Do corticosteroids prevent oesophageal stricture after corrosive ingestion?

Can we predict the risk of esophageal stricture after caustic injury?

Nonoperative management of severe caustic injuries has demonstrated its feasibility, avoiding the need for emergency esogastric resection and resulting in low mortality rates. However, leaving superficial necrosis in place could increase the risk of esophageal stricture development. Data on the risk factors of esophageal stricture secondary to caustic ingestion are scarce. The aim of our study was to identify the risk factors for esophageal strictures after caustic ingestion at admission. From February 2015 to March 2021, all consecutive patients with esophageal or gastric caustic injury score ≥ II according to the Zargar classification were retrospectively analyzed. For each patient, we collected over 50 criteria at admission to the emergency room and then selected among them 20 criteria with the best clinical relevance and limited missing data for risk factor analyses. Among the 184 patients included in this study, 37 developed esophageal strictures (cumulative rate 29.4%). All esophageal strictures occurred within 3 months. In multivariate analyses, the risk factors for esophageal strictures were voluntary ingestion (cause-specific hazard ratio 5.92; 95% confidence interval 1.76-19.95, P = 0.004), Zargar's esophageal score ≥ III (cause-specific hazard ratio 14.30; 95% confidence interval 6.07-33.67, P < 0.001), and severe ear, nose, and throat lesions (cause-specific hazard ratio 2.15; 95% confidence interval 1.09-4.22, P = 0.027). Intentional ingestion, severe endoscopic grade, and severe ENT lesions were identified as risk factors for esophageal stricture following caustic ingestion. Preventive measures for this population require further evaluation.

Clinical evaluation and treatment outcomes of caustic ingestion injuries in Syrian pediatric patients: A retrospective study: Short title: High-dose steroids for pediatric caustic ingestions in Syria

Introduction

Accidental ingestion of caustic agents poses a significant concern in pediatric emergency departments globally. It is a growing public health concern in low-to-middle income countries, which often lack comprehensive data reporting. This study examines high doses of corticosteroid treatment outcomes of caustic ingestion injuries in Syrian pediatric patients, addressing clinical features, and associated variables.

Methods and materials

A retrospective observational study was conducted at University Pediatric Hospital from January 2016 to January 2019. Medical records were reviewed for patients aged <10 years with esophagoscopy-confirmed grade IIa, IIb, or III burns. Data collected included sociodemographics, esophagoscopy results, treatment details, and outcomes.

Results

Among 114 pediatric patients, 76 (67%) were males and 38 (33%) were females. Age groups included <1 year (11%), 1-3 years (39%), 3-5 years (29%), 5-7 years (11%), and >7 years (11%). Alkaline burns accounted for 54% of injuries, acidic for 32%, and other substances for 13%. Complications included bleeding (19%) and psychomotor disability (7%). The most common burn site was the entire esophagus (62%), with 81% having grade II burns. Healing was achieved in 71% of patients with high doses of corticosteroids treatment, and 29% required dilation, with final 92% healing rate.

Conclusion

The use of corticosteroids for esophageal strictures remains inconclusive, demanding further robust research with larger sample sizes and control groups. While our study revealed that high doses of corticosteroids treatment followed by esophageal dilation had a 92% success rate. However, our study demonstrates promising results, methodological limitations and absence of a control group underscore the need for more definitive evidence. Both alkali and acidic ingestion contribute to stricture development.

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.

Profiling of inflammatory cytokines in patients with caustic gastrointestinal tract injury

Introduction

Study of inflammatory cytokines in patients with caustic gastrointestinal tract injury is sketchy. This study investigated the cytokine profiling of patients with caustic substance ingestion, and analyzed the differences between patients with severe and mild injury.

Methods

This prospective, cross-sectional study enrolled 22 patients admitted to Chang Gung Memorial Hospital between March and October 2018. All patients underwent esophagogastroduodenoscopy in 24 hours. Patients were categorized into two subgroups, as mild (<2b, n = 11) or severe (≥2b, n = 11) group.

Results

The neutrophil count was higher in severe than mild group (P = 0.032). Patients in mild and severe groups exhibited significantly higher circulating inflammatory cytokines than healthy control, including interleukin (IL)-2, IL-5, IL-8, IL-9, IL-12, IL-13, interferon-gamma inducible protein-10, macrophage inflammatory protein-1 beta, regulated upon activation, normal T cell expressed and presumably secreted and tumor necrosis factor-alpha. Furthermore, the levels of IL-2 and tumor necrosis factor-alpha were significantly higher in patients with severe group than mild group. Although there was no difference in cumulative survival between both groups (P = 0.147), the severe group received more operations (P = 0.035) and suffered more gastrointestinal complications (P = 0.035) than mild group.

Conclusion

Caustic substance ingestion produces mucosal damages and leads to excessive neutrophils and inflammatory cytokines in peripheral blood.

Alkaline substances gastroesophageal injury in young children: emphasis on Asian food preparation habits

BACKGROUND

Ingestion of alkaline substances should not be disregarded because a small amount can cause chemical burns in the esophagus, with esophageal stricture being the most common late complication.

METHODS

We enrolled children with alkaline corrosive damage receiving treatment at China Medical University Children's Hospital's emergency department between 2008 and 2018. Patients were divided into groups A (ingested causative agents other than alkaline oil), and B (ingested alkaline oil).

RESULTS

Altogether, 40 (27 [67.5%] male and 13 [32.5%] female) patients aged 7 months-7 years were enrolled. The most commonly ingested agent was alkaline oil (13 cases, 32.5%), followed by oven and drainage cleaners (8 cases, 20%), bleach (6 cases, 15%), laundry and dish cleaners (4 cases, 10%), sodium hydroxide (4 cases, 10%), sodium carbonate (2 cases, 5%), sodium phosphate (2 cases, 5%), and sodium citrate (1 case, 2.5%). High proportions of children had esophagitis (40/40, 100%), erosive gastritis (7/40, 17.5%), and gastric ulcer (6/40, 15%). The incidence of esophageal stricture was 38.4% (5/13) and 7.4% (2/27) in groups B and A, respectively. In group B, 4 children developed growth stunting or malnutrition during the first decade after onset, with reduced immunity and feelings of inferiority.

CONCLUSION

Alkaline ingestion usually results in esophageal injury that is difficult to cure. Corrosive esophageal strictures cause swallowing difficulties and growth stunting in children. Young children who ingested alkaline oil have more complications. Given that alkaline corrosive injuries are often accidental, prevention of corrosive agent ingestion is crucial.

Presentation and management outcome of childhood corrosive oesophageal injury in Benin City

BACKGROUND

Corrosive ingestion in children occurs usually at home and frequently results in debilitating strictures. Prevention and early intervention programs are very important for good outcomes.

AIMS AND OBJECTIVES

This study aims at examining the immediate causative factors and problems of this subset of patients with a special focus on treatment and outcome. This study was to audit the management of patients in the paediatric age group who presented for treatment with history and sequelae of corrosive ingestion seen by the cardiothoracic unit of the University of Benin Teaching Hospital from January 2005 till December 2018.

MATERIALS AND METHODS

This is a 14year retrospective study of patients that presented with oesophageal burn injuries from ingestion of corrosive agents to the Cardiothoracic Unit at the University of Benin Teaching Hospital between January 2005 and December 2018. Essentially the first 5years were retrospectively included but the subsequent years were prospective. All available medical data on these patients were retrieved and studied for epidemiological, clinical and operative procedures and outcome.

RESULTS

A total of 49 patients were seen and admitted during the period under review. Male (29) : Female (20) ratio was 1:1.4 Mean age was 4.7±4.8 years with a range of 1-16years, The males presented earlier and had worse strictures as well as more surgical procedures. Caustic soda preparations ingested more (93.9%), all ingestions were within the household setting, and all had first aid given by way of oral palm oil. Only two (4.1%) ingested acids with only one flat battery ingestion. 45.5% of the patients had dilatation only and of these 50% recovered after 3 sessions and required no more sessions. A further 50% were lost to follow up. 38.8% had oesophageal replacement with colon following oesophagectomy.

CONCLUSION

In conclusion, corrosive oesophageal stricture is a debilitating disease in children and affects males more, but it is treatable by multiple dilatations and oesophageal replacement with colon. Prevention should be actively pursued as well as early intervention.

A prospective randomized controlled trial of omeprazole for preventing esophageal stricture in grade 2b and 3a corrosive esophageal injuries

OBJECTIVES

Esophageal stricture is a significant complication of grade 2b and 3a esophageal injuries and causes much patient suffering. Preventing strictures would be beneficial to patients but there are currently no proven effective drugs. This study aimed to evaluate the effect of omeprazole for preventing esophageal stricture in adults with grade 2b and 3a corrosive esophageal injuries.

METHODS

This study was an open single-center prospective randomized controlled trial that took place from April 2018 to January 2020. Patients were randomized to standard treatment or 80 mg/day intravenously × 3 days followed by 40 mg/day orally for 4 weeks. They were endoscoped at baseline and 4 weeks post discharge. Strictures were confirmed radiologically.

RESULTS

20 patients were enrolled: 15 with grade 2b and five with grade 3a injuries. Standard care and omeprazole groups numbered 10 each. At 1 month, seven and two patients developed strictures in the standard and omeprazole groups, respectively, p = 0.024, for a risk reduction of 71.4%.

CONCLUSIONS

Omeprazole reduced the risk of short-term developing esophageal strictures following grade 2b and 3a corrosive esophageal injuries. Larger studies are needed to reconfirm this finding. Thai Clinical Trials Registry (TCTR) number TCTR20190504001.

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.

Corrosive Ingestion

Corrosive ingestion remains a common problem in developing countries, such as India due to the lack of strict laws that regulate the sale of caustics. While appropriate treatment of the acute phase can mitigate tissue damage improper management of the acute corrosive injury is widely prevalent due to the limited experience of the individual physicians in managing this condition. The aim of this review is to summarize the epidemiology and pathophysiology of corrosive ingestion, principles in the management of acute phase injury, long-term effects of caustic ingestion, and prevention of corrosive ingestion.

HOW TO CITE THIS ARTICLE

Kalayarasan R, Ananthakrishnan N, Kate V. Corrosive Ingestion. Indian J Crit Care Med 2019;23(Suppl 4):S282-S286.

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.

Evaluation of the efficacy of Hypericum perforatum (St. John's wort) oil in the prevention of stricture due to esophageal corrosive burns

BACKGROUND/PURPOSE

The inflammatory response that follows the caustic burns results in fibrosis on the esophageal wall leading to esophageal stricture, dysphagia, and malnutrition. The controversy over the use of corticosteroids warrants alternative therapeutic interventions. We investigated the effect of extracts from St. John's wort (SJW) with known wound-healing activity on stricture formation in rat esophageal injury models.

METHODS

Five experimental groups were involved: sham group with no injury, control group with injury without treatment, and three different treatment groups (methylprednisolone, SJW extract, and combination of the two). Histopathological examination of esophageal damage and collagen accumulation, stenosis index, and tissue hydroxyproline levels were used to assess stricture and the effect of treatments.

RESULTS

There was a significant weight loss in all groups except for those without injury and those treated with SJW extract, the latter gained weight albeit not significant. Stenosis index was increased in all groups compared to sham but not significantly in those treated with SJW extract. Histopathological and biochemical analyses produced mixed results.

CONCLUSIONS

Some of the experimental indicators such as weight gain and stenosis index suggested the treatment of esophageal injury models using extracts of St. John's wort effective while other histopathological indicators show no significant benefit.

UK guidelines on oesophageal dilatation in clinical practice

These are updated guidelines which supersede the original version published in 2004. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG. The original guidelines have undergone extensive revision by the 16 members of the Guideline Development Group with representation from individuals across all relevant disciplines, including the Heartburn Cancer UK charity, a nursing representative and a patient representative. The methodological rigour and transparency of the guideline development processes were appraised using the revised Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.Dilatation of the oesophagus is a relatively high-risk intervention, and is required by an increasing range of disease states. Moreover, there is scarcity of evidence in the literature to guide clinicians on how to safely perform this procedure. These guidelines deal specifically with the dilatation procedure using balloon or bougie devices as a primary treatment strategy for non-malignant narrowing of the oesophagus. The use of stents is outside the remit of this paper; however, for cases of dilatation failure, alternative techniques-including stents-will be listed. The guideline is divided into the following subheadings: (1) patient preparation; (2) the dilatation procedure; (3) aftercare and (4) disease-specific considerations. A systematic literature search was performed. The Grading of Recommendations Assessment, Develop-ment and Evaluation (GRADE) tool was used to evaluate the quality of evidence and decide on the strength of recommendations made.

Corticosteroids for Preventing Caustic Esophageal Strictures: Systematic Review and Meta-analysis

OBJECTIVES

Caustic ingestion can have a complicated clinical course. Corticosteroids are widely used but there is uncertainty about its role in preventing esophageal stricture formation following caustic ingestion. This systematic review and meta-analysis assessed the available clinical evidence regarding the efficacy and safety of corticosteroids for preventing esophageal strictures following caustic injury.

METHODS

We assessed randomized controlled trials (RCTs) that compared corticosteroids versus no corticosteroids in the prevention of esophageal stricture formation following caustic ingestion. We searched the following databases from inception to March 2017: PubMed, Embase, and the Cochrane Central Register of Controlled Trials. Two reviewers retrieved eligible articles, assessed risk of bias, and performed data extraction. The main outcome measure was the prevention of esophageal stricture formation.

RESULTS

The search identified 763 citations. Three RCTs involving 244 participants met the inclusion criteria. There was no benefit of corticosteroids in the prevention of esophageal strictures following the ingestion of caustic materials (risk ratio [RR] = 0.63, 95% CI = 0.29-1.37).

CONCLUSIONS

The available evidence does not support the use of corticosteroids for the prevention of esophageal strictures following caustic ingestion. The overall quality of the evidence is limited because of methodological weaknesses and small sample sizes in the primary studies.

Risk factors for symptomatic esophageal stricture after caustic ingestion-a retrospective cohort study

Esophageal stricture is a major secondary complication of ingesting caustic agents. We examined our experiences with caustic injuries with a view to finding clinical and biological risk factors of esophageal strictures secondary to caustic ingestion. Records were retrieved for 58 adults admitted consecutively to our intensive care unit for caustic ingestion. Fifty cases were managed conservatively and therefore retained for analyses. Patients were grouped according to whether they developed strictures or not during the follow-up period. Mucosal damage was assessed by emergency endoscopy. Eleven patients (22%) developed a stricture. At referral, dysphagia, epigastric pain, and hematemesis were associated with secondary stricture (respectively P = 0.047, P = 0.008, P = 0.02). A high Zargar endoscopic grade (above IIa; P = 0.02), the ingestion of strong acids or alkalis (P = 0.006), hyperleukocytosis (P = 0.02), and a low prothrombin ratio (P = 0.002) were associated with a higher risk of developing a stricture. The median delay of stricture diagnosis was 12 (8;16) days after ingestion, with extreme values from 4 to 26 days. Initial symptoms such as dysphagia or hematemesis, early endoscopy showing >IIa grade esophagitis, and certain laboratory results should draw the physician's attention to a high risk of esophageal stricture.

Caustic Ingestions and Foreign Bodies Ingestions in Pediatric Patients

Children inevitably swallow foreign material accidentally or intentionally. Each type of ingestion carries their own set of risks and complications, short and long term, some requiring immediate attention while others close monitoring. Alkalotic household cleaning products and lithium button batteries are increasingly common and damage the esophagus quickly. While many toys with rare-earth metals are banned, they are already present in many households and can cause necrosis of bowel that is between the magnets. This article reviews the incidence and assessment along with current literature to provide guidelines for management of pediatric patients with suspected caustic or foreign body ingestion.

Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines

This guideline refers to infants, children, and adolescents ages 0 to 18 years. The areas covered include indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; corrosive ingestion and stricture/stenosis endoscopic management; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography; and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease has been dealt with in other guidelines and are therefore not mentioned in this guideline. Training and ongoing skill maintenance are to be dealt with in an imminent sister publication to this.

Evaluation of 968 children with corrosive substance ingestion

Background and Aims:

The aim of the study was to evaluate the etiology, treatment, and prognosis in children who had presented at our clinic with corrosive substance ingestion and comparison of our results with the literature.

Materials and Methods:

The patients were put on nil by mouth and broad-spectrum antibiotics were administered. Oral fluids were started for patients whose intraoral lesions resolved and who could swallow their saliva. Steroids were not given, a nasogastric catheter was not placed, and early endoscopy was not used.

Results:

A total of 968 children presented at our clinic for corrosive substance ingestion during the 22-year period. The stricture development rate was 13.5%. Alkali substance ingestion caused a stricture development rate of 23%. A total of 54 patients required 1–52 sessions (mean 15 ±12) of dilatation.

Conclusion:

We do not perform early endoscopy, administer steroids, or place a nasogastric catheter at our clinic for patients who had ingested a corrosive substance. This approach has provided results similar to other series. We feel that determining the burn with early esophagoscopy when factors that prevent or decrease the development of corrosive strictures will be very important.

Caustic ingestion management: world society of emergency surgery preliminary survey of expert opinion

Caustic material ingestion injuries (CMI) are uncommon. Only 5,000 cases are reported in the United States each year and most acute care healthcare facilities admit only a few cases annually. Accordingly, no single institution can claim extensive experience, and management protocols are most probably based on either expert opinion or literature reports.

In this study, we will attempt to review opinions and practices of representatives of the board members of the World Society of Emergency Surgery and compare them to the current literature.

[Ingestion of caustic substances in children: 3 years of experience]

INTRODUCTION

There is no clear consensus on the management of accidental ingestion of caustic substances in paediatrics. The aim of this study was to determine the profile of the paediatric population treated due to caustic ingestion in a Healthcare Centre.

PATIENTS AND METHOD

A descriptive study was conducted on patients treated for the ingestion of caustic substances in our hospital during the period 2008-2011.

RESULTS

A total of 12 patients were treated, with a mean age of 3.8 years (1-13 years), with the majority males (58.8%). An alkaline product was ingested by 58.3%, and an acid by 41.6%. The majority (58.3%) did not refer to symptoms and the remainder referred to vomiting (33.3%), odynophagia (16.6%), haematemesis (8.3%), hyper-salivation (8.3%) and shortness of breath (8.3%). Oral cavity lesions were observed in 75% of cases. All, except one, were accidental. An endoscopy was performed on all of them (100%) between 12 and 24hours post-ingestion, with pathological findings in 41.6%. In the group that ingested an alkali, 2 (16.6%) patients had lesions, one a grade 2B and one a grade 3 oesophagitis. In the acid ingestion group, 4 (33.3%) patients had lesions; one grade 1-2A oesophagitis, two acute non-erosive gastritis, and one acute haemorrhagic gastritis. A follow-up endoscopy was performed depending on the previous endoscopic findings. Only two patients presented with complications.

CONCLUSIONS

Emphasis is placed on the endoscopic evaluation in the first 24hours of deliberate asymptomatic ingestions, as well as a strict follow-up in those that ingested acids, due to delayed associated lesions.

Steroid Administration is Effective to Prevent Strictures After Endoscopic Esophageal Submucosal Dissection: A Network Meta-Analysis

Esophageal stricture is a severe adverse event after circumferential endoscopic submucosal dissection (ESD). Steroid administration is a new method to prevent stricture formation. We performed a meta-analysis to investigate the efficacy and safety of steroid administration to prevent esophageal stricture after circumferential ESD. PubMed, the Cochrane Library, EMBASE, Chinese Biomedical Database, and Clinicaltrials.gov were searched. Studies on steroid administration + endoscopic balloon dilation (EBD) versus EBD alone for esophageal stricture were included and pooled analyzed in random-effects models. Besides, subgroup analysis and network analysis were performed to define the influence of ESD type and steroid administration method. Twelve studies involving 513 patients were included. Meta-analysis showed that steroid administration significantly achieved a lower stricture rate (risk ratio [RR], 0.40; 95% CI, 0.20-0.81) and less required EBD sessions (mean difference [MD], -4.33; 95% CI, -6.10 to -2.57) than control. Subgroup analysis indicated that steroid was effective after both semi- and complete circumferential ESD. Network meta-analysis showed that compared with oral steroid, local injected steroid had a similar effect to prevent stricture (RR, 1.16; 95% CI, 0.48-2.85), whereas a better effect to reduce required EBD sessions (MD, 7.77; 95%CI, 0.26-15.3). Additional steroid administration is effective to reduce the stricture rate and required EBD sessions. And local injected steroid was superior to oral steroid in EBD reduction, whereas due to the varied method and dose of steroid administration, the finding needs to be clarified in the future.

Esophageal stenting in caustic injuries: a modified technique to avoid laparotomy

OBJECTIVE

To compare the outcomes of a modified laparoscopic intraluminal stenting with the conventional laparatomic technique in patients with esophageal caustic injuries.

METHODS

A total of 103 patients with esophageal burns were included in this retrospective analysis. Patients were candidates for esophageal stenting to prevent future stenosis. According to patient preference, stenting was done with either the innovatory stent with the modified technique (52 patients) or the conventional method that required laparotomy (51 patients). The modified technique consists of placing an inflation balloon stent via laparoscopy. Overall mortality and complications after follow-up period (3 months) were compared between the two groups.

RESULTS

Two perioperative mortalities were seen, one in each group. Except one patient in the modified technique, all patients returned to normal intake after 3 months of follow-up. However, five patients of the modified group and three in the conventional group developed esophageal strictures (p > 0.05). Gastric outlet obstruction was observed in three patients of the modified group and one in the conventional group (p > 0.05). DeMeester scores showed that there was no gastro-esophageal reflux in both groups (p > 0.05).

CONCLUSION

Our results show that the modified technique can reach the efficacy of the conventional method without requiring laparotomy. Thus, far several studies have demonstrated the advantages of laparoscopy over laparotomy. Thus, and in line with the clinical guidelines of the Society of American Gastrointestinal and Endoscopic Surgeons, we recommend using the presented modified technique in patients with caustic esophageal injuries.

Caustic ingestions mimicking anaphylaxis: case studies and literature review

Anaphylaxis presents in children with rapid involvement of typically 2 or more organ systems including cutaneous, gastrointestinal, and respiratory. Caustic ingestions (CI) may also present with acute involvement of cutaneous, gastrointestinal, and respiratory systems. We present 2 cases of "missed diagnosis" that illustrate how CI presenting with respiratory symptoms can be mistaken for anaphylaxis owing to these similarities. Both of these patients had delay in appropriate care for CI as a result. These cases demonstrate the importance of considering CI in children who have gastrointestinal symptoms, respiratory distress, and oropharyngeal edema.

[Caustic injury of upper gastrointestinal tract: 20 year experience at a tertiary referral center]

BACKGROUND/AIMS

Caustic ingestion can cause severe injury to upper gastrointestinal tract. There were few studies about clinical characteristics and treatments of caustic injury in Korea. We investigated the changes in clinical features of caustic injury over the past 20 years including pattern of endoscopic mucosal injury and treatment modality.

METHODS

This study was a retrospective review of medical records from patients with caustic injury from September 1993 through December 2012. Patients were classified into two groups based on the year when caustic ingestion occurred: patients who visited the hospital from 1993 to 2002 (early group) and patients who visited the hospital from 2003 to 2012 (late group).

RESULTS

A total 140 patients were included (early group [n=50] vs. late group [n=90]). Annual number of caustic ingestions did not show decreasing tendency over the past 20 years. Alkali ingestion increased (20.0% vs. 65.6%, p<0.001) and cases with more than grade 2b of esophageal mucosal injury decreased (41.3% vs. 20.7%, p=0.012) in late group. There were no differences between two groups in sex, age, proportion of accidental ingestion, and systemic/gastrointestinal complications. Use of gastric lavage (p<0.01) and broad spectrum antibiotics (p=0.03) decreased in late group. However, there was no difference in use of steroid between two groups.

CONCLUSIONS

In this study, overall caustic ingestion did not decrease and ingestion of alkali agents increased over the past 20 years. Tighter legislation on caustic agents is required and we need to be alert to the best management of caustic injury.

Should computerised tomography replace endoscopy in the evaluation of symptomatic ingestion of corrosive substances?

INTRODUCTION

Corrosive ingestions are common, although most ingestions do not result in clinically significant effects. Limited guidance is available on the role of endoscopy and/or computerised tomography (CT) in the investigation of individuals with corrosive ingestion, and the present data regarding predictors of poor outcome are confusing. Furthermore, whilst there are many case series describing the use of endoscopy in corrosive ingestions, no clear ideal time frame has been established as to when it should be undertaken. More recently, CT has been used to grade injuries, but there are few studies on its role in managing corrosive injuries, and those studies that have been reported are conflicting in their results.

METHODS

A Medline search was performed with the terms 'Caustic ingestion' and 'Corrosive ingestion' and a second search by adding the words 'Endoscopy', 'CT', and 'Computerised tomography' as a subject term or keyword. These searches revealed a total of 277 reviews and papers, of which 33 original papers were relevant for analysis. Three further papers were identified during the analysis of these papers and a PubMed search of the same terms added one further paper, bringing the total to 37. There have been no prospective, randomised controlled trials directly comparing endoscopy and CT. Only two retrospective studies compared the use of CT and that of endoscopy. Thirty-five studies examined whether an endoscopy is always needed, and if so, within what time frame this should be done: CT or endoscopy? A review of these studies suggests that the data regarding the use of CT in these circumstances are not yet of sufficient weight to replace endoscopy as the first-line investigation in corrosive ingestion-related injury. Who needs investigation after corrosive ingestion? We believe that signs and symptoms indicate the likelihood of clinically significant injury in adults. Specifically, any evidence of oropharyngeal burns, drooling, vomiting, pain or dysphagia clearly indicates the need for an endoscopy. In children, it appears that an even greater degree of caution is needed. How soon after ingestion should investigation be performed? For whom an endoscopy is required, it is prudent to enable surgery and other specifics regarding management of corrosives to be decided quickly (< 12 h). There are many incidences where endoscopy has been done safely beyond 48 h although this is not needed frequently. Management recommendations Asymptomatic patients, particularly adults with a normal clinical examination and who can eat and drink normally, can be discharged safely without endoscopy. Endoscopy is preferred over CT in the assessment of risk in symptomatic patients with corrosive ingestion. If patients have any oropharyngeal injury and in particular symptoms of drooling, vomiting, dysphagia or pain (retrosternal or otherwise), the risk of having a high-grade injury is higher, and urgent endoscopy should be performed to grade the injury and determine whether surgical intervention is required. Patients who have non-specific symptoms, such as cough, should also undergo endoscopy, but this is less urgent.

CONCLUSIONS

Despite the lack of high-quality clinical trial data, the available evidence and clinical experience support the use of early endoscopy (< 12 h) in patients who are symptomatic after ingestion of a corrosive substance. We propose a clinical guideline that can be used to help plan management of corrosives.

Predicting the progress of caustic injury to complicated gastric outlet obstruction and esophageal stricture, using modified endoscopic mucosal injury grading scale

Severe caustic injury to the gastrointestinal tract carries a high risk of luminal strictures. The aim of this retrospective study was to identify predicting factors for progress of caustic injury to gastric outlet obstruction (GOO) and esophageal strictures (ES), using modified endoscopic mucosal injury grading scale. We retrospectively reviewed medical records of patients with caustic injuries to the gastrointestinal tract in our hospital in the past 7 years. We enrolled 108 patients (49 male, 59 female, mean age 50.1 years, range 18–86) after applying strict exclusion criteria. All patients received early upper gastrointestinal endoscopy within 24 hours of ingestion. Grade III stomach injuries were found in 58 patients (53.7%); 43 (39.8%) esophageal, and 13 (12%) duodenal. Of the 108 patients, 10 (9.3%) died during the acute stage. Age over 60 years (OR 4.725, P = 0.029) was an independent risk factor of mortality for patients after corrosive injury. Among the 98 survivors, 36 developed luminal strictures (37.1%): ES in 18 patients (18.6%), GOO in 7 (7.2%), and both ES and GOO in 11 (11.3%). Grade III esophageal (OR 3.079, P = 0.039) or stomach (OR 18.972, P = 0.007) injuries were independent risk factors for obstructions. Age ≥60 years was the independent risk factor for mortality after corrosive injury of GI tract. Grade III injury of esophagus was the independent risk factor for development of ES. Grade III injury of stomach was the independent risk factor for development of GOO.

High doses of methylprednisolone in the management of caustic esophageal burns

OBJECTIVE

Caustic substance ingestion in childhood is a public health issue in developing countries, and several management protocols have been proposed to prevent the resulting esophageal strictures. The role of corticosteroids in preventing corrosive-induced strictures is controversial. Our aim was to study the influence of high doses of corticosteroids in preventing esophageal strictures.

METHODS

Eighty-three children with a mean age of 4.10 6 2.63 years and with grade IIb esophageal burns (an esophagogastroscopy was performed within 24–48 hours of injury) due to corrosive substance ingestion were enrolled in our study between 2005 and 2008. Forty-two children (study group) received methylprednisolone (1 g/1.73 m2 per day for 3 days), ranitidine, ceftriaxone, and total parenteral nutrition. Forty-one children (control group) were administered the same regimen excluding methylprednisolone. Stricture development was compared between groups based on endoscopic and radiologic findings.

RESULTS

During the endoscopic examination, stricture development was observed in 4 patients (10.8%) in the study group and in 12 patients (30%) in the control group. The difference was statistically significant (P = .038). The stricture development rate in the upper gastrointestinal system with barium meal was 14.3% and 45.0% in the study and control groups, respectively. The difference was statistically significant (P = .004). The duration of total parenteral nutrition was shorter in the study group compared with the control group (P = .001). High doses of methylprednisolone were well tolerated in the study group without any side effects.

CONCLUSIONS

High doses of methylprednisolone used for the management of grade IIb esophageal burns may reduce stricture development.

Updates in pediatric gastrointestinal foreign bodies

Although most ingested foreign bodies in children pass spontaneously, certain foreign bodies can be harmful and they require special attention and emergent medical intervention to prevent significant morbidity and mortality. This article presents an overview of the epidemiology, diagnosis, management, and complications of foreign body ingestions in children. Particular attention is paid to coins, sharp objects, long objects, food bolus, caustic liquids, batteries, and magnets.

Conservative therapeutic approach to corrosive poisonings in adults

INTRODUCTION

In this study, we assess the effectiveness of a conservative therapeutic treatment of acute corrosive poisonings in adults, and we define therapeutic protocols based on clinical and endoscopic criteria.

METHODS

We analyzed clinical records of patients with acute corrosive poisonings who were hospitalized and treated at the Toxicology Clinic at the University of Skopje, Republic of Macedonia, during a 5-year period (2006-2010). A total of 481 patients' records with cases of acute corrosive poisonings were analyzed. There were 317 female (65.9 %) and 164 male (34.1 %) patients. The purpose of the therapy in the cases of acute corrosive poisonings is to prevent perforation as well as progressive fibrosis and stenosis of the esophagus and stomach. Therapeutic approach mainly consists of proton pump inhibitors, H(2) blockers, antibiotics, and intensive hyperalimentation. There are different opinions regarding conservative treatment of acute corrosive poisonings in adults.

CONCLUSION

Based on our study of corrosive poisonings of adults, we propose a list of optimal treatment recommendations.

Preliminary study of efficacy of hyaluronic acid on caustic esophageal burns in an experimental rat model

BACKGROUND

The aim of this study was to investigate the effectiveness of hyaluronic acid on the prevention of esophageal damage and stricture formation after experimental caustic (alkaline) esophageal injury in rats.

MATERIALS AND METHODS

Twenty-one Wistar albino rats were randomly divided into three groups. A caustic esophageal burn was created following the Gehanno model: Group l (n=7) underwent operation, but no injury; Group 2 (n=7) was injured and left untreated; and Group 3 (n=7) was injured and treated with hyaluronic acid, first topically and then orally by gavage (2×0.3mL; 12.5mg/mL for 7days). The caustic esophageal burn was created by instilling 25% NaOH into the distal esophagus. All rats were euthanized on day 22 for evaluation. The efficacy of hyaluronic acid treatment was assessed histopathologically and biochemically via blood determination of the total antioxidant status (TAS), total oxidant status (TOS), oxidative stress index (OSI), and sulfhydryl group (SH) and lipid hydroperoxidase (LOOH) levels. Statistical analyses were performed.

RESULTS

Weight gain was significantly lower in Group 2 than in the other two groups (P<0.05). The mean stenosis index, histopathologic damage score, TAS, TOS, OSI, and SH and LOOH levels were higher in Group 2 than in the other two groups. The mean stenosis index, inflammation, TAS, SH and OSI in Group 2 were significantly different than those in the other two groups (P<0.05).

CONCLUSION

Hyaluronic acid treatment is effective in treating damage and preventing strictures after caustic esophageal burn in rats.

Corrosive poisonings in adults

Ingestion of corrosive substances may cause severe to serious injuries of the upper gastrointestinal tract and the poisoning can even result in death. Acute corrosive intoxications pose a major problem in clinical toxicology since the most commonly affected population are the young with psychic disorders, suicidal intent and alcohol addiction. The golden standard for determination of the grade and extent of the lesion is esophagogastroduodenoscopy performed in the first 12-24 hours following corrosive ingestion. The most common late complications are esophageal stenosis, gastric stenosis of the antrum and pyloris, and rarely carcinoma of the upper gastrointestinal tract. Treatment of the acute corrosive intoxications include: neutralization of corrosive agents, antibiotics, anti-secretory therapy, nutritional support, collagen synthesis inhibitors, esophageal dilation and stent placement, and surgery.

Caustic ingestion in children

Caustic ingestion continues to be a significant problem worldwide especially in developing countries. In 2008 over 200,000 exposures to caustic substances were reported to the National Poison Data System. The presence or absence of symptoms or oral lesions does not predict the existence or severity of lesions. The best predictor of morbidity and mortality is the extent of injury as assessed during initial evaluation. Upper endoscopy remains the mainstay diagnostic modality for the evaluation of patients with caustic ingestion. There is a pressing need for noninvasive diagnostic modalities and effective therapeutic options to evaluate and treat the complications associated with caustic ingestion.

Features and management of esophageal corrosive lesions in children in Sierra Leone: lessons learned from 175 consecutive patients

PURPOSE

This study aims to highlight the peculiar presentation and management of children's corrosive ingestions in developing countries associated with malnutrition, delay in management, lack of technology, and sporadic follow-up.

METHODS

An observational study was carried out since 2005 on all children (<15 years old) admitted for caustic soda ingestion to the "Emergency" Surgical Center in Sierra Leone, either in the acute postinjury phase or for dilatation of esophageal strictures. Complications, mortality, stricture recurrence, and ability to swallow were the main outcome measures. Improvement in nutritional status (ie, gaining weight) and sustained esophageal patency were both considered reference points to successful treatment.

RESULTS

In 4 years (2005-2009), 175 children were admitted, 53.7% at more than 1 month after ingestion. Dilatations were carried out in 77.7%, and a gastrostomy was placed in 64%. Perforations and death rate were 4.5% and 2.8%, respectively. Sixty-two patients (35.4%) required more than 7 dilatations, whereas 15 (8.5%) were unable to maintain a satisfactory luminal diameter. Follow-up (range, 1-36 months; median, 7 months) was possible in 52.7%. Long-term success according to the aforementioned criteria was observed in only 16%.

CONCLUSIONS

Delayed presentations and complex strictures with repeated postdilatation recurrence are characteristics of children's corrosive ingestion in developing countries. Malnutrition is common, and gastrostomy is frequently compulsory. Esophageal patency with improvement in nutritional state is achieved only in a small percentage of patients.

Feasibility study of corticosteroid treatment for esophageal ulcer after EMR in a canine model

BACKGROUND

Intralesional or systemic steroid administration is a promising strategy for the prevention of esophageal stricture after endoscopic therapy. The aim of this study was to evaluate the influence of steroid therapy on the process of healing of defects in the esophageal mucosa after endoscopic mucosal resection (EMR).

METHODS

Nine beagle dogs were divided into three equal groups: group A, intralesional injection (n = 3), group B, peroral administration (n = 3), and group C, untreated control (n = 3). In group A, triamcinolone acetonide 1 ml (10 mg) was injected directly into the exposed submucosal layer immediately after EMR, and again on postoperative day (POD) 7. In group B, dogs were administered prednisolone 0.5 mg/kg/day orally for 14 days after EMR. In group C, 1 ml normal saline was injected by the same method as that used for group A. On POD 28, histological examination was performed to evaluate epithelialization, inflammation, angiogenesis, and atrophy of the muscularis propria.

RESULTS

In groups A, B, and C, the mean ulcer area was 50.1, 22.7, and 7.4 mm(2), respectively. The difference between groups A and C was significant (p < 0.01). Inflammatory cells were significantly more evident in the lesions of group A than in those of group C (p < 0.05). In all groups, atrophy of the muscularis propria was evident. However, transmural destruction and fibrosis were observed only in group A.

CONCLUSION

It was speculated that the esophageal ulcer causes the fibrosis of the submucosa and atrophy of the muscularis propria during process of healing. Intralesional steroid injection deepened the esophageal ulcers and delayed epithelialization, whereas systemic administration did not clearly improve the lesion healing process.

[Caustic ingestion: current situation and review of updated recommendations]

BACKGROUND

Household product ingestion is the second cause of visiting an Emergency Department for poisoning in children. Among these products, caustics are of great interest because of their potential toxicity and risk of sequelae.

OBJECTIVES

To describe the epidemiological and clinical features of patients admitted to our hospital due to possible caustic ingestion. To analyse the risk factors associated with oesophageal or gastric injury. To review the latest treatment recommendations.

MATERIALS AND METHODS

Retrospective review of all patients admitted with suspicion of caustic ingestion between January 2005 and April 2010. Epidemiological, clinical and therapeutic aspects were recorded.

RESULTS

A total of 78 patients were admitted, 45 (57.7%) were male, with a median age of 2.2 years (range: 1-17.3 years). In 13 cases the product was kept in a container different than the original. In 36 children, the family had induced vomiting or had given a liquid to dilute the product. Fifty two patients were symptomatic, and 46 of them had some sign on physical examination. Thirty nine oesophagoscopies were performed, and 7 oesophageal or gastric lesions were observed. When patients with normal and abnormal endoscopic findings were compared, the factors associated with an increased risk of mucosal injury were vomiting (P=0.01), and two or more symptoms at admission (P=0.03). No complication was described in patients without endoscopy.

CONCLUSIONS

Family education about preventive and initial measures after caustic ingestion must be improved in an attempt to prevent wrong actions which can be harmful. Some patients might benefit from clinical observation without aggressive therapeutic measures.

Acute corrosive injuries of the stomach: a single unit experience of thirty years

Introduction. The spectrum of gastric injury due to corrosives can vary. This paper presents a single center experience of over 30 years of corrosive gastric injuries of 39 patients with acute gastric injuries from 1977 till 2006. Patients and Methods. Two thirds of the patients in the acute injury group had a concomitant esophageal injury. The age of the patients ranged from 4 years to 65 years with a slight preponderance of males. (M : F ratio 22 : 17). Results. 36 out of 39 acute gastric injuries were due to ingestion of acids. Three patients had history of caustic soda ingestion. Oral hyperemia or ulcers of varying extent were seen in all patients. The stomach showed hyperemia in 10, extensive ulcers in 13, and mucosal necrosis in 10 patients. Fifteen patients (15/39, 38.5%) were managed conservatively. Twenty four patients (24/39, 61.5%) underwent laparotomy: one for frank peritonitis, 10 for gastric mucosal necrosis, and 13 others for extensive gastric ulcerations. Overall the mortality rate was 29.6 %. Conclusion. Although the mortality and morbidity of acute corrosive gastric injuries is high, the key to improve the survival is early identification of perforation, maintenance of nutrition and control of sepsis.

Battery ingestion in children

INTRODUCTION

Ingestion of batteries by children became more frequent in recent years, due to the increasing accessibility of electronic toys and devices to children. Due to their electrochemical composition, impacted batteries in the esophagus may cause an extensive damage. Following the removal of a battery, the post-esophagoscopy management is still controversial.

CASE PRESENTATION

An otherwise healthy 8 year-old boy presented to the pediatric emergency room 3h after the unintentional swallowing of a lithium battery. On examination, the patient was diaphoretic and tachypneic. Plain PA chest film revealed a 2.5 cm diameter radiopaque round object in the upper esophagus. The patient was scheduled for an urgent rigid esophagoscopy which was performed 2h after admission. Esophagoscopy findings included an impacted lithium battery in an advanced emptying process at a level of 17 cm from the incisor teeth, with a 3rd degree ulcerative esophagitis. It was not possible to visualize either the distal esophagus or the stomach. A nasogastric tube was not inserted because of a significant risk for esophageal perforation if bluntly passed. Post-operative medical therapy included fasting, administration of intravenous antibiotic therapy, antacids, and steroids. Flexible esophagoscopy superior to the level of the mucosal injury performed one day later, revealed erosive esophagitis, without evidence of perforation. Upper digestive tract gastrografin swallow test performed 2 days after esophagoscopy did not demonstrate a leak from the esophagus, and oral feeding was carefully re-initiated. Treatment was discontinued the following day. Follow up on days 10 and 14 revealed a healthy child with normal swallowing.

DISCUSSION

Battery ingestion-related injury results from direct pressure necrosis, local electrical currents and alkali leakage. Signs and symptoms of ingested battery are related to impaction duration, size of battery, battery content and peristaltic waves of the esophagus. Appropriate imaging studies should be performed to maximize identification of the foreign body before esophagoscopy. Esophageal stenting and adjuvant medical therapy (steroid therapy, antibiotic therapy and anti-reflux therapy) have a low evidence level of clinical benefit following caustic injuries from impacted batteries and spillage of their content to the esophagus. A judicious management should be tailored in each patient. Increased public and health personnel awareness is necessary to diminish the incidence of battery ingestion.

Chronic corrosive injuries of the stomach-a single unit experience of 109 patients over thirty years

BACKGROUND

Corrosive gastric injuries are not uncommon in developing countries because acids, which are more frequently associated with gastric injury, constitute the major type of offending chemical. The spectrum of gastric injury may vary from acute to varying types of chronic gastric involvement.

METHODS

The 109 consecutive patients with chronic corrosive gastric injuries treated in a single tertiary care superspecialty institute over a period of 30 years were reviewed with special reference to presentation and problems in management.

RESULTS

Acids contributed to 82.6% of chronic injuries. Chronic gastric injuries were usually one of five types in these patients. The majority had prepyloric strictures (83.5%). The remaining strictures were antral (4.6%), body (3.7%), pyloroduodenal (2.7%), or diffuse (5.5%).Twenty-one (22.8%) patients had a delayed gastric outlet obstruction, and18 patients had a concomitant esophageal stricture requiring a bypass. Most of the patients with chronic injury underwent surgical correction with Billroth I gastrectomy (77.1%), loop gastrojejunostomy (11.0%), and distal gastrectomy with Polya reconstruction (3.7%). Other procedures performed were pyloroplasty in 1 patient and colonic conduit jejunal anastomosis in 6 patients. One patient (1%) died in the postoperative period.

CONCLUSIONS

The management of chronic corrosive gastric injury depends on the type of gastric involvement, the presence of co-existent esophageal stricture, and the general condition of the patient. A limited resection of the affected stomach is the ideal procedure for the common type of gastric injury. In patients whose general condition prohibits major resection or where the stricture extends to the antrum the best treatment is a loop gastroenterostomy. Type III, IV, V strictures require individualized treatment. Delayed gastric outlet obstruction affects the treatment plan of combined gastric and esophageal injuries.