Caustic ingestion in children-A review

Neonatal chemical burns and child neglect

Differential diagnosis of agents of chemical burns can be challenging in neonates, especially in absence of a clear history of the event. A wide variety of chemical agents, from acids to basics, can be involved. Massive chemical burns over 21% of the body surface of a four-day-old male neonate were observed. At the physical examination, lower chest, abdomen, genital area and upper limbs showed full-thickness contact burns with a clear demarcation line of the skin breakdown related to necrosis of the subcutaneous layer. Head and fingers exhibited small hard brownish eschars. No clear history was referred by the parents, raising the suspect of a child neglect. Due to the critical conditions, it was not possible to identify the chemical agents causing the burns. The prompt excision and synthetic skin grafting was successfull and the baby survived. Considering all the different chemical agents found in the domestic environment, a combination of acid-basic agents may have been involved. Both parents were sentenced to nine years imprisonment for child neglect and wounding with intent.

Inflammatory Causes of Dysphagia in Children

Gastroesophageal reflux (GER) and eosinophilic esophagitis (EoE) are the most common inflammatory causes of pediatric dysphagia, but several other less prevalent conditions should be considered. These conditions can affect one or several aspects of the swallowing process. In some inflammatory conditions dysphagia may be an early symptom. Esophagoscopy and instrumental swallow studies are often needed to determine the underlying diagnosis and best treatment plan. In some inflammatory conditions dysphagia can portend a worse outcome and need for more aggressive treatment of the underlying condition. Consultations with speech language pathology, gastroenterology, dietetics, allergy/immunology and/or rheumatology are often needed to optimize management.

Areca nut-induced oral fibrosis - Reassessing the biology of oral submucous fibrosis

BACKGROUND

Oral submucous fibrosis (OSF) is a pathological condition characterized by excessive tissue healing resulting from physical, chemical, or mechanical trauma. Notably, areca nut consumption significantly contributes to the development of oral fibrosis. The current definition of OSF, recognizing its potential for malignant transformation, necessitates a more comprehensive understanding of its pathophysiology and etiology.

HIGHLIGHTS

Areca nut induces fibrotic pathways by upregulating inflammatory cytokines such as TGF-β and expressing additional cytokines. Moreover, it triggers the conversion of fibroblasts to myofibroblasts, characterized by α-SMA and γSMA expression, resulting in accelerated collagen production. Arecoline, a component of areca nut, has been shown to elevate levels of reactive oxygen species, upregulate the expression of various cytokines, and activate specific signaling pathways (MEK, COX2, PI3K), all contributing to fibrosis. Therefore, we propose redefining OSF as "Areca nut-induced oral fibrosis" (AIOF) to align with current epistemology, emphasizing its distinctive association with areca nut consumption. The refined definition enhances our ability to develop targeted interventions, thus contributing to more effective prevention and treatment strategies for oral submucous fibrosis worldwide.

CONCLUSION

Arecoline plays a crucial role as a mediator in fibrosis development, contributing to extracellular matrix accumulation in OSF. The re-evaluation of OSF as AIOF offers a more accurate representation of the condition. This nuanced perspective is essential for distinguishing AIOF from other forms of oral fibrosis and advancing our understanding of the disease's pathophysiology.

A Novel Rat Model to Simulate the Benign Esophageal Stricture Induced by Endoscopic Submucosal Dissection

Objective

This study aimed to establish a rat model that simulates benign esophageal strictures induced by endoscopic submucosal dissection (ESD).

Materials and Methods

Sixteen male Sprague-Dawley rats were randomly divided into mucosal resection (n = 8) and sham-operated groups (n = 8). The rats in the mucosal resection group underwent a 5-mm three-fourths mucosal resection by way of a 3-mm incision in the distal esophagus under direct visualization via laparotomy. Rats in the sham-operated group underwent a 3-mm incision of the muscularis propria layer in the distal esophagus via laparotomy without mucosal resection. Dysphagia score, weight gain, mucosal constriction rate, and histology were evaluated 2 weeks after surgery.

Results

Technical success was achieved in all the animals. One rat in the mucosal resection group died of infection, and no other complications were observed. Weight gain (P < 0.001) and luminal diameter derived from the esophagograms (P < 0.001) were significantly lower in the mucosal resection group than those in the sham-operated group. Dysphagia score (P < 0.001) and mucosal constriction rate (P < 0.001) were significantly higher in the mucosal resection group than those in the sham-operated group. The inflammation grade (P = 0.002), damage to the muscularis propria (P < 0.001), number of nascent microvessels (P = 0.006), and degree of α-SMA positive deposition (P = 0.006) were significantly higher in the mucosal resection group.

Conclusion

A rat model of benign esophageal stricture induced by ESD was successfully and safely established by mucosal resection.

Experiences of parents of children with corrosive esophageal ingestion: a qualitative study

PURPOSE

To describe the experiences of parents of children treated for corrosive esophageal ingestion.

METHODS

In-depth interviews were conducted with 17 parents (nine mothers and eight fathers) of children who had suffered a corrosive esophageal ingestion requiring hospitalization. Online interviews were also conducted with parents of children who were still undergoing treatment for corrosive esophageal ingestion. The interview guide explored the parents' overall experiences and included research questions that explored the participants' perceptions, thoughts, feelings and problems. The interviews were digitally recorded and transcribed verbatim. Inductive reflective thematic analysis was performed using MAXQDA.

RESULTS

Analysis of the interview transcripts generated three themes and nine sub-themes describing parents' experiences: emotional consequences, social consequences and facilitators. The results reveal that caregivers experienced anxiety and difficulties, prompting them to seek support from their family and social environment.

CONCLUSION

These findings highlight the importance of identifying and understanding parental experiences. This understanding will also enable healthcare professionals to optimize the parental experience in caring for children with corrosive esophageal ingestion within a holistic clinical service. Understanding the experiences of children with corrosive esophageal ingestion from the parents' perspective identifies opportunities for systematic treatment and care.

[Clinical analysis of endoscopic esophageal dilation for the treatment of corrosive esophageal strictures in children]

OBJECTIVES

To investigate the clinical application of endoscopic esophageal dilation in the treatment of corrosive esophageal strictures in children.

METHODS

A retrospective analysis was performed on the clinical data of 15 children with corrosive esophageal strictures who underwent endoscopic esophageal dilation in Children's Hospital, Zhejiang University School of Medicine. The clinical features, treatment modality of endoscopic esophageal dilation, number of dilations, complications, and prognosis were reviewed.

RESULTS

A total of 96 esophageal dilations were performed in the 15 children with corrosive esophageal strictures, with a median of 6 dilations per child. Among them, 9 children (60%) underwent 6 or more dilations. The children with a stricture length of >3 cm had a significantly higher number of dilations than those with a stricture length of ≤3 cm (P<0.05). The children with strictures in a single segment had a significantly better treatment outcome than those with strictures in multiple segments (P=0.005). No complication was observed during all sessions of dilation. The overall effective rate (including significant improvement and improvement) of endoscopic esophageal dilation treatment was 87%, with 2 cases of failure.

CONCLUSIONS

Endoscopic esophageal dilation is an effective and relatively safe treatment method for corrosive esophageal strictures in children, and children with strictures in a single segment tend to have a better treatment outcome than those with strictures in multiple segments.

Outcomes of pneumatic dilation in pediatric caustic esophageal strictures: a descriptive and analytic study from a developing country

OBJECTIVES

Corrosive substance ingestion in children represents a significant public health issue due to its long-term health sequelae. Esophageal stricture, main complication of this dangerous condition, is treated by pneumatic dilation and eventually by esophageal replacement. We aimed, through this study, to report the outcomes of esophageal pneumatic dilation complicating corrosive substance ingestion in children in a developing country.

METHODS

This cross-sectional study was performed on the population of pediatric patients with caustic esophageal stenosis between January 2005 and December 2020. All patients underwent pneumatic balloon dilation. A logistic regression model was built to predict the probability of the occurrence of the event (success/failure) of the dilation. The ROC curve is used to evaluate the performance of the logistic regression model to discriminate between positive and negative values of the dependent variable.

RESULTS

The success rate of pneumatic balloon dilation was 80.4%. The median duration of overall management was 11 months. The severity of caustic stricture observed during endoscopy was significantly linked to worse outcomes (p = 0.001). Multivariate analysis indicated that the severity of stenosis and the number of dilation sessions were independent risk factors for failure of dilation. ROC curve analysis showed that the area under the curve was 71.7%. A Cut-Off point value of 7 provided the best sensitivity and specificity.

CONCLUSION

Pneumatic balloon dilation has been proven to be efficacious in infants with caustic esophageal stricture. Pediatric surgeons should take into account factors to promptly switch to replacement surgery and avoid unnecessary and time-consuming serial dilations.

Procedural and Surgical Interventions for Esophageal Stricture Secondary to Caustic Ingestion in Children

BACKGROUND

Esophageal injury after caustic ingestion can vary in severity and may result in significant long-term morbidity due to stricture development. The optimal management remains unknown. We aim to determine the incidence of esophageal stricture due to caustic ingestion and quantify current procedural and operative management strategies.

METHODS

The Pediatric Health Information System (PHIS) was utilized to identify patients 0-18 years old who experienced caustic ingestion from January 2007-September 2015 and developed subsequent esophageal stricture until December 2021. Post-injury procedural and operative management was identified utilizing ICD-9/10 procedure codes for esophagogastroduodenoscopy (EGD), esophageal dilation, gastrostomy tube placement, fundoplication, tracheostomy, and major esophageal surgery.

RESULTS

1,588 patients from 40 hospitals experienced caustic ingestion of which 56.6% were male, 32.5% non-Hispanic White, and the median age at time of injury was 2.2 years (IQR: 1.4,4.8). Median length of initial admission was 1.0 day (IQR: 1.0, 3.0). 171/1,588 (10.8%) developed esophageal stricture. Among those who developed stricture, 144 (84.2%) underwent at least 1 additional EGD, 138 (80.7%) underwent dilation, 70 (40.9%) underwent gastrostomy tube, 6 (3.5%) underwent fundoplication, 10 (5.8%) underwent tracheostomy, and 40 (23.4%) underwent major esophageal surgery. Patients underwent a median of 9 dilations (IQR 3, 20). Major surgery was performed at a median of 208 (IQR: 74, 480) days after caustic ingestion.

CONCLUSION

Many patients with esophageal stricture after caustic ingestion will require multiple procedural interventions and potentially major surgery. These patients may benefit from early multi-disciplinary care coordination and the development of a best-practice treatment algorithm.

LEVEL OF EVIDENCE

III.

Caustic ingestion leads to pneumonectomy and right colonic interposition, a unique case report

INTRODUCTION

Corrosive ingestion forms serious problem, with various outcomes depending on the time of diagnosis and treatment. We report here a case with rare and dangerous complications.

PRESENTATION OF CASE

A two-year-old girl came to our hospital, complaining of solids' dysphagia. Retrieving her medical history showed that she had ingested a corrosive liquid accidentally. Without knowing the nature of the ingested agent, the local doctor removed it, using nasal gastric tube. This procedure induced vomiting, which in turn led to more damage. She stayed in the area's hospital for 40 days with just supportive treatment. The radiological investigations suggested severe stenosis. The dilation was done, but the patient did not respond after three months of treatment. Therefore, a gastrostomy was done. The esophagus replacement was inevitable, but the parents refused the surgical approach. Three months later, she returned to our hospital complaining of a productive cough. The radiological investigations suggested destruction in the left lung with a high suspicion of tracheoesophageal fistula. The treatment was through a surgical approach by removing the damaged lung tissue and closing the tracheoesophageal fistula. The patient got better after a month of the surgery, which allowed us to replace the esophagus and close the tracheoesophageal fistula.

DISCUSSION

corrosive treatment varies a lot, depending on the patient's situation. Accurate treatment prevents severe and unexpected complications.

CONCLUSION

More stringent instructions should be enacted among medical providers, corrosive agents' producers, and the public to be more careful when dealing with corrosive chemicals.

Caustic esophageal stenosis: A case report of endoscopic dilatation with nasogastric tubes

The management of the esophageal strictures that may result from caustic ingestion has evolved over time, from surgical to endoscopic management. Dilation with nasogastric tubes may be a valuable alternative in places with limited resources.

Caregiver burden of families of children with corrosive esophageal injuries

This cross-sectional and descriptive study aimed to determine care burden of families of children with corrosive esophageal injuries. The study involved 112 parents who had children with corrosive esophageal injury. Caregiver's Stress Scale and Reactions to Helping Family Members Scale were used to assess care burden of families. Caregiver's Stress Scale median score was 7.0 [interquartile range 5.0], and Reactions to Helping Family Members Scale median score was 45.0 [interquartile range 14.0]. The burden of family caregivers was thus found to be high. Factors affecting the care burden were found to be child's age, parents' age, child's weight, substance type and pH, surgery status, and number of surgeries. Nurses should consider these factors when advising and educating these families. Additionally, initiatives including support groups should be planned with regard to the needs of these families with a high care burden.

Decellularized esophageal tubular scaffold microperforated by quantum molecular resonance technology and seeded with mesenchymal stromal cells for tissue engineering esophageal regeneration

Current surgical options for patients requiring esophageal replacement suffer from several limitations and do not assure a satisfactory quality of life. Tissue engineering techniques for the creation of customized “self-developing” esophageal substitutes, which are obtained by seeding autologous cells on artificial or natural scaffolds, allow simplifying surgical procedures and achieving good clinical outcomes. In this context, an appealing approach is based on the exploitation of decellularized tissues as biological matrices to be colonized by the appropriate cell types to regenerate the desired organs. With specific regard to the esophagus, the presence of a thick connective texture in the decellularized scaffold hampers an adequate penetration and spatial distribution of cells. In the present work, the Quantum Molecular Resonance^® (QMR) technology was used to create a regular microchannel structure inside the connective tissue of full-thickness decellularized tubular porcine esophagi to facilitate a diffuse and uniform spreading of seeded mesenchymal stromal cells within the scaffold. Esophageal samples were thoroughly characterized before and after decellularization and microperforation in terms of residual DNA content, matrix composition, structure and biomechanical features. The scaffold was seeded with mesenchymal stromal cells under dynamic conditions, to assess the ability to be repopulated before its implantation in a large animal model. At the end of the procedure, they resemble the original esophagus, preserving the characteristic multilayer composition and maintaining biomechanical properties adequate for surgery. After the sacrifice we had histological and immunohistochemical evidence of the full-thickness regeneration of the esophageal wall, resembling the native organ. These results suggest the QMR microperforated decellularized esophageal scaffold as a promising device for esophagus regeneration in patients needing esophageal substitution.

Functional, nutritional, and developmental assessment of gastric transposition and colonic interposition: Long-term follow-up outcome analysis

PURPOSE

The choice of Esophageal replacement (ER) depends on surgeons' preference and patients' anatomical condition. A cross-sectional study was done to compare the long-term outcomes of two methods of ER, Gastric transposition (GT) and Colonic interposition (CI).

METHODS

Children who had undergone ER from January 1997 to December 2017 with a minimum of two-year post-ER follow-up were evaluated by anthropometry, hepatobiliary scintigraphy, gastroesophageal reflux study, gastric emptying test, pulmonary function test and blood tests.

RESULTS

Twenty-six (Male:female=17:9) children were recruited. The median age at ER was 13 months (interquartile range 9-40 months) and mean follow-up post-ER was 116.7 ± 76.4 months (range 24-247 months). GT:CI was done in 15(57.7%):11(42.3%) cases. A greater number of abnormal oral contrast studies (p = 0.02) and re-operations (p = 0.05) were documented as baseline characteristics with CI group. The presence of gastroesophageal reflux 9/23(39.1%), duodenogastric reflux 6/24(25%), delayed gastric emptying 6/25(24%), abnormal pulmonary function test 14/22(63.6%) were documented during the study period. However, there was no significant(p>0.05) difference in nutritional, developmental and functional outcomes of both operative methods of ER in the study.

CONCLUSION

Assessment of nutritional, developmental and functional parameters in children after ER reveals good long-term results. There was no significant difference in CI and GT.

LEVEL OF EVIDENCE

Comparative study; II.

Caustic Ingestion in Children: The Otolaryngologist Perspective

OBJECTIVES

Caustic ingestion in children is a significant cause of morbidity despite preventive measures. Upon arrival to the emergency department, these children are often initially seen by the otolaryngologist and later on by the gastroenterologist. This study aimed to determine which otolaryngological and gastrointestinal signs and symptoms can better predict abnormal findings on imaging, esophagogastroduodenoscopy (EGD), and complications development.

METHODS

We performed a retrospective chart review of children 18 years or younger admitted because of caustic ingestion between January 2007 and November 2019.

RESULTS

Forty-one children with a median age of 4.2 years (interquartile range, 1.7-16.7 years) were included; of them, 22 (53.6%) were males. Nineteen children (46.3%) underwent EGD, which revealed no pathology in 13 cases (68.4%). Most ingested substances were in the form of liquid (82.9%), accidentally ingested (82.9%), and with an alkaline pH (57.5%). Stridor, dyspnea, drooling, abnormal oral cavity findings, dysphagia, and vomiting were significantly associated with pathological findings on imaging and/or EGD and/or complications development ( P = 0.028, P = 0.028, P = 0.022, P = 0.02, P < 0.001, and P = 0.01 respectively). Laryngopharyngeal group of findings (dyspnea, stridor, hoarseness, sore throat, and/or drooling) predicted a higher risk for complications development than the gastrointestinal group (dysphagia, abdominal pain, vomiting, or abdominal swelling and/or tenderness) ( P = 0.011, P = 0.31 respectively).

CONCLUSIONS

In children, after caustics ingestion, laryngopharyngeal signs and symptoms may predict a higher risk for complications development in comparison with gastrointestinal signs and symptoms. We therefore stress the importance of otolaryngological examination upon arrival to the emergency department.

Caustic ingestion in children treated at a tertiary centre in South Africa: can upper endoscopy be omitted in asymptomatic patients?

PURPOSE

Considering that clinical presentation and gastrointestinal tract (GIT) injuries post-caustic ingestion vary in children, this study aims to establish whether a correlation exists between clinical presentation and endoscopic findings.

METHODS

This retrospective study comprised patients referred to a paediatric surgical unit between 2016 and 2018 within 72 h post-caustic ingestion. Data collected included caustic agents ingested, clinical presentation, endoscopic findings and management. Oesophageal injuries were graded according to the Zargar's endoscopic classification and gastric injuries classified as mild to severe.

RESULTS

Fifty patients with a mean age of 2.4 years were managed during the study period. Potassium permanganate (KMNO4) was the most frequently ingested substance in 27 (54%) patients. All 30 (60%) asymptomatic patients had no positive endoscopic findings regardless of clinical signs. Among the symptomatic patients (n = 20), 15 (75%) had oesophageal injuries (p = 0.01). Stridor was associated with a higher grade of oesophageal injury (p = 0.007).

CONCLUSIONS

Clinical signs and symptoms post-caustic ingestion correlated with endoscopic findings in our study. Endoscopy can be safely omitted in asymptomatic patients, including those with isolated staining secondary to KMNO4 ingestion. Symptomatic patients should have an endoscopy performed within 48-72 h of the insult to diagnose injuries.

Evaluation of Pediatric Early Warning System and Drooling Reluctance Oropharynx Others Leukocytosis scores as prognostic tools for pediatric caustic ingestion: a two-center, cross-sectional study

Caustic chemicals are widely distributed in our environment. Exposure to caustic agents is a lifelong problem associated with severe tissue and mucous membrane injuries. In pediatrics, corrosive exposure is the most common cause of nonpharmaceutical exposure presenting to poison control centers. Therefore, this study evaluated the role of the Pediatric Early Warning System (PEWS) and Drooling Reluctance Oropharynx Others Leukocytosis (DROOL) scores as early in-hospital outcome predictors following corrosive ingestion. The current study was a two-center, retrospective, cross-sectional study carried out among pediatric patients diagnosed with acute caustic ingestion during the past 4 years. Most exposure occurred accidentally among boys (59.4%) living in rural areas (51.9%) of preschool age (50% were 2-4 years old). Residence, body temperature, respiratory rate, vomiting, skin and mucosal burns, retrosternal pain, respiratory distress, Oxygen (O2) saturation, Glasgow Coma Scale score, HCO₃ level, total bilirubin level, anemia, leukocytosis, and presence of free peritoneal fluid were significant predictors of esophageal injuries (p < 0.05). DROOL and PEWS scoring were the most significant predictors of esophageal injuries with worthy predictive power, where odds ratio (95% confidence interval (CI)) was 1.76 (0.97-3.17) and 0.47 (0.21-0.99) for PEWS and DROOL, respectively. At a cutoff of < 6.5, the DROOL score could predict esophageal injuries excellently, with AUC = 0.931; sensitivity, 91.7%; specificity, 72.5%; and overall accuracy, 91.3%. At a cutoff of > 6.5, PEWS could significantly predict unfavorable outcomes, with AUC = 0.893; sensitivity, 94.4%; specificity, 71.9%; and overall accuracy, 89.3%. However, PEWS better predicted the need for admittance to the intensive care unit (ICU). Pediatric Early Warning System (PEWS) and Drooling Reluctance Oropharynx Others Leukocytosis (DROOL) are potentially useful accurate scorings that could predict the esophageal injuries and ICU admission following corrosive ingestion in pediatrics.

Esophageal Diameter as a Function of Weight in Neonates, Children and Adolescents: Reference Values for Dilatation of Esophageal Stenoses

INTRODUCTION

Esophageal stenoses are frequent complications after esophageal atresia surgery as well as after acid, alkali and battery ingestion. Worldwide, repeated balloon dilatations are the most frequently performed procedures for these stenoses. In most cases the stenoses can be dilated sufficiently to allow adequate enteral nutrition. Until recently, age dependent esophageal lumen size has not been established; which was aim of the current study.

METHODS

All children in whom an esophageal contrast imaging was performed between 1/2011 and 5/2021 were included. The width was measured by two investigators at two measuring points in two planes, the diameter was calculated and plotted against the respective weight of the child. Bland-Altmann plots have confirmed the validity of the measurements of both investigators.

RESULTS

Esophagus diameter was measured in more than 100 children. The resulting curves show a very good correlation with weight (upper measuring point: r = 0.86743, p < 0.0001; lower measuring point: r = 0.80593, p < 0.0001).

CONCLUSION

These results are the first to define the esophageal diameter in children. The results of this study may guide physicians performing esophageal interventions including dilatations in future.

The effects of hesperidin on stricture formation in corrosive esophageal burns: an experimental study

AIM/BACKGROUND

Esophageal strictures in children that develop as a result of accidental ingestion of corrosive substances remain an important health problem. The purpose of this study is to determine the effects of Hesperidin, an effective bioflavonoid in the proliferative and exudative phase of inflammation, on the stricture formation in corrosive esophageal burns.

METHODS

Experimental esophageal burns in rats were created using a modified Gehanno and Guedon model with 20% NaOH. Rats were divided into 5 groups. In the Sham group, the distal esophagus was prepared and cannulated according to the model, but no NaOH was administrated. The esophageal burn was created with NaOH in the other groups. The burned groups were divided into two groups as untreated (T¹⁴, T²¹) and treated with 100 mg/kg/day Hesperidin (H¹⁴, H²¹) intraperitoneally, and these groups were divided into two according to their sacrification periods (14 and 21 days). Inflammation, fibrosis, and necrosis were graded by histopathological evaluation in all groups. The efficacy of treatment was evaluated using the weight of rats, stenosis index, and histopathological parameters.

RESULTS

Histopathologic damage scores such as inflammation, necrosis, and fibrosis were lower in the H¹⁴ and H²¹ groups and higher in the T¹⁴ and T²¹ groups. And also stenosis index was found higher in T¹⁴ and T²¹ groups (p < 0.05), while it was similar to the Sham group in H¹⁴ and H²¹ groups. No statistically significant difference was found between the H¹⁴ and H²¹ groups in terms of stenosis index. When weights of the rats at the beginning and end of the experiment were compared, weights of the H¹⁴ and H²¹ groups and the Sham group were similar. There was a significant decrease in the weight of the rats in the T¹⁴ and T²¹ groups (p < 0.001).

CONCLUSIONS

This study is the first to use Hesperidin in preventing esophageal damage in an esophageal caustic burn model. It was shown that Hesperidin was effective in reducing macroscopic and microscopic histopathologic damage in the corrosive esophageal burn model, preventing the stricture formation, and has positive effects on nutrition in rats with an esophageal burn.

Corrosive upper gastrointestinal strictures in children: Difficulties and dilemmas

Children constitute 80% of all corrosive ingestion cases. The majority of this burden is contributed by developing countries. Accidental ingestion is common in younger children (< 5 years) while suicidal ingestion is more common in adolescents. The severity of injury depends on nature of corrosive (alkali or acid), pH, amount of ingestion and site of exposure. There are multiple doubts and dilemmas which exist in management of both acute ingestion and chronic complications. Acute ingestion leads to skin, respiratory tract or upper gastrointestinal damage which may range from trivial to life threatening complications. Esophagogastroduodenoscopy is an important early investigation to decide for further course of management. The use of steroids for prevention of stricture is a debatable issue. Upper gastrointestinal stricture is a common long-term sequelae of severe corrosive injury which usually develops after three weeks of ingestion. The cornerstone of management of esophageal strictures is endoscopic bougie or balloon dilatations. In case of resistant strictures, newer adjunctive therapies like intralesional steroids, mitomycin and stents can be utilized along with endoscopic dilatation. Surgery is the final resort for strictures resistant to endoscopic dilatations and adjunctive therapies. There is no consensus on best esophageal replacement conduit. Pyloric strictures require balloon dilatation , failure of which requires surgery. Patients with post-corrosive strictures should be kept in long term follow-up due to significantly increased risk of carcinoma. Despite all the endoscopic and surgical options available, management of corrosive stricture in children is a daunting task due to high chances of recurrence, perforation and complications related to poor nutrition and surgery.

EFFICACY OF ENDOSCOPIC TOPICAL MITOMYCIN C APPLICATION IN CAUSTIC ESOPHAGEAL STRICTURES IN THE PEDIATRIC POPULATION: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

BACKGROUND

Caustic ingestion and development of esophageal strictures are recognized major public health problems in childhood. Different therapeutic methods have been proposed in the management of such strictures.

OBJECTIVE

To evaluate efficacy and risk of endoscopic topical application of mitomycin C in the treatment of caustic esophageal strictures.

METHODS

We searched MEDLINE, EMBASE, Central Cochrane, and LILACS databases. The outcomes evaluated were dysphagia resolution rate, number of dilations performed in resolved cases, and the number of dilations performed in all patients.

RESULTS

Three randomized clinical trials were included for final analysis with a total of 190 patients. Topical mitomycin C application group showed a significant increase in dysphagia resolution rate, corresponding to a 42% higher dysphagia resolution as compared to endoscopic dilation alone, with statistical significance between the two groups (RD: 0.42 - [CI: 0.29-0.56]; P-value <0.00001). The mean number of dilations performed in resolved cases were significantly less in the topical mitomycin C application group, compared to endoscopic dilations alone, with statistical significance between the two groups (MD: 2.84 [CI: 1.98-3.69]; P-value <0.00001). When comparing the number of dilations in all patients, there was no statistical difference between the two groups (MD: 1.46 [CI: -1.53-4.44]; P-value =0.34).

CONCLUSION

Application of topical mitomycin C with endoscopic dilations in caustic esophageal strictures was more effective in dysphagia resolution than endoscopic therapy alone in the pediatric population. Moreover, topical mitomycin C application also reduced the number of dilation sessions needed to alleviate dysphagia without rising morbidity.

Pediatric tracheal trauma

Tracheal trauma is an uncommon but potentially serious cause of airway injury in children. Presentation may be acute in cases of blunt or penetrating trauma, or delayed in cases of chronic irritation or indwelling endotracheal tubes. Symptoms include dyspnea, progressive respiratory distress, neck and chest swelling and ecchymosis, and dysphonia. Workup is pursued as allowed by the patient's clinical status and may include plain radiography, computed tomography, and endoscopy. Accuracy and efficiency of diagnosis is paramount for those at risk of rapid decompensation. Treatment may include observation, elective and strategic intubation, or primary surgical repair.

Paediatric chemical burns: a clinical review

Although they account for a small proportion of burns in paediatrics, injuries from chemicals can be just as devastating as other mechanisms of burn injury. At least 25,000 chemicals exist which can cause burns: in children, they are often caused by household chemicals via accidental exposure. The mechanism by which corrosive substances produce chemical burns highlights the importance of early and plentiful irrigation of the burn area, removal of contaminated clothes and careful clinical assessment. Surgical intervention is uncommon but often follows the principles for thermal burns. This article reviews the aetiology, incidence, clinical presentation, management, complications and prevention of chemical burns. What is Known • Chemical burns in paediatrics are often caused by accidental exposure to chemicals available at home • Differences in the pathophysiology of chemical burns reinforces the need for early irrigation What is New • New irrigation fluids show promise in adults and need further study in children • The nature of chemical cutaneous burns can make assessment of wound depth difficult. Laser Doppler Imaging (LDI) is an accurate technique that can be used clinically to determine burn depth in thermal burns and is an area of future interest in the assessment of chemical burns.

Iatrogenic esophageal perforation caused by endoscopic dilatation of caustic stricture: Current management and possibility of esophageal salvage

BACKGROUND

Iatrogenic esophageal perforation (EP) is an undesirable complication of endoscopic dilatation of caustic esophageal stricture. We reported our current management protocol with possibility of continuing the dilatation program.

PATIENTS AND METHODS

From January 2009 to January 2020 medical records were reviewed for patients presented with iatrogenic EP. Management according to each case condition was reported.

RESULTS

24 patients were enrolled, aged from 1.5 to 6 years old. Perforation was cervical in one case, abdominal in two cases, and thoracic in 21 cases. Immediate surgical repair was performed in the abdominal cases. Conservative management was chosen in 22 cases; two cases didn't respond and underwent esophageal diversion, and one of them died owing to severe sepsis. Three patients refused another trial of dilatation. Two cases failed to be redilated. 17 patients continued a dilatation program. Time passed between perforation and redilatation ranged from 35 days to 7 months. 15 patients were cured completely from dysphagia, one patient had marked improvement of his dysphagia, and one case with a resistant stricture was referred for esophageal replacement.

CONCLUSION

Preserving the native esophagus is possible after iatrogenic EP of caustic esophageal stricture. A conservative approach should be attempted with caution not to endanger patient's life. Level IV of evidence.

Vocal cord paralysis following lithium button battery ingestion in children

This study reports on vocal cord paralysis caused by esophageal button battery (BB) ingestion in children. Medical records of children with vocal cord paralysis and esophageal BB ingestion treated at a tertiary referral institute between January 2016 and March 2020 were reviewed. Five patients aged 9-58 months were identified; three were male. Each patient had accidentally swallowed a 20-mm-diameter lithium battery (3 CR2032 type and 2 CR2025 type). One battery was removed within 4 h after ingestion, and three batteries were removed within 12 h. Removal of the battery was achieved with rigid esophagoscopy in four patients and direct laryngoscopy in one patient. Four patients had bilateral, and one had unilateral vocal cord paralysis. Three patients underwent tracheotomy; two were tracheotomy-dependent until follow-up, while the third patient died of multiple organ dysfunction syndrome a month after surgery. The two cases without tracheotomy remain under close follow-up.Conclusion: Accidentally ingested button batteries should be removed promptly to avoid severe complications. Respiratory support and neurotrophic treatment in the early stage of vocal cord paralysis may be beneficial for recovery of vocal cord movement. What is Known: • Button battery ingestion in children is extremely harmful, especially when the diameter of the button battery exceeds 20 mm. • Esophageal button battery impaction can cause serious complications such as esophageal perforation, mediastinal infection, tracheoesophageal fistula, vocal cord paralysis, and life-threatening bleeding. What is New: • Vocal cord paralysis in children with button battery ingestion plays an early warning role for identifying the severity of the disease. • Early neurotrophic drugs and glucocorticoid therapy may be helpful for the recovery of vocal cord movement, thereby avoiding tracheotomy.

Accuracy of contrast swallow study in assessment of caustic esophageal stricture length in children: Agreement study

BACKGROUND

Caustic esophageal stricture length assessment is essential for planning endoscopic management and predicting its prognosis. We aimed to assess the accuracy of contrast swallow study (CSS) in measuring stricture length in comparison to endoscopy (definitive investigation for actual length measurement).

METHOD

Medical records of caustic esophageal strictures between 2010 and 2020 were retrospectively reviewed. Reliability study was done to compare between radiological and endoscopic measurement of stricture length.

RESULT

124 CSSs for 91 patients were analyzed. Six studies showed no stricture, single stricture was reported in 101 studies, double strictures were reported in 16 studies, triple strictures were reported in one study (136 radiological stricture). Endoscopy revealed 133 true strictures. Number of the strictures was consistent between CSS and endoscopy in 112 studies (90.3%) and different in 12 studies (9.7%). Eight endoscopies revealed strictures not reported in CSS (5.5% false negative strictures), while 10 CSSs reported 11 strictures that were not detected during the endoscopy (7.6% false positive strictures). Reliability analysis revealed interclass correlation coefficient = 0.6 (95% CI 0.5 to 0.7) indicating moderate reliability.

CONCLUSION

CSS is not accurate in assessing caustic esophageal stricture length. Combination of CSS and endoscopic investigation is better for proper evaluation of these patients. Level III of evidence.

Foreign Body and Caustic Substance Ingestion in Childhood

Foreign body and caustic substance ingestion in childhood are common and require accurate and timely diagnosis to provide appropriate management consistent with the ingested substance/foreign body and clinical presentation as well as the associated risk status to prevent significant complications and morbidity. The aim of this paper was to present foreign body and caustic ingestion in childhood in terms of epidemiology, pathophysiology, diagnostic work-up and appropriate management and potential complications in accordance with clinical presentation and the type of ingested substance/foreign body.

Foreign body and caustic ingestions in children: A clinical practice guideline

Foreign body and caustic ingestions in children are usually the most common clinical challenges for emergency physicians, general pediatricians and pediatric gastroenterologists. Management of these conditions often requires different levels of expertise and competence. Endoscopy is often necessary but there is a high risk of misusing this tool with incorrect timing and indications. The imprecise clinical history frequently leaves clinicians uncertain about timing and nature of the ingestion. Few clinical guidelines regarding management of these ingestions in children have been published, none of which from the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP). An expert panel of Italian endoscopists was convened by the SIGENP Endoscopy Working Group to produce the present article that outlines practical clinical approaches to the pediatric patient with a variety of foreign body and caustic ingestions. The Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) has also endorsed the project since many adult endoscopists usually manage children with these conditions. Differently from the other published guidelines, the proposed one focuses on the role of the endoscopists (regardless of whether they are adult or pediatric gastroenterologists) in the diagnostic process of children with foreign body and caustic ingestions.

Corticosteroid injection of impassable caustic esophageal strictures without dilatation: Does it pave the way to interval endoscopic dilatation?

BACKGROUND/PURPOSE

Endoscopic dilatation of caustic esophageal stricture is the mainstay of therapy. The need for esophageal replacement has decreased over the past decades owing to advancement in techniques of dilatation. In this study, we aimed to assess our results of four-quadrant corticosteroid injection of impassable caustic esophageal strictures followed by a trial endoscopic dilatation.

METHODS

During the period from June 2003 to May 2017, in 340 patients in whom a trial of endoscopic dilatation after corrosive ingestion failed, corticosteroid was injected in 4 quadrants at the site of the stricture in the same setting. After 2 weeks, another trial of endoscopic dilatation was done.

RESULTS

Out of the 340 patients with failed first trial of endoscopic dilatation followed by four-quadrant corticosteroid injection, the second trial of endoscopic dilatation, after 2 weeks, was possible in 255 patients (75%). In the remaining 85 patients (25%), the endoscope could not pass and they were candidate for esophageal replacement.

CONCLUSIONS

Four-quadrant corticosteroid injection of impassable caustic esophageal stricture followed by endoscopic dilatation is a minor procedure which decreased the need of a major procedure to replace the injured esophagus.

TYPE OF THE STUDY

Clinical research paper.

LEVEL OF EVIDENCE

Level III.

Complications of esophageal strictures dilatation in children. A tertiary-center experience

OBJECTIVES

To report the results of endoscopic dilatation of esophageal strictures in children, its complications, and their management. The outcomes of esophageal dilatation differ according to the underlying etiology.

METHODS

The study included 46 patients who underwent esophageal dilatation between 2014-2019. All patients underwent a contrast study of the esophagus before endoscopic dilation to determine the location, number, and length of the narrowing. In addition, the type of dilators (balloon versus semi-rigid dilators), the number of dilatation sessions, the interval between them, and the duration of follow-up were also documented. The median age was 2.47 years, and 26 patients were females. Dysphagia was the main presenting symptom, and the leading cause of stricture was esophageal atresia.

RESULTS

The main treatment modality was endoscopic balloon dilatation (n=29, 63%). The esophageal diameter was significantly increased after dilation (9 [7-11] versus 12 [10-12.8]) mm; p less than 0.001). Topical mitomycin-C was used as adjuvant therapy in 3 patients (6.5%). Esophageal perforation was reported in 2 cases (4.3%). Patients needed a median of 3 dilatation sessions, 25-75th percentiles: 1-5, and the median duration between the first and last dilatation was 2.18 years 25-75th percentiles: 0.5-4.21.

CONCLUSION

Esophageal dilatation is effective for the management of children with esophageal stricture; however, repeated dilatation is frequent, especially in patients with corrosive strictures. Complications are not common, and open surgery is not frequently required.

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.

Pediatric Esophageal Dilatations: A Cross-Specialty Experience

Aim of the Study: Esophageal dilatations are commonly performed in pediatric patients who have undergone an esophageal atresia/tracheoesophageal fistula (EA/TEF) repair or following caustic injury. We sought to compare the practice of esophageal dilatation across different specialties. Methods: We analyzed all patients who had an esophageal dilatation at our center between April 2014 and December 2018. Patients were identified via prospectively maintained databases and clinical coding records. Patients had a combination of dilatations under each specialty: interventional radiology (IR), surgery, and gastroenterology. Results: Thirty-five individual patients underwent 226 dilatations, median dilatations per patient was 3 (1-40). The median age at first dilatation was 18 months (1-194 months). Sixty-eight percent of patients had a previous EA/TEF repair. IR performed 59% of dilatations, surgeons 26%, and 15% by gastroenterologists. Surgeons more frequently were performing initial dilatations (P < .05) and performed more dilatations in EA/TEF patients (P < .0001). There was a significant difference between the time from a surgical dilatation until the next dilatation, 3.7 months, compared with an IR dilatation, 1.8 months (ANOVA, P < .05). Surgeons more frequently increased the size of balloon used (57% versus 33% versus 39%, P < .01). There was no significant difference in balloon size between specialties or in the incremental increase in size between subsequent dilatations. There was one postprocedure perforation, managed conservatively (complication rate = 0.4%). Conclusion: We have demonstrated that on average, patients wait longer after a surgical dilatation until their next procedure, and surgical teams are more likely to increase the size of the dilating balloon. Surgeons tend to be more involved in their postoperative patients in the initial phases of stricture management. Our results suggest the feasibility and safety of a multispecialty approach for these patients.

Immediate and long-term outcome of corrosive ingestion

BACKGROUND

Corrosive ingestion (CI) has short- and long-term consequences. The aim of this study was to assess the outcome of mucosal injury grade ≥ 2A.

METHODS

Consecutive patients between January 2008 and January 2015 who presented within 48 h of CI were included. Details of substance ingested, intent, symptoms, injury grade at endoscopy, and treatment were obtained by a review of medical records. Patients aged less than 15 years or injury grade less than 2A were excluded. Patients were followed up using a structured symptom-based questionnaire and barium swallow.

RESULTS

A total of 112 patients were admitted with CI during the study period. Eighty-two patients were included in the study. There was no relationship between the presence of symptoms or oral mucosal injury and the grades of gastrointestinal mucosal injury. Grades 2B and 3A were the most common grades of mucosal injury. Five patients died at index hospitalization. Patients were followed up for a median period of 31 months (6-72) during which 11 patients were lost to follow up. During follow up, 2 patients with high-grade injury died as a consequence of CI and 4 died of unrelated causes. Sixteen (26.6%) patients remained symptomatic. Forty-three patients underwent barium swallow. Esophageal stricture was identified in 11 patients, gastric stricture in 8, and combined esophageal and gastric in 2. High-grade esophageal mucosal injury was associated with a high risk of stricture formation (p = 0.02).

CONCLUSIONS

CI is associated with high immediate and long-term morbidity and mortality.

Efficacy and risk profile of self-expandable stents in the management of pediatric esophageal pathology

PURPOSE

The purpose of this study was to evaluate the efficacy and risk profile of esophageal stents in the management of complicated pediatric esophageal disease.

METHODS

An IRB-approved, single-center, retrospective review was performed on all pediatric patients (n = 13) who underwent esophageal stent placement (2005-2017). Demographic, perioperative, and outcome data were analyzed (p < 0.05).

RESULTS

Forty-one stents were placed due to recalcitrant strictures (n = 36), perforations (n = 2), and/or fistulae (n = 3). Median age at initial stent placement was 23.8 months (range, 50 days to 16 years), and median stent duration was 36 days (range, 3-335). The recurrence rate for strictures after initial stent removal was 100%. Four (31%) children subsequently underwent definitive operative repair. There were 5 deaths, including 2 related to stent placement. Seventy-one percent of stents were associated with an adverse event, most commonly intraluminal migration (56%). Younger children experienced an increased risk for airway compression and retching (p = 0.010).

CONCLUSION

These data suggest that stents are associated with high complication rates and are not effective as definitive therapy for recalcitrant strictures in children. Although there may be a temporizing role for stents in selected patients, further refinements in stent technologies are needed to help manage this difficult patient population.

LEVEL OF EVIDENCE

Level IV.

Accidents in childhood: casuistry of a tertiary service in a medium-sized city in Brazil

OBJECTIVE

to investigate the main causes and most common risk situations related to childhood accidents, in our local reality.

METHODS

an observational, cross-sectional, retrospective, descriptive, and analytical study from the medical records of patients attended in the pediatric emergency services of the hospital complex of Hospital das Clínicas, Botucatu Medical School - UNESP, in 2016. We included patients from zero to 15 years old who had received medical care related to accidents, determining age, gender, type of accident, period of the day, accident place, and history of previous accidents.

RESULTS

considering all consultations with appropriate medical records, 936 (27.5%) were related to accidents: 588 (62.8%) in male patients and 348 (37.2%) in female patients. As to age, 490 (52.3%) happened with children from zero to five years, 245 (26.2%) with children from six to ten years, and 201 (21.5%) with children over ten years. Falls and local traumas were the most common types of accidents in all analyzed age groups. Most accidents occurred in the afternoon (46.1%), at home (60.7%), and 26.6% of the patients had a history of previous accidents.

CONCLUSION

accidents were responsible for a large portion of urgent care. The high rate of patients with previous accident records indicated the repeated exposure of these children to risk situations.

Caustic Agents Ingestion in Children: A 51-Year Retrospective Cohort Study

OBJECTIVES

Children experience serious gastrointestinal tract injuries due to consumption of caustic agents more often than adults. The aim of the study was to analyze diagnostic methods and treatment of children with esophageal burns according to the degree of the injury.

METHODS

Our one-center population-based retrospective cohort study included 150 children admitted between 1967 and 2018 to Clinic of Pediatric Otolaryngology, Phoniatrics and Audiology of University Children's Hospital in Lublin, Poland, due to the chemical burn of the mouth, throat, larynx, and esophagus. Each patient underwent a thorough laryngological examination and endoscopy to assess the place and degree of injury.

RESULTS

Of 150 patients, 65.3% were male and 34.7% female. The median age was 4 years and 3 months. Salivation, dysphagia, burning sensation, edema, and whitish coating on the oral mucosa, palate, and throat were the most common clinical symptoms. In addition, dyspnea and chest pain were observed in 30% of patients. Esophagus endoscopy results were: Zargar grade I burn (84.7%), grade IIA (8%), grade IIB (2.6%), grade III (0%), and grade 0 (4.7%). Treatment included antibiotics, proton pump inhibitors, analgesics, and intravenous fluid therapy. Late sequelae (scarred esophageal strictures) developed in 20 (13.3%) patients.

CONCLUSIONS

Accidental intake of caustic agents is observed in young children, especially younger than the age of 5. Early esophagus endoscopy should be performed in all patients to assess the grade of injury, plan initial treatment, and predict the risk of developing complications. Early diagnosis and immediate pharmacological treatment reduce the number of late sequelae.

Esophageal caustic injuries in pediatrics: a sobering global health issue

Caustic material ingestion by children is considered a global healthcare issue, especially in low-to-middle income countries. The aim of this article was to review the epidemiology, prevention, and management of caustic material ingestion in pediatric patients, comparing low-to-middle income countries with high-income countries. We conducted an English literature review using PubMed with the following keywords: (caustic OR corrosive) AND ingestion AND (pediatric OR pediatric). Our search retrieved 253 citations; all abstracts were screened by the authors, and 52 articles were finally included in our review. Prevention is key in tackling this issue, but legislation is scarce in low-to-middle income countries. Diagnosis of caustic ingestion is mostly achieved using flexible endoscopy, computed tomography, and endoscopic ultrasound, but access is limited in low-to middle income countries and diagnosis is often delayed. After stabilizing patients, the mainstay of treatment is graded endoscopic dilatation, and rarely, esophageal replacement. We concluded that caustic ingestion represents a serious condition where prevention is the key. Once a child suffers an injury, rapid and careful evaluation of the injury with endoscopy, and a course of close observation and dilations if needed, will often avoid esophageal replacement. When necessary, the stomach is the best first option if it is viable, followed by the colon, and finally, the jejunum.

Transhiatal esophagectomy with gastric pull-up, pyloric exclusion and Roux-en-Y gastroenterostomy for the management of esophageal caustic injury

•

The authors present a surgical option for the management of esophageal caustic injury.

•

The surgery consists of a transhiatal esophagectomy with gastric pull-up, pyloric exclusion and Roux-en-Y gastroenterostomy.

•

The technique can be indicated when esophagectomy is necessary and there is pyloric stenosis associated.

Introduction

Ingestion of caustic materials can lead to digestive tube perforation involving the mouth, pharynx, esophagus and stomach (Vezakis et al., 2016 [1]). In this case report, the authors opted for gastric pull-up in a case of esophageal and pyloric stenosis secondary to caustic ingestion, and a Roux-en-Y gastroenterostomy in the lower portion of the gastric pull-up.

Presentation of case

A 37 years-old male presented complaints of dysphagia, which had started 28 days before admission after the ingestion of a caustic liquid. An esophagogastroduodenoscopy was performed, and showed a complete occlusion of the esophagus, without the possibility of performing an esophagus dilatation or placing a nasoenteric tube. The option was made for a transhiatal esophagectomy with gastric pull-up, pyloric exclusion and Roux-en-Y gastroenterostomy. The patient was later admitted with a stenosis of the esophageal anastomosis, which was resolved after performing endoscopic dilatation.

Discussion

The medical team opted to use the stomach for the reconstruction of the gastrointestinal transit due to less morbidity during manipulation of that organ, as well as safer anastomosis, when compared to the colon. In this case report, the esophagus and pylorus were generally compromised, however, with no apparent damage whatsoever in the stomach. Therefore, we opted to resect the esophagus and used the stomach to perform a gastric pull-up with the exclusion of the pylorus and reconstruction with a Roux-en-Y gastroenterostomy.

Conclusion

The proposed surgery is an option when dealing with similar cases, where endoscopic dilatation is not an option, and there is an associated pyloric stenosis.

Overview of caustic ingestion cases at the Children's Hospital of Vilnius University Hospital Santaros klinikos between 2011 and 2018

Background

Although not common, caustic ingestion can cause serious injury and sequelae. Clinical symptoms do not always represent the depth of lesions of the intestinal tract, which makes management of these patients difficult.

Materials and methods

Between 2011 and 2018, we performed a retrospective one-centre study on ingestion of corrosive agents by children. We used ICD-10 codes of X49, X54.X, and T28.2. Cases of eye or skin burns were excluded.

Results

Sixty-five cases were found. Due to a lack of data, we analysed 56 cases. The majority of them were boys (64%); 41% of patients were between 12 and 24 months old. The median age was one year. In 68% of cases, the corrosive substance was alkali: laundry detergent pods and sodium hydroxide accounting for 25% and 14%, respectively. Of the  hospitalised patients and all those admitted to the paediatric intensive care unit (PICU), 78% had oesophagogastroduodenoscopy (EGD), 61% within 24 h after ingestion. The time of EGD was not known for 29% of patients. Nine (29%) had 2nd- or 3rd-degree burns of the oesophagus or the  stomach, one of them did not have any visible changes of the lips and oral mucosa or any symptoms.

Conclusions

Physicians should be suspicious about potential lesions of the gastrointestinal tract when managing caustic ingestion cases. It is recommended to perform EGD for symptomatic children within 24 hours after the accident.

Correlation of 99mTc sucralfate scan and endoscopic grading in caustic oesophageal injury

PURPOSE

To determine a correlation between the 99mTc sucralfate scan and the endoscopy findings in children with caustic oesophageal injury.

METHODS

This is an observational analytic study of children who had both 99mTc sucralfate scan and endoscopy after caustic substance ingestion at our institution in a period between January 2009 and September 2016. The oesophageal injury was classified into low grade and high grade according to the degree of adhesion on 99mTc sucralfate scan and modification of Zargar endoscopic grading.

RESULTS

Out of a total of 197 children, 40 children were identified who had both investigations done on average 26 h post-injury. Low-grade adhesion on 99mTc sucralfate scan was found in 27 children (68%), and all had low-grade Zargar's oesophageal injuries. None of these subsequently developed residual pathology. Thirteen had high-grade adhesion and five of these had high-grade injury on endoscopy. Three (23%) developed oesophageal strictures. Correlation of 99mTc sucralfate and endoscopic findings reached statistical significance with a p value of 0.0014. No morbidity was associated with either the scan or endoscopy.

CONCLUSIONS

We concluded that low-grade sucralfate scan finding has the potential to successfully eliminate the need for invasive endoscopy under general anaesthesia and thereby reducing procedure-related morbidity, hospitalization and associated costs. However, mandatory endoscopy is required in children with high-grade adhesion seen on 99mTc sucralfate scan. This requires confirmation using a larger prospective study.