraperitoneal treatment group), the esophagus was injured and treated immediately after the burn injury with a single intraperitoneal dose (20 mg/kg) of 5-FU; group 4 (local treatment group), the esophagus was injured and treated immediately after the burn injury with a single intraesophageal application of 5-FU at a concentration of 25 mg/mL. Caustic esophageal burn was produced by instilling 10% NaOH in the distal esophagus. The distal esophagi were harvested at 28 days postoperatively. Histologic sections were assessed by measuring the stenosis index (SI) and histopathologic damage score. Hydroxyproline (HP) levels in the tissues were determined biochemically.

RESULTS

There were significant reductions in the SI (P < .05), histopathologic damage score (P < .05), and HP level (P < .05) in the intraperitoneal treatment group when compared with the control group. No significant differences in the SI and histopathologic damage score were detected between the control and local treatment groups (P > .05), whereas significant reduction in the HP level was determined between these groups (P < .05).

CONCLUSION

A single intraperitoneal dose of 5-FU had a preventive effect on stricture formation after caustic esophageal burn. This observation suggests that 5-FU may prevent this undesirable complication in the clinical setting. Clinical studies are now required to verify this form of treatment. Local intraesophageal application of 5-FU immediately after the burn injury was not effective. Further investigations are required to determine the appropriate timing of application of 5-FU at the local site of injury.

New experimental corrosive esophagitis model in rats

PURPOSE

Caustic esophagitis is a serious clinical problem and many agents are currently tried out in many experimental models. The model of Gehanno is the most commonly used invasive model, which is required general anesthesia and laparotomy. We aimed to form a new pratic and non-invasive model.

METHODS

Twenty rats were studied. The stomachs of the rats were reached through guidance catheter with ether anesthesia, Fogarty catheter was send in through, it was filled with pressure in the stomach. Then, Fogarty was pulled back and stomach entrance was closed. Control group was given; n = 10; 0.25 cc isotonic, injury group was given; n = 10; 0.25 cc, %40 NaOH and it was waited for 60 s. Their esophagi were examined after 28 days.

RESULTS

In the histopathologic evaluation of the control group, no pathology was discovered. Sub-mucosal collagen increase, muscularis mucosa and tunica muscularis damage have all been detected in the injury group p < 0.005; p < 0.003; p < 0.005).

CONCLUSIONS

Corrosive esophagitis was formed without general anesthesia and laparotomy. Burn was formed in the total esophagus, unlike other models in which the burn is just formed at the below end. With our less invasive, more easily applied model; treatment agents can be given just as the corrosive esophagitis can be formed.

The protective effect of erythropoietin on the acute phase of corrosive esophageal burns in a rat model

INTRODUCTION

An experimental study was conducted to investigate the effects of erythropoietin on the acute phase of esophageal burn damage induced by sodium hydroxide.

MATERIALS AND METHODS

A standard esophageal alkaline burn was produced by the application of 10% sodium hydroxide to the distal esophagus in an in vivo rat model. Fifty-six female rats were allocated into three groups: Group BC (baseline control, n = 8) rats were uninjured and untreated, Group PC (positive control, n = 24) rats were injured but untreated and Group EPO (erythropoietin-treated, n = 24) rats were injured and given subcutaneous erythropoietin (1,000 IU/kg per day), 15 min, 24, and 48 h after administration of the NaOH solution. Six animals from Group PC and six from Group EPO were killed at 4, 24, 48, and 72 h after application of NaOH to the esophagus. All of animals in Group BC were killed 4 h after exposure to 0.9% NaCl. Oxidative damage was assessed by measuring levels of malondialdehyde (MDA) and nitric oxide (NO), and activities of superoxide dismutase (SOD) and catalase (CAT) in homogenized samples of esophageal tissue. Histologic damage to esophageal tissue was scored by a single pathologist blind to groups.

RESULTS

MDA levels in the BC and EPO groups were significantly lower than those in the PC group (p < 0.05). CAT and SOD activities, and NO levels in the BC and EPO groups were significantly higher than in the PC group (p < 0.05). Esophageal tissue damage measured at 4, 24, 48, and 72 h after NaOH application was significantly less in the EPO group than in the PC group (p < 0.05).

CONCLUSIONS

When administered early after an esophageal burn induced by 10% sodium hydroxide in this rat model, erythropoietin significantly attenuated oxidative damage, as measured by biochemical markers and histologic scoring.

Mitomycin C decreases the rate of stricture formation in caustic esophageal burns in rats

BACKGROUND

Although the incidence of caustic ingestion is declining, the management of caustic esophageal strictures remains a challenge. Although many agents have been tried experimentally to treat strictures, few have gained clinical application. The aim of this study was to investigate the influence of mitomycin C (MMC), which inhibits fibroblastic proliferation in treating delayed caustic esophageal strictures.

METHODS

Forty-two rats were allocated into 3 groups. Caustic esophageal burns were created as described by Gehanno. Group A was instilled only with saline. Group B was injured with 10% NaOH and left untreated. Group C was injured and received topical MMC at 0.04% concentration in the fourth week. At 56 days, stenosis index (SI), collagen deposition, and hydroxyproline content (HP) were determined in distal esophageal segments. Statistical analyses were performed.

RESULTS

The mean SI in group B was significantly higher than others (SI: 1.15 +/- 0.37 d/lum, P < .05). Collagen accumulation was highest in group B, followed by groups C and A, respectively. Collagen deposition in group C was statistically lower than group B (P < .018). The mean HP in group B was statistically higher than others (5.07 +/- 1.30 microg/mg tissue, P < .05), and similar between groups A and C (1.20 +/- 0.20, 1.91+/- 0.79, respectively, P = .73).

CONCLUSION

In the current study, MMC treatment ameliorated caustic esophageal stricture as reflected in the significantly lower SI. We conclude that MMC application is effective in the treatment of caustic esophageal strictures.

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.

Protective effects of melatonin against caustic esophageal burn injury in rats

Caustic ingestion is one of the most life-threatening events in the pediatric age group, which requires the immediate management and subsequent treatment of its most significant complication, i.e. alterations in esophageal structure. We investigated whether melatonin could reduce the esophageal burn damage induced by sodium hydroxide. It was assumed that melatonin could be effective because of its function as a direct free radical scavenger, its antioxidative actions and its ability to diminish tissue hydroxyproline (HP) levels. Esophageal burns were induced in male rats by the administration of 10% sodium hydroxide. Lipid peroxidation (LPO) products were then measured at the following times: 0, 1, 6, 24, 48 and 72 hr after treatment. Tissue HP concentrations in the injured area were assessed at 14 days after the administration of sodium hydroxide. The groups received either systemic melatonin or normal saline. There were two, non-ischemic, sham control groups treated with or without melatonin. LPO products, malondialdehyde (MDA) and 4-hydroxyalkenal (4-HDA), increased immediately after the administration of sodium hydroxide; this indicates the participation of free radicals in the development of damage. Melatonin diminished the oxidative response and the amount of HP in the late phase of the lesion. Melatonin reduced oxidative damage in the early phase of the esophageal burns induced by sodium hydroxide.

A different aspect of corrosive ingestion in children: socio-demographic characteristics and effect of family functioning

OBJECTIVE

Corrosive ingestion is thoroughly investigated in terms of its complications and treatment modalities but to date family functioning, behavior, attitude and knowledge of mothers of children who ingested corrosives has not been investigated and socio-demographic data has rarely been mentioned. Therefore a study was planned to investigate the socio-demographic data, family functioning, knowledge, behavior and attitude of mothers of children who ingested corrosive materials.

METHODS

The mothers of 50 children who ingested corrosive materials and 60 controls were asked to answer a questionnaire which included socio-demographic data and questions about their attitude, behavior and knowledge of corrosive ingestion. The mothers were also asked to reply family assessment device (FAD) and parental attitude research instrument (PARI).

RESULTS

The average ages of the children were 5.31+/-2.32 in the corrosive group with an M:F ratio of 1:1. The level of education of both mothers (p=0.000) and fathers (p=0.000) in the corrosive group were lower than that of the controls. There was no difference between the two groups in terms of number of working mothers (p=0.085). In the corrosive group the families used to have three or more children (42%) and the socioeconomic status of this group was lower than the controls (p=0.001). In the corrosive group these substances were purchased unlabeled (64%) and kept mainly in coke bottles. The affective involvement dimension of the FAD and the attitude of over-parenting and democratic attitude dimensions of the PARI tests were significantly different in the corrosive group among mothers from lower educational level whereas no difference was detected among mothers from higher educational level in this regard.

CONCLUSION

It was found that both level of education of the parents and socioeconomic factors played important role in shaping the habits that might lead to corrosive ingestion in children. For the prevention of corrosive ingestion broad based strategies including education are required.

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.

Serious injuries from dishwasher powder ingestions in small children

AIMS

To describe patterns and severity of caustic injuries sustained from dishwasher powder ingestion and highlight need for national safety standards.

METHODS

Retrospective chart review of admissions for caustic ingestion to Starship Children's Hospital from January 2003 to January 2005 and review of New Zealand National Poisons Centre data.

RESULTS

Between January 2003 and January 2005, the National Poisons Centre recorded 610 dishwashing powder ingestions, with 88% of children less than 2 years old. Twenty-three children were admitted to Starship Children's Hospital following caustic ingestion, of whom 11 were identified as having ingested dishwasher powder (9 boys and 2 girls) and were aged 11 to 30 months (mean 17.5). Five children (45%) were admitted to the Paediatric Intensive Care Unit over 4 months (October 2004 to January 2005), requiring intubation for airway control. Two children needed tracheostomy. Three of the 11 children (27%) required repeated oesophageal dilatation, and two underwent gastrostomy formation. One brand of dishwasher detergent and container type was implicated in over half of the cases.

CONCLUSIONS

Dishwasher detergents are highly corrosive substances that cause potentially life-threatening injuries and ongoing morbidity. The recent surge of incidents may be related to change in product constituents or non-compliance with New Zealand safety standards. Efforts to limit product alkalinity, legislative requirement of Child-Resistant Packaging and public education may reduce injuries from these common household substances.

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.

Effect of the prostacyclin derivate iloprost in experimental caustic esophageal burn

Previous experimental studies have suggested that administration of antithrombotic, antioxidant, and cytoprotective agents have protective effects in caustic injury of the esophagus. Therefore, an experimental study was carried out to investigate the effects of iloprost, a stable analogue of prostacyclin, on the esophagus after caustic burns. Sixty Wistar albino rats were divided into three groups of 20 animals each. In group A, animals were uninjured and untreated. In group B, animals were injured but untreated. In group C, rats were injured and administered intravenous iloprost for 3 days. Caustic esophageal burn was produced by 1 ml of 15% NaOH. Efficacy of the treatment was assessed by measuring the tissue malondialdehyde (MDA), superoxide dismutase, and glutathione levels with biochemical methods on the 3rd postoperative day. Histopathological evaluation was done on the 28th postoperative day. The level of MDA was significantly increased in group B compared with the other groups. In group B, the histopathological damage score was significantly higher than in groups A and C. There was also a significant difference between groups A and C regarding the histopathologic damage. These results indicate that iloprost has a preventive effect in experimental caustic esophageal burn in rats.

Mitomycin C prevents strictures in caustic esophageal burns in rats

BACKGROUND

Caustic esophageal injuries lead to stricture formation. Although a number of agents have been tried experimentally to prevent strictures, few have gained clinical application. The purpose of this study was to investigate the effectiveness of Mitomycin C (MMC), which inhibits fibroblastic proliferation in preventing caustic esophageal strictures.

MATERIAL AND METHODS

Fifty-six rats were allocated into four groups. Caustic esophageal burns were created as described by Gehanno. Group A was instilled only with saline. Group B was injured and untreated. Groups C and D were injured and received topical MMC at 0.02 and 0.04% concentrations, respectively. At 28 days, stenosis index (SI), collagen deposition, and hydroxyproline content (HP) were determined in distal esophageal segments. Statistical analyses were done.

RESULTS

Mean SI in Group B was significantly higher than others (P < 0.05). Mean SI was statistically higher in Group C than A and D and similar between groups A and D. The greatest accumulation of collagen was found in Group B, followed by Group C, D, and A, respectively. Collagen deposition in Group D was statistically lower than Group B (P < 0.01) and similar to Group C. Mean HP in Group B was statistically higher than others (P < 0.05), significantly higher in Group C than Group D (P = 0.047), and similar between Groups A and D (P = 0.73).

CONCLUSION

MMC was effective in preventing strictures following experimental caustic esophageal injury, in a dose-dependent manner. We consider that it can gain clinical utilization with the establishment of effective mode, dose, and timing of therapy.

Trimetazidine reduces the degree of fibrosis in alkali burns of the esophagus

PURPOSE

The aim of this study was to investigate the efficacy of trimetazidine (TMZ), an antioxidant agent, on the prevention of stricture development after esophageal caustic injuries in rat.

METHODS

Thirty rats were divided into 3 equal groups. A standard esophageal caustic burn was produced by application of 37.5% NaOH for a period of 90 seconds followed by water rinse. Group A (sham) animals were uninjured. Group B rats were injured but untreated. Group C rats were injured and received TMZ (5 mg/kg/d) via intraperitoneal route. Efficacy of the treatment was assessed in 28 days by measuring stenosis index and histopathologic damage score and by determining tissue hydroxyproline content.

RESULTS

The stenosis index in the TMZ-treated group was significantly lower than the untreated group, similarly in the sham laparotomy group (stenosis index: 0.34 +/- 0.10, 0.94 +/- 0.21, 0.38 +/- 0.05, respectively; P < .05). The hydroxyproline level (microgram per milligram of wet tissue) was significantly lower in the TMZ-treated group compared with untreated group, similarly in the sham laparotomy group (1.06 +/- 0.14, 1.33 +/- 0.08, 0.68 +/- 0.15 microg/mg wet tissue, respectively; P < .05). In the untreated group, histopathologic damage score was significantly higher than TMZ-treated group (P < .05).

CONCLUSIONS

Trimetazidine reduces the degree of fibrosis and ameliorates histopathologic damage in experimental model of corrosive esophagitis in rats.

Trapidil, an Inhibitor for Phosphodiesterase and Platelet-Derived-Growth Factor, Ameliorates Corrosive Esophageal Burn in Rats

Corrosive esophageal burn is a common health problem in the pediatric age group and causes serious esophageal injuries. The medical treatment in acute phase of corrosive esophageal injury is of particular importance for prevention of esophageal stricture. We therefore aimed to investigate the possible beneficial effect of trapidil (triazolopyrimidine), an inhibitor for phosphodiesterase and platelet-derived-growth-factor, during acute phase of esophageal corrosive injury. Wistar albino rats were randomly allocated to untreated, treated, and sham-operated groups (n = 10 for each group). Corrosive esophageal burn was generated with 10% NaOH solution. The rats were left untreated (untreated group) or treated with trapidil as a single dose of 40 mg/kg intraperitoneally after one hour of the injury (treated group). Abdominal esophageal segment was isolated and tied in sham-control group. The studied esophageal segment was removed from each animal after 24 hours. Malondialdehyde (MDA) and nitric oxide (NO) levels were measured in the esophageal tissues. The ulcer depth was graded by histopathologic examination. MDA and NO levels were significantly higher in the untreated group than in the treated group. Namely, trapidil treatment significantly decreased MDA and NO levels in the injured tissues, the levels of which are similar to those in the tissues of control animals. The grades of ulcer depth were significantly improved in the treated group. These results indicate that the reactive oxygen radicals increase in the early phase of corrosive esophagitis and cause tissue damage. We suggest that trapidil treatment may be useful in acute phase of corrosive esophageal injury.

Corrosive esophagitis in children

We evaluated the outcome and optimal management of corrosive esophagitis in 24 children (male:female=8:16, mean age 5.0+/-5.4 years old, ranged from 15 months to 18 years of age) from January 1984 to July 2001. In 20 patients this was the result of accidental ingestion, 4 were suicide attempts and 15 patients (63%) were below 3 years of age. The ingested substances included alkali (n=17, 71%), acid (n=6, 25%), and neutral detergent (n=1, 4%). The "dumpling alkaline oil", a traditional food additive used in Taiwan, was the most common culprit in this study. A total of 9 patients ingested the dumpling alkaline oils, which comprised 38% of the total 24 patients and 53% of the 17 alkaline ingestion accidents. Of the patients 21 (88%) suffered from esophageal injury, and 15 among these 21 patients developed esophageal strictures. Esophageal strictures occurred in all patients with second or third-degree burns. Of these 15 patients with esophageal strictures, 9 (60%) received endoscope-associated dilatation and 6 (40%) underwent an operation (esophagectomy and intestinal interposition). The 9 patients who did not develop esophageal strictures had good body weight gain without feeding difficulty (functionally normal recovery). On the other hand, among the 15 patients with esophageal strictures, 9 patients had functionally subnormal recovery and 6 patients had poor recovery with either frequent feeding difficulty or growth retardation. In conclusion, accidental ingestion of alkaline oil is the most common cause of corrosive esophagitis in Taiwan. The degree of burns correlated with stricture formation.

The effect of halofuginone, a specific inhibitor of collagen type 1 synthesis, in the prevention of esophageal strictures related to caustic injury

BACKGROUND

To assess the effects of halofuginone, a specific inhibitor of synthesis of collagen type 1, which is the major constituent of fibrosis, on esophageal stricture formation due to caustic ingestion.

METHODS

Sixty rats were divided into four equal groups: control group; sham laparotomy group; caustic injury without treatment group; caustic injury with halofuginone treatment group. Caustic injuries were done by 50% sodium hydroxide. Halofuginone was administered by the first postoperative day. All animals were sacrificed on day 21; and the results were evaluated by hydroxyproline levels, stenosis index, lumen diameter, histopathological evaluation, wall thickness, and animal weights.

RESULTS

Mortality differences were significant comparing group 3 with group 1 and 2 (P = 0.006) and group 4 (P = 0.03). According to hydroxyproline levels, the differences are significantly higher (P <0.001) comparing group 3 with group 1, 2, and 4. The P value was considered significant in all other parameters (P <0.001) for all the groups but group 1 versus group 2 (P >0.05).

CONCLUSIONS

Halofuginone, a specific inhibitor of collagen type 1 synthesis, significantly reduced esophageal stricture occurrence.

Oral Burn Contractures in Children

Oral burn contractures in children present major reconstructive problem. Only few reports in literature discussed oral burns in children. Electrical, chemical, and thermal agents are the main causative agents for oral burns. Oral contractures can be classified into anterior, posterior, and total. Anterior contractures are usually caused by electrical burns and involve the oral commissure, lips, anterior buccal sulcus and surrounding mucosa, and anterior tongue. Posterior oral contractures are caused by caustic ingestion and involve the posterior buccal mucosa, posterior tongue, retro-molar area and oro-pharynx. Total oral contractures involve the lips, tongue, oral cavity, and oro-pharyngeal mucosa and are caused by lye caustic ingestion. This report reviews three children; one with posterior, two with total oral cavity contracture. All cases were managed by linear release of scar contracture and skin grafting followed by a prolonged intra-oral splinting with a fixed mouth-block and commissural splint. A successful outcome was observed in all cases.

Estudo morfológico macro e microscópico da gastrite cáustica em ratos

OBJETIVOS: A ingestão de álcalis provoca graves lesões no tubo digestório alto. A comercialização de substâncias cáusticas em forma líquida facilita o seu uso com intenções suicidas e torna as afecções por elas provocadas relativamente comuns. Nesse sentido, o objetivo do presente trabalho foi avaliar as conseqüências morfológicas da infusão de substância cáustica no estômago murino. MÉTODO: Foram estudados 20 ratos Wistar adultos, de ambos os sexos. Após jejum alimentar de 12 horas, instilou-se 1ml de hidróxido de sódio (NaOH) a 5% através de cateter orogástrico. Os ratos foram divididos aleatoriamente em quatro grupos (n=5), de acordo com o tempo de acompanhamento: 24 horas, sete dias, 30 dias e 90 dias, respectivamente. Decorrido o tempo de acompanhamento, os ratos foram mortos e seus estômagos foram avaliados macro e microscopicamente. RESULTADOS: Após 24 horas, os estômagos estavam dilatados e com aderências ao fígado, omentos e pâncreas. Suas mucosa e submucosa apresentavam áreas de necrose de coagulação do corpo e do antro entremeada por intensa infiltração bacteriana. Após sete dias, os estômagos permaneciam dilatados e mantendo o mesmo padrão necrótico anterior, porém sem os focos sépticos. Nos grupos de um e três meses, a cavidade abdominal teve aspecto normal. Os estômagos apresentavam consistência endurecida e com proliferação fibrovascular. CONCLUSÃO: Os animais que sobreviveram à necrose e à intensa infiltração bacteriana da primeira semana desenvolveram reparação progressiva de seus estômagos, porém acompanhada de complicações decorrentes da fibrose cicatricial.

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.

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.

Gastric tubes in children with caustic esophageal injury: a 32-year review

PURPOSE

Caustic injury to the upper aerodigestive system with scarring of the pharynx, hypopharynx, and esophagus is a challenging reconstructive problem. The author has used the gastric tube for this purpose for three decades.

METHODS

During the last 32 years (1965 to 1996 inclusive) the author treated 11 patients who required esophageal replacement with a gastric tube conduit, which was anastomosed to the cervical esophagus. At the time of injury, ages ranged from 2 months to 13 years (mean, 3 years) in seven boys and four girls. Time from injury to esophageal replacement was 12 months to 14 years (mean, 5 years). All 11 had multiple dilations before the replacement. Two had injury and scarring of the epiglottis and larynx that required pharyngeal reconstruction and tracheostomy before replacement. Nine patients underwent reconstruction with a gastric tube anastomosed to the cervical esophagus, and the other two had an interposition with an intrathoracic anastomosis. Eight tubes were antiperistaltic and three isoperistaltic. Seven tubes were placed in the retrosternal space, three were transthoracic, and one was subcutaneous. Six tubes were completed in two stages and five in a single stage.

RESULTS

Nontube complications were wound infection (n = 2), perforation (n = 2), paralyzed hemidiaphragm (n = 1), and recurrent laryngeal nerve injury requiring tracheostomy (n = 1). Tube complications were anastomotic leak (n = 9), stricture (n = 8), anastomotic resection (n = 3), ulcer (n = 1), and perforation (n = 1). Six required posttube multiple dilations for several years including self-bouginage (n = 2). All learned to swallow and eat initially with minimal aspiration; only one remains on tube feed supplements. Long-term follow-up (3 to 30 years) includes nine eating normally and not requiring dilations (the tracheostomy boy has chronic lung disease), one lost to follow-up after 1 year, and one death from tube hemorrhage 2 months after operation.

CONCLUSION

Children with caustic injury to the upper aerodigestive system can undergo gastric tube replacement with good results. The majority of the problems relate to the esophagogastric tube anastomosis.

Thermal characteristics of neutralization therapy and water dilution for strong acid ingestion: an in-vivo canine model

OBJECTIVE

To determine whether in-vivo neutralization therapy for acid ingestions will superimpose a thermal injury upon tissue already damaged by acid.

METHODS

An in-vivo canine model was used with repeated measures of tissue and luminal temperatures. All dogs were placed under halothane general anesthesia. The stomach was exteriorized and temperature probes were placed in the lumen and mucosa. 25 mL of 0.5 N HCl (25 degrees C) was placed in the gastric lumen followed 5 minutes later by 75 mL of either 8% NaHCO3 neutralization (25 degrees C, n = 10) or water dilution (25 degrees C, n = 10). Temperature measurements were recorded at specified intervals for 5 minutes post HCl acid exposure and for 30 minutes post treatment. Temperature profiles were analyzed by repeated-measures ANOVA. Post-treatment changes were evaluated using signed-rank tests.

RESULTS

In both treatment groups, treatment resulted in significant decreases in initial mucosa and intraluminal temperatures. Both the mucosa and intraluminal temperatures decreased immediately after treatment with HCO3 by an average of 1.6 degrees C (p = 0.05). In the water dilution treatment group, both temperatures decreased by 1.1 degrees C (p = 0.05). Ensuing post-treatment temperatures increased but did not reach baseline temperatures at any time up to 30 minutes post treatment.

CONCLUSIONS

In the in-vivo setting, there is no evidence of hazardous temperature elevation when a weak alkali or dilution therapy is used to neutralize strong acid-induced injury. Contraindication of this form of emergency treatment should not be based on the preconceived idea that a resultant exothermic reaction will cause a superimposed thermal injury. Further clinical study is needed to determine the clinical utility of this emergency therapeutic modality.

Liquid household bleach ingestion in children: a retrospective review

Current literature and some standard reference textbooks fail to adequately delineate the management of liquid household bleach (sodium hypochlorite) as different from other caustic agents. A literature review and retrospective study were conducted to focus attention on the clinical course and the low potential for development of long-term sequelae secondary to liquid household bleach ingestion in children. The records of 19 patients were reviewed. The mean age of children ingesting bleach was 24 months. Most children obtained the liquid from an open container such as a cup. There were no short- or long-term sequelae. We introduce an algorithm for the management of accidental ingestion of liquid household bleach in children. We conclude that in the United States accidental bleach ingestion in children is usually associated with a benign clinical course and usually does not require hospitalization, corticosteroids, or antibiotics unless there is severe dysphagia or signs of significant injury. Esophagoscopy may not be necessary, but fiberoptic examination of the pharynx and larynx should be included in the assessment of these children.

Automatic dishwasher detergent poisoning: opportunities for prevention

We investigated the antecedents of ingestion of dishwashing machine detergent to enable the development of effective countermeasures. Parents who had sought advice from the Victorian Poisons Information Centre about dishwasher detergent poisoning exposures of their children were interviewed by telephone. Almost all the children (94 per cent) were aged between 6 and 29 months. Of the 61 children included in the survey, 53 (87 per cent) gained access to the detergent from the dishwasher. Of these, 50 (94 per cent) took the detergent from the dispenser on the internal surface of the door of the machine, and 38 (76 per cent) of these ingested detergent remaining in the dispenser after operation of the machine. Parents were present in the room on 78 per cent of occasions at the time of ingestion. Most parents (72 per cent) were aware of the toxicity of the detergents. Relocation of the dispenser or redesigning it to prevent access both before and after operation would have prevented most of the exposures to detergent. Altering the detergent to prevent caking or sludging might prevent many of the exposures to detergent remaining in the dispenser after operation of the machine. The level of prior knowledge about toxicity suggests that education or additional warnings are unlikely to contribute substantially to prevention of poisoning. Telephone call-back to identified cases is a useful method of investigating complex poisoning problems and developing effective countermeasures.

The rat as a model to evaluate the gastric irritation potential of alkaline products

Animal models historically used to assess the acute gastric irritation potential of accidental ingestion of consumer products include the dog, pig, rabbit, and cat. In looking at alternative methods that are of shorter duration and more cost-effective, the rat is being evaluated as a potential model. Acute gastric irritation is known to increase as the reserve alkalinity of the formulation increases. In initial experiments to assess the rat as a potential model, animals were dosed via oral gavage with 1 of 4 formulations ranging in reserve alkalinity from 4.0 to 10.8. Necropsies were performed at 15 and 60 min after dosing. Macroscopic and microscopic evaluations of the stomach revealed morphological differences in the various treatment groups that distinguish granular formulations having either a low (R.A. = 4.0), moderate (R.A. = 7.1), or higher (R.A. = 10.8) reserve alkalinity. Additionally, it was observed that the acute gastric changes in rats dosed with a liquid formulation having a low (R.A. = 4.2) reserve alkalinity were similar to those in rats dosed with a granular formulation having a moderate reserve alkalinity (R.A. = 7.1). This suggests that other factors such as types of ingredients, pH, and physical form influence the extent of acute gastric irritation and demonstrates that an evaluation of only reserve alkalinity is not sufficient to ensure the safety of these products. This preliminary work supports the rat as a potential model to assess the acute gastric irritation potential of alkaline formulations or substances.

Caustic burns of the upper digestive and respiratory tracts

In a series of 51 children presenting with an accidental caustic burn, symptoms were analysed for their predictive value of significant i.e. necrotizing oesophageal lesions (grade II or III). For the whole group, the incidence of significant oesophageal lesions was 37%. Vomiting and/or respiratory distress were associated with high incidence of significant oesophageal burn (84% and 75% respectively). The particular location of each caustic burn was analysed for its association with caustic burns at other anatomical sites. Of the 18 patients with a laryngeal burn, 72% also had a grade II or III oesophageal burn. The 19 patients with a grade II or III oesophageal burn and the 18 patients with a laryngeal burn, all had lesions at other sites. In the group of 19 patients with a caustic lesion limited to one site, only 1 patient showed mild oesophagitis (grade I) without late sequelae.