Chemical trauma of the esophagus and stomach

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

METHODS

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

CONCLUSIONS

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

Caustic esophageal lesions in childhood: prevention of stricture formation

Accidental caustic ingestion, a problem of childhood, can lead to esophageal stricture formation. We studied 132 children less than 19 years of age who were admitted to our hospital for suspected caustic ingestion. Forty-nine had burns in the esophagus, 11 of whom had deep and circular burns and were therefore prone to developing esophageal strictures. Only these 11 children were treated for prevention of stricture formation with a special nasogastric tube, functioning as intraluminal stent; this was their sole treatment. No corticosteroids were used. Only one of the 11 developed mild stenosis. In none of the other untreated children was stricture formation observed. Therefore, we believe that this approach spares many children unnecessary treatment and hospitalization, that our nasogastric tube effectively prevents stricture formation, and that there is no need for the use of corticosteroids in the treatment of caustic esophageal lesions in childhood.

Alkaline ingestions

Alkaline ingestion is a potentially life-threatening problem that may confront the emergency physician. It is similar to many other toxins in that children and those who attempt suicide are its most common victims; however, implications in terms of initial stabilization and definitive care are quite distinct. Mucosal exposure to lye results in a quick, deep liquefactive necrosis. Consequently, blind nasotracheal intubation may result in the perforation of damaged tissues in the pharynx and trachea. For similar reasons, the blind passage of a nasogastric tube is contraindicated. The use of diluents in this setting is controversial. If a diluent is used, water and milk are considered the liquids of choice. They may be used to irrigate oropharyngeal burns, but are contraindicated in the face of respiratory compromise, shock, liquid lye ingestion, and perforation of the esophagus or stomach. Cathartics and charcoal are not used after alkaline ingestion. Cathartics, however, are used in miniature alkaline battery ingestions to diminish bowel transit time. Esophagoscopy should be done within 12 to 24 hours after ingestion to directly observe the extent of damage. This procedure should be stopped at the first sign of injury to protect against iatrogenic esophageal perforation. Steroids should be started for circumferential esophageal burns and in those patients with significant injury who are unable to undergo esophagoscopy. IV antibiotics are administered for gastrointestinal perforation and may be used concomitantly with steroids. Miniature alkaline batteries lodged in the esophagus must be removed immediately. The available modalities include fluoroscopy-directed Foley catheter removal, endoscopy, and surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

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.

Prosthetic treatment for chemical burns of the oral cavity

Chemical burns of the mouth, pharynx, and digestive passages have been reviewed in regard to the nature of the injury and wound description. Fabrication of custom mouth protectors to minimize oral scar contracture and its sequelae has been described. Mouth protectors provide flexible but active resistance to the forces of scar contracture and avoid a constant unyielding force that could cause pressure necrosis. Protectors are easy to fabricate and adjust, and permit movement and function of the injured area.

Ingestion of hydrochloric acid

A case of intentional ingestion of concentrated acid, in which both disseminated intravascular coagulation and acute respiratory insufficiency complicated initial resuscitation, is reported. The assessment and the acute management of this unusual problem are reviewed, with emphasis on early endoscopy and laparotomy.

Late sequelae of gastric acid injury

The late sequelae of gastric acid injury follow a predictable pattern and often require operative correction. Pyloric and antral stenoses are the most commonly cited late complications of acid ingestion. Other late sequelae include intractable pain, achlorhydria, protein-losing gastroenteropathy, duodenal atonicity, radiographic abnormalities, mucosal metaplasia, and gastric carcinoma. Resection of the injured gastric segment appears to provide the most favorable long-term result. Diligent patient follow-up is required to ensure adequate restoration of gastrointestinal function and to correct late-appearing complications. The distinction between the expected sites of gastrointestinal injury in acid versus alkali ingestion has become less clear with the recent introduction of readily available concentrated liquid household alkaline products, and the incidence of late gastric sequelae of caustic injuries has increased accordingly.

Severe corrosive gastritis related to Drano: an unusual case

A case of lye ingestion by a suicidal patient in the form of Drano in capsules is reported. Although lye ingestion usually causes lesions in the oropharynx and severe esophagitis, in our patient it produced severe gastritis with minimal esophageal findings because of the protective capsules which dissolved primarily in the stomach. Endoscopy should be the first method of evaluating patients with ingestion of corrosives, but an upper gastrointestinal (UGI) series can accurately demonstrate mucosal injury and extent of involvement. UGI can be used as an adjunct in patients incompletely examined by endoscopy and can play an important role in the follow-up examination of these patients.

Acid ingestion: toxicology and treatment

The effects of strong acid ingestion are distinctly different from those of alkali. Strong acids produce superficial injuries to the esophagus and deep injuries to various portions of the stomach. Prevailing early treatment recommendations of simple dilution or weak-base neutralization are inappropriate because of their extraordinary thermal results. Dilution of concentrated sulfuric acid with an equivalent volume of water results in a temperature elevation of approximately 80 C. Neutralization results in even greater heat production. Vigorous gastric aspiration prior to cold fluid lavage is the management of choice in cases treated immediately following acid ingestion.

Emergency management and sequelae of acid ingestion

Because it causes immediate pain when taken into the mouth, strong mineral acid is less often swallowed than corrosive alkali, but psychotic, inebriated or determined individuals may consume lethal amounts. Burns of the oropharynx and glottis may lead to asphyxial death. Acid has only superficial effects upon the esophagus but, upon reaching the stomach, flows along the lesser curvature, induces pylorospasm, and pools in the distal antrum. Pyloric stricture is the most common late complication among survivors. Due to the rapidity with which acid acts, local and systemic therapy must be expeditious. Neutralization and demulcification are recommended but no time should be lost if weak alkali is not readily available. Lavage has limited applicability and induced emesis is strictly contraindicated. Aggressive intravenous fluid therapy, antibiotics, and opiates for pain are needed in most instances. Immediate gastrectomy and steroids are controversial but operative intervention is eventually required following most significant ingestions.

Caustic ingestion and subsequent damage to the oropharyngeal and digestive passages

The characteristics, diagnosis, and management of oropharyngeal and digestive passage lesions due to ingestion of caustic agents are presented. Previous experimental and clinical studies are reviewed with discussion of the peculiar qualities of the newer caustics. Differentiation in treatment of burns caused by solid and liquid agents is stressed.

Surgical management of corrosive gastric injuries

Four cases of extensive corrosive gastric injury requiring surgical treatment are presented. Appropriate management of this life-threatening entity requires an awareness of its subtle presentation plus a well planned surgical approach.

Effect of delayed administration of corticosteroids on wound contraction

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