Epidemiology and prevention of caustic ingestion in children

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.

Effectiveness of Hypericum perforatum Extract in the Treatment of Corrosive Esophageal Burns

PURPOSE

The purpose of our study is to determine the effectiveness of "Hypericum perforatum" extract in corrosive esophageal burns and to shed light on the search for new treatments.

MATERIALS AND METHODS

A total of 32 Sprague Dawley rats were separated into 4 groups. A standard esophageal burn model was created. Group 1 was identified as the sham group. Group 2 was burned and no treatment was performed afterward. Group 3 was burned and then 2 cc/day H. perforatum extract was given for 21 days. Group 4 was not applied any process and 2 cc/day H. perforatum extract was given for 21 days. The rats were sacrificed and biopsy specimens were taken for histopathological examination for the presence of inflammation, fibrosis, and necrosis.

RESULTS

There was a significant difference between groups in terms of inflammation, fibrosis, and necrosis. Furthermore, in the bilateral comparisons between the groups, there was a meaningful difference in terms of inflammation and fibrosis between Group 2 and Group 3. However, there was no meaningful difference between the same groups in terms of necrosis.

CONCLUSION

H. perforatum extract may be effective on inflammation, fibrosis, and necrosis in corrosive esophageal burns.

Caustic Ingestion in Children: 1 Year Experience in 3 Italian Referral Centers

OBJECTIVES

Despite the efforts to reduce the exposure to corrosive household products, caustic ingestion in children is currently a significant medical problem. The aims of the present study were to evaluate the clinical consequences of caustic ingestion and to identify prognostic factors that could concur in driving both diagnostic and therapeutic management.

METHODS

All consecutive children referred for ingestion of a caustic substance from June 2017 to June 2018 were enrolled. Medical records, laboratory and endoscopic findings were reviewed and analyzed.

RESULTS

We enrolled 44 children with caustic ingestion. Alkaline agents were ingested by 26 of 44 (59.1%) patients, whereas acid agents were ingested by 18 of 44 patients (40.9%). Alkaline rather than acid agents were associated with a worse endoscopic score (r: 0.45) and a higher probability of early esophageal stricture occurrence (r: 0.38). The specific risk of the presence of severe esophageal lesions rose progressively with increasing number of symptoms whereas no esophageal injury was found in asymptomatic patients.

CONCLUSIONS

Our data suggest that endoscopic evaluation is mandatory in symptomatic patients to direct therapeutic management, but it could be avoided in asymptomatic patients after accidental ingestion, particularly if the ingestion is only suspected and patients have no oropharyngeal burns.

Corrosive injury of the trachea in children

The secondary injury may present weeks to months after the initial insult and repeat bronchoscopy, and long-term follow-up is required for the respiratory complications of CSI.Ingestion of caustic fluid may cause severe tracheal stenosis. Repeated airway dilatation may be a lifesaving intervention until such point that surgery can be performed.

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.

Caustic ingestion in children-A review

Various domestic or industrial chemicals may cause significant upper aerodigestive tract burns. Preventive measures should be up-scaled, especially in the developing world, to reduce the epidemic of accidental victims, largely unsupervised preschool children. External signs do not predict degree of injury. Non-invasive diagnostic screening includes radio-nuclear imaging, but early oesophago-gastroduodenoscopy remains the standard to predict stricture formation from circumferential submucosal scarring. Serial dilation is the mainstay of oesophageal stricture therapy, with oesophageal replacement reserved for severe refractory strictures. Intra-lesional steroid or mitomycin C may decrease the dilatations required for severe strictures, although long-term effects are unknown. Risk of secondary oesophageal carcinoma mandates long-term surveillance.

Oral Chemical Burns Reported to the Poisons Information Centre in Erfurt, Germany, from 1997 to 2014

Devastating oral burns often followed by lifelong complications can result from ingestion of caustic substances. However, although being one of the most challenging situations in clinical practice, literature data on the epidemiology of oral burns are still scarce. Retrospective analysis of all cases of oral burns after ingestion of corrosive substances reported to the Poisons Information Centre in Erfurt, Germany, from 1997 to 2014 was performed. In total, 482 calls because of oral burns were registered, with no change in the numbers of cases during the years. In the majority of the instances (47%), toddlers were affected, followed by middle-aged adults (33%). In both age groups, the male sex prevailed. Ingestion of corrosive substances with babies, schoolchildren, adolescents, and elderly were much less frequent. In most cases (78%), the injury occurred accidentally and only in 5% of the instances in suicidal intent; 85% of the suicidal attempts were committed by middle-aged adults and 15% by elderly. Main agents involved in oral burns were cleansing agents (37%), remedies (12%), disinfectants (7%), acids or bases (6%), technical fluids (6%), cosmetics (5%), and foods (5%). Mostly, the calls came from emergency department doctors (58%), in 19% laymen were calling from home, and in 18% the calls came from a doctor's office. Most of the injuries occurred accidentally, in the domestic setting and in toddlers, and would have been preventable. Thus, a more comprehensive education of the population, especially of parents, regarding the dangers arising from household chemicals is still needed.

Fatal corrosive ingestion: A study from South and South-East Delhi, India (2005-2014)

The study presents a retrospective analysis of 64 cases of death resulting from ingestion of corrosive substances. The cases represented approximately 0.4% of all autopsies conducted and 13.6% of all fatal poisonings studied during the 10-year period from January 2005 to December 2014 at the Department of Forensic Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi. The data was analyzed with regard to age, sex, nature and source of corrosive substance used, survival period, cause and manner of death. Males (64.06%) outnumbered females (35.94%), with a male-to-female ratio of 1.78:1. The most common age group involved was 21-30 years (35.94%). Sulfuric acid (68.75%) presented as the most common corrosive substance ingested. Household cleaning substances (39.06%) were identified as a common source of such type of corrosive substance, but the exact source could not be identified in 56.26% of cases. In the majority of cases (46.88%) death was due to perforation peritonitis. Most of the victims (54.69%) succumbed to their injuries within a day of ingestion. In 87.5% of cases, the corrosive substance was consumed for suicidal purposes. A strict regulatory framework is required for the production, distribution, storage and use of corrosive substances. Preventive guidelines and creating awareness among the masses will go a long way towards curbing such unfortunate incidents.

Predictability of gastroesophageal caustic injury from clinical findings: is endoscopy mandatory in children?

INTRODUCTION

The aim of this study was to present our patients with corrosive ingestion retrospectively, to analyze the validity of clinical signs as predictors of outcome, and to emphasize the necessity of esophagogastroduodenoscopy.

MATERIALS AND METHODS

Data were evaluated from the medical records of patients admitted at the Mother and Child Health Care Institute, Serbia over a 10-year period.

RESULTS

A total of 176 children, mean age 36.2 ± 18.1 months (range 9 months to 18 years), with corrosive ingestion were evaluated. The ingested substances were alkali in 96 cases (54.5%), acid in 41 (23.3%), and others in 39 cases (22.1%). In all, 116 patients (65.9%) were symptom free on admission. Positive clinical findings were observed in 60 (34.1%) patients. Upper endoscopy was performed in all children within the first 48 h. Ninety-five patients (54%) had normal endoscopic evaluation, 54 (30.6%) had mild lesions, and 27 (15.3%) had severe corrosive injuries. The validity of clinical findings in predicting the severity of esophageal and gastric injury was as follows: sensitivity - 74 and 75% and specificity - 73 and 68%, retrospectively. Eighteen patients (10.2%) developed esophageal stricture.

CONCLUSION

Endoscopy is a mandatory technique in children with gastroesophageal caustic injuries, and should be performed to prevent unnecessary hospitalization and to plan future treatment. This study emphasizes that clinical signs and symptoms are not predictors of esophageal and gastric injury and that the absence of any clinical findings does not rule out a severe esophageal or gastric injury.

Corrosive oesophageal injuries: a preventable menace

Introduction

Potentially catastrophic presentations and lifelong complications resulting from corrosive ingestions in humans is one of the most challenging situations encountered in clinical medical practice. This study reviewed pattern, mechanisms and associated socio-medical challenges with ingestion of corrosive agents as seen in a tertiary health institution in South-western Nigeria.

Methods

A retrospective review of all patients that were managed for corrosive ingestion at Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Osun State, Nigeria, over a seven year period.

Results

A total of 28 patients M:F: 1.6:1. There were 7 children and 21 adults. Majority (78.6%) of the patients ingested alkaline substances. Accidental ingestion occurred in 28.6% while 71.4% resulted from deliberate self harm especially among adults (66.7%). Almost two thirds (64.3%) of the patients presented after 48hrs of ingestion. Patients who presented early were managed conservatively. Most patients (64.3%) who presented late had nutritional and fluid rehabilitation. Two patients died from oesophageal perforation and resulting septicaemia. Psychiatric evaluation revealed that seven adults (25%) had psychotic illness while (42.9%) of the patients developed oesophageal strictures. Short segment strictures were managed with oesophageal dilatation with good outcome while long and multiple segment strictures were referred to cardiothoracic surgeons for management.

Conclusion

Corrosive oesophageal injuries remain a prevalent and preventable condition in the developing countries. Preventive strategies should include regulation and packaging of corrosive substances, organization of psychiatric services, and education of the population on corrosive ingestion.

Caustic soda poisoning in Ghana--an alarming increase

BACKGROUND

In 2010, there was a sudden increase in the number of children admitted to Okomfo Anokye Teaching Hospital, Kumasi with caustic soda poisoning.

AIM

To quantify the increase and identify possible causes.

METHODS

Detailed review of case-notes of all children admitted with poisoning from January 2009 to June 2010 was undertaken using a standardised proforma.

RESULTS

From January to June 2010, there was a six-fold increase in the number of children admitted with caustic soda poisoning compared with January to June 2009 (13 vs 2). Owing to the increase in caustic soda ingestion, there were almost twice the number of cases of chemically-induced poisoning in January-June 2010 (34) as in January-June 2009 (19 cases). In the entire period (January 2009 to June 2010), the majority of admissions for chemical poisoning were children ≤3 years of age and 50 of the 72 (69.4%) cases were boys. In six of the 13 cases in the January-June 2010 period, caustic soda was drunk directly from a plastic water bottle. All children with caustic soda poisoning had been given palm oil to drink by their guardians.

CONCLUSION

It is suggested that the recent introduction of bottled water is an important element in the increase of caustic soda poisoning. Previously, water was sold in plastic bags. The plastic water bottles are re-used to store caustic soda which children then drink, mistaking it for water.

Socio-demographic factors associated with caustic substance ingestion in children and adolescents

OBJECTIVE

Caustic substance ingestion is a public health issue in some underdeveloped countries. Published information on socio-demographic factors related to this problem is scarce. The aim of this study was to evaluate the association of socio-demographic factors with caustic ingestion in children.

DESIGN

case-control study. Cases were children with caustic substance ingestion who were attended to during 2006 (n=94) at a pediatric referral hospital in Guadalajara, Mexico; the controls were a random sample of children who were hospitalized or seen as outpatients in the same pediatric referral hospital (n=641). The socio-demographic variables were studied using a validated questionnaire (Children Nutrition Organization Survey).

STATISTICS

OR, 95% CI and logistic regression.

RESULTS

Mean age of the cases was 3.2 years (SD 2.4) and 37.2% of cases were girls. Caustic ingestion occurred at home in 63.8% of cases and at a relative's home in 23.4% of cases. Alkaline products were ingested by 85.1%; containers had no warning labels in 72.3% of cases and no childproof safety caps in 92.6% of cases. The socio-demographic variables associated with caustic ingestion included higher family income, lower educational level of the mother, higher proportion of fathers working as independent professionals, extended family, mother's age <30 years, and mother working outside the home.

CONCLUSIONS

The observed family risk profile for caustic ingestion was higher family income, young working mother with low educational level, father working as independent professional, and extended family.

Oesophageal corrosive injuries in children: a forgotten social and health challenge in developing countries

PROBLEM

An unsafe environment is a risk factor for child injury and violence. Among those injuries that are caused by an unsafe environment, the accidental ingestion of corrosive substances is significant, especially in developing countries where it is generally underreported.

APPROACH

To address this challenging, unmet medical need, we started a humanitarian programme in Sierra Leone. By reviewing the current literature from developing countries and our own experience in the field, we developed a flowchart for management of this clinical condition.

LOCAL SETTING

This injury is underreported in developing countries. Data available are heavily skewed towards well-resourced centres and do not reflect the entire reality of the condition. Late oesophageal strictures are usually severe. Parent's lack of knowledge, crowded living conditions and availability of chemicals in and around houses account for most ingestions. The widespread lack of any preventive measures represents the strongest risk factor.

RELEVANT CHANGES

Timely admission was observed in 19.5% of 148 patients studied. A gastrostomy was performed on 62.1% of patients, 42.8% had recurrent strictures and 19% are still on a continuous dilatation programme. Perforation and death rate were respectively 5.6% and 4%.

LESSONS LEARNED

The majority of oesophageal caustic strictures in children are observed late, when dilatation procedures are likely to be more difficult and carry a significantly higher recurrence rate. Gastrostomy is necessary to maintain adequate nutritional status but mothers need training in feeding techniques. Both improvement in nutritional status and sustained oesophageal patency should be the reference points to a successful dilatation.

Oesophageal corrosive injuries in children: a forgotten social and health challenge in developing countries

PROBLEM

An unsafe environment is a risk factor for child injury and violence. Among those injuries that are caused by an unsafe environment, the accidental ingestion of corrosive substances is significant, especially in developing countries where it is generally underreported.

APPROACH

To address this challenging, unmet medical need, we started a humanitarian programme in Sierra Leone. By reviewing the current literature from developing countries and our own experience in the field, we developed a flowchart for management of this clinical condition.

LOCAL SETTING

This injury is underreported in developing countries. Data available are heavily skewed towards well-resourced centres and do not reflect the entire reality of the condition. Late oesophageal strictures are usually severe. Parent's lack of knowledge, crowded living conditions and availability of chemicals in and around houses account for most ingestions. The widespread lack of any preventive measures represents the strongest risk factor.

RELEVANT CHANGES

Timely admission was observed in 19.5% of 148 patients studied. A gastrostomy was performed on 62.1% of patients, 42.8% had recurrent strictures and 19% are still on a continuous dilatation programme. Perforation and death rate were respectively 5.6% and 4%.

LESSONS LEARNED

The majority of oesophageal caustic strictures in children are observed late, when dilatation procedures are likely to be more difficult and carry a significantly higher recurrence rate. Gastrostomy is necessary to maintain adequate nutritional status but mothers need training in feeding techniques. Both improvement in nutritional status and sustained oesophageal patency should be the reference points to a successful dilatation.

Farming-related caustic ingestion by a 2-year-old: innocent play with costly results

Young children continue to ingest caustic materials while playing in farm work areas. However, recent agricultural safety and health literature scarcely mentions caustic ingestion, and national incidence data specific to childhood caustic ingestion occurring on farms were not found. We present a case report of a 2-year-old child who, while playing with her brother, ingested dairy pipeline cleaner (an alkali). This case, although not unique, raises concerns about current prevention efforts related to the use and storage of chemicals on farms, long-term medical problems and associated costs, and the level of tolerance regarding the intermingling of innocent child play with adult work.

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.

Corrosive esophageal injuries in children. A shortlived experience in Sierra Leone

OBJECTIVE

Children with caustic ingestions in developing countries are often treated at home, sometimes by traditional healers, or are referred, frequently late, to tertiary hospitals, which only seldom offer adequate endoscopic and dilatation facilities. Therefore, when dilatations are performed, the stricture is often already well established, making dilatation more difficult. The aim of this paper is to report our experience in the management of corrosive injuries in a group of children of Sierra Leone, all complaining accidental ingestion of caustic soda, many of them treated months after the ingestion.

METHOD

We considered all children admitted after corrosive ingestion, from November 2001 to November 2005, to the "Emergency" Surgical Center in Goderich-Freetown, Sierra Leone. In December 2005 the hospital was supplied with endoscopes and dilatation devices. The children still followed up clinically were recalled to submit them to an endoscopic follow-up and to a dilatation, if needed.

RESULTS

Forty children were admitted (mean age: 4.5 years): 16 (group A) after an esophageal perforation during dilatation performed elsewhere (death rate: 56%). Twenty-four children (group B) were observed after ingestion, 58% being submitted to a surgical gastrostomy. Death rate after ingestion was nil. The mean interval between ingestion and endoscopy was 8.8 months. Fifty-three dilatations were carried out in 17 children over a 3 months period. We report three perforations (17.6%) and a death rate of 5.8% (1/17). Two patients were lost to follow-up. Three patients (17.6%) did not show any improvement. Four children complained recurrent dysphagia after the first dilatation cycle. Overall, 10 children (58.8%) showed a clear-cut improvement at 6 months.

CONCLUSIONS

The majority of treated strictures were late, therefore difficult to dilate and at higher risk of perforation. Dilatation with Savary bougies seems safer than with balloon catheters. Recurrent strictures and a long-term dilatation treatment should be expected. Retrograde dilatations through gastrostomies should be the preferred method of treatment and surgical gastrostomies should be performed without hesitation. Esophageal replacement is unlikely in these countries, except in very few referral centres. Therefore, any effort should be made to treat caustic strictures by timely dilatation programs.

A rare and preventable cause of respiratory insufficiency: ingestion of benzalkonium chloride

Caustic agents stored in ordinary containers can be ingested by children. These materials should be stored in soft distinctive bottles and in safe places. The probability of ingestion of a caustic agent is low in the newborn period, and caustic burns have been reported infrequently. In this case study, a newborn baby with severe respiratory insufficiency after ingestion of benzalkonium chloride is reported.

Effects of time of contact and concentration of caustic agent on generation of injuries

OBJECTIVES

Solid caustic soda (CS) ingestion levels continue high in Brazil. The aggressiveness of a caustic agent depends, among other factors, on its concentration and time of contact with mucosa. However, the interdependence of these factors in the production of caustic lesion in the esophageal mucosa is not known, especially regarding CS as the strongest corrosive agent. We analyze the effects of concentration and time of contact on the aggressiveness of CS to the esophagus of live animals.

STUDY DESIGN/METHODS

One milliliter of CS at concentrations between 1.83% and 73.33% was applied to rats. The solution was kept in contact with the mucosa for 10 to 120 minutes. Internal and external organ aspects were analyzed and the epithelium, submucosa, muscle layer, and adventitia were analyzed microscopically

RESULTS

Epithelial necrosis was observed at all concentrations. Among the necrotic layers, the submucosa was observed starting at the 7.33% concentration, and the muscular layer and adventitia were observed at 14.66% concentration. Damage to the pulmonary parenchyma and trachea occurred at 33.66% after 10 minutes, and perforation of the esophagus was observed only after 120 minutes. After 10 minutes, important corrosive lesions installed in the esophageal layers, expanding in depth and superficial extension. The use of heparin had no effect on the production of lesions.

CONCLUSIONS

Ten minutes were sufficient to provoke necrosis, and longer contact increased the area of necrosis. Solution concentration levels were more important in damage production: 1.83% was sufficient for epithelial necrosis, 7.33% caused submucosal necrosis, and 14.66% muscle and adventitia necrosis; 33.66% solutions caused lung and trachea damage after 10 minutes and esophageal perforation after 120 minutes.

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.

Hair relaxers: a benign caustic ingestion?

BACKGROUND

Despite federally legislated safety regulations, caustic ingestions remain a significant problem in the pediatric population. The current standard of care for caustic ingestion includes upper gastrointestinal endoscopy in most cases. Hair relaxers are a common caustic ingestion at our institution, yet few data have been published describing the clinical or endoscopic outcome. We explored the relative frequency of hair relaxer ingestion, the incidence of associated upper gastrointestinal injury, and the adverse clinical sequelae resulting from these ingestions.

METHODS

Consecutive caustic ingestions admitted to our institution between January 1990 and January 2001 were identified. The data were collected through retrospective physician chart review, were analyzed, and were pooled with the existing literature to evaluate for the presence of esophageal injury.

RESULTS

96 charts were reviewed, 29 (30%) of which were hair relaxer ingestions that underwent esophagogastroduodenoscopy; these ingestions served as our study cohort. The median age of the cohort was 14.0 months and patients were evenly divided in gender. The most common symptoms at presentation were drooling and emesis. At endoscopy, lip and oropharyngeal mucosa were most commonly affected. While six patients (20.7%) had Grade I esophageal mucosal injury and five patients (17.2%) had Grade I gastric mucosal injury, none had greater than Grade I mucosal damage. No adverse clinical events were identified. When our data were combined with all previously published cohort data, the findings were similar and no adverse clinical outcomes were reported.

CONCLUSIONS

Hair relaxer is the most common childhood caustic ingestion presenting to our large metropolitan tertiary care center. Symptoms are common at presentation. However, despite the high pH of these products, no clinically significant esophageal or gastric mucosal injuries and no long-term sequelae were identified.

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.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Accidental caustic ingestion in children: is endoscopy always mandatory?

BACKGROUND

Patients who have experienced severe caustic injury to the gastrointestinal tract are at high risk of esophageal strictures. Early endoscopy is usually recommended systematically in children after caustic ingestion to assess the severity of the initial digestive lesions. The aim of this study was to determine the predictive value of clinical symptoms and ingested-substance types as markers of severe esophagogastric lesions and to define indications for endoscopy.

METHODS

Ingested-product types, clinical symptoms, endoscopic data and outcome were prospectively recorded in 85 children admitted after accidental caustic ingestion.

RESULTS

Forty-eight children (57%) had no symptoms; the others presented with vomiting, hematemesis, drooling, respiratory distress, and/or oropharyngeal lesions. Endoscopy showed no or minimal lesions in 63 cases (74%). None of the children developed digestive sequelae. Severe esophagogastric lesions were present in 22 cases (26%), mostly caused by lye ingestion (14 of 22) but also by strong acids (4 of 22); 9 of the 22 children (41%) developed esophageal stenosis. Vomiting, drooling, and oropharyngeal lesions did not predict severe endoscopic lesions. Hematemesis, respiratory distress, or presence of at least three of the symptoms was associated with severe lesions (positive predictive value = 1). The absence of symptoms was always associated with no or minimal lesions (negative predictive value = 1).

CONCLUSIONS

In conclusion, endoscopy is not recommended for children living in developed countries who are asymptomatic after accidental caustic ingestion.

Ingestion of caustic substances and its complications

CONTEXT

Caustic substances cause tissue destruction through liquefaction or coagulation reactions and the intensity of destruction depends on the type, concentration, time of contact and amount of the substance ingested.

OBJECTIVES

To analyze the complications in patients who ingested caustic substances and correlate them with the amount of caustic soda ingested.

DESIGN

Retrospective study.

SETTING

University hospital, a referral center.

PARTICIPANTS

A total of 239 patients who ingested caustic soda.

MAIN MEASUREMENTS

The amount of granulated caustic substance ingested was measured as tablespoonfuls and the following complications were analyzed: esophagitis, esophageal stenosis and progression to cancer, fistulas, perforations, stomach lesions, brain abscesses, and death. Stenosis was classified as mild, moderate or severe according to the radiological findings.

RESULTS

We observed an 89.3 % incidence of esophagitis; 72.6 % of the cases involved progression to stenosis and 1 per cent died during the acute phase. Stenosis was mild in 17.6 % of cases, moderate in 59.3 % and severe in 23 %. The incidence of stenosis was 80.8 per cent in women and 62.5 % in men. The incidence of stenosis was 46.9 % in the group that ingested "fragments" and 93.6 % in the group that ingested one or more tablespoonfuls of caustic substances. Among subjects who ingested one or more tablespoonfuls, 32.2 % developed lesions of the stomach-duodenum, whereas the ingestion of "fragments" was not sufficient to induce these lesions. There was no correlation between the intensity of lesions of the esophagus and of the stomach. Progression to cancer of the esophagus occurred in 1.8 % of cases, death during the chronic phase in 1.4 %, perforations in 4.6 %, fistulas in 0.9 %, and brain abscesses in 1.4 %.

CONCLUSIONS

The complications were related to the amount of caustic soda ingested. Small amounts caused esophagitis or stenosis and large amounts increased the risk of fistulas, perforations and death.

Evaluation of a poison prevention lesson for kindergarten and third grade students

OBJECTIVES

The purpose of this study was to evaluate the MORE HEALTH poison prevention lesson that is given to kindergarten and third grade students in Hillsborough County, Florida. The lesson reaches approximately 6000 students per year.

METHODS

The evaluation was based on a post-test only control group design. Three schools were chosen as evaluation sites and three served as control settings. Students were administered a previously tested, age appropriate questionnaire that addressed the goals of the poison lessons. In addition, a survey was developed for intervention school parents to determine their poison prevention practices.

RESULTS

One hundred ninety four intervention schoolchildren and 184 control schoolchildren completed the study. Children in the intervention schools consistently answered more questions correctly than those in the control schools. The parent survey showed that the majority have homes that are safe from poisons, although fewer than 50% said they had syrup of ipecac in their homes.

CONCLUSIONS

These results show that key concepts related to poison prevention can be communicated effectively to primary school students and parents report having homes safe from many poisons.

[Severity of ingestion of caustic substance in children]

BACKGROUND

Caustic ingestion is frequent in children, sometimes leading to esophageal stricture.

PATIENTS AND METHODS

Between 1988 and 1994, esogastroscopy was performed in 65 children after caustic ingestion. The children were classified in three groups: no lesion (group A), minimal lesions (group B) and severe lesions (group C). Nature of the caustic substance, clinical signs and evolution were compared in the three groups.

RESULTS

Median age was 2 years for the 65 children (24 girls, 41 boys). Ingestion occurred at home (94%) during meal periods. Substances were dishwater detergents (n = 14), oven cleaner (n = 10), bleach (n = 9), washing powder (n = 4), others (n = 20), more often in a liquid form (n = 37) than solid (n = 28). Children had no symptoms (57%), presented emesis (n = 20) or abdominal pain (n = 10) not correlated to endoscopic findings, and hematemesis (n = 3) or respiratory distress (n = 4), both symptoms seen only in group C. Buccal lesions (41%) were not correlated to endoscopic findings. After endoscopy, 28 children (43%) were classified into group A and 20 children (31%) in group B. Among the 17 children (26%) of the group C, eight developed an esophageal stricture: seven long strictures requiring replacement of the esophagus, one short stricture requiring repeated dilations.

CONCLUSION

Esophageal stricture is still a severe complication after caustic ingestion. These data stress the interest of controlled studies to confirm the preventive role of high dose corticosteroids, and the importance of the prevention of accidental caustic ingestions in children.

Prediction of complications following unintentional caustic ingestion in children. Is endoscopy always necessary?

The records of 115 children hospitalized following caustic ingestion over an 18.5-year period from 1976 to 1994 were reviewed. The relationship between types of product ingested, signs and symptoms, degree of esophageal injury and complications was analyzed. All complications were the result of strong alkali ingestion (sensitivity = 1.0). Among the 102 incident patients, 36.8% of lye ingestions resulted in complications, whereas only 2.7% (one) of automatic dishwasher detergent (ADD) ingestions caused any complications (p < 0.01). Endoscopy 6 h to 4 days after injury was accurate in predicting or identifying complications in all types of strong alkali ingestions. In lye ingestions, endoscopy was not superior to the test, "one or more signs or symptoms" in predicting complications (predictivity = 1.0). Endoscopy is recommended to establish or confirm a prognosis, or to identify acute respiratory complications, in symptomatic ingestions of lye or ammonia water, in children with respiratory symptoms, and in rare cases of severe symptoms following ADD or strong acid ingestion. It is suggested that children who are non-symptomatic following unintentional ingestions are not at risk of complications and do not need endoscopic examination.

Prediction of complications following caustic ingestion in adults

The records of 86 adults admitted to hospital following caustic ingestion were reviewed. Eighteen patients (21%) developed complications; of these, six were fatal. Patients without symptoms or signs did not develop complications. Complications occurred only following lye ingestion, or intentional ingestion of hydrochloric acid or ammonia water. Of patients with such ingestion, and two signs or symptoms or more, 70% developed complications. Oesophagoscopy did not significantly improve the prediction of complications. There was a strong trend, however, for more severe complications with more severe submucosal, circumferential oesophageal injuries (P = 0.003). The study suggests that only adults with symptoms or signs following strong alkali or strong acid ingestion are at risk of complications. In adults who are symptomatic following ingestion of strong acid or alkali, oesophagoscopy is important to identify the potentially fatal transmural injuries.

Caustic ingestion in adults--epidemiology and prevention

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