NUTRITIONAL THERAPY IN THE TREATMENT OF ACUTE CORROSIVE INTOXICATION IN ADULTS

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.

Severe Intentional Corrosive (Nitric Acid) Acute Poisoning: A Case Report and Literature Review

Despite being one of the most debilitating conditions encountered in the field of toxicology, there is a lack of neutralization measures for the toxins involved in acute corrosive poisoning, and this promotes progressive contact injury of deep tissues after poisoning has occurred. Multiple controversies still surround management strategies during the acute phase of poisoning and the long-term follow-up of the patient. Here, we report a severe case of intentional poisoning with nitric acid complicated by extensive injury of the upper digestive tract, multiple stricture formation, and complete dysphagia. Serial endoscopic dilation and insertion of a jejunostomy feeding tube were necessary, and underlying psychiatric illness negatively affected the outcome of the patient. We conclude that an interdisciplinary approach is necessary to properly reduce the extent of lesions and sequelae induced by corrosion. Early endoscopic mapping of injuries is of major importance to better predict the evolution and possible complications of poisoning. Interventional and reconstructive surgical procedures may significantly improve the life expectancy and quality of life of patients following intoxication with corrosive substances.

Dietary and Nutritional Support in Gastrointestinal Diseases of the Upper Gastrointestinal Tract (I): Esophagus

The esophagus is the centerpiece of the digestive system of individuals and plays an essential role in transporting swallowed nutrients to the stomach. Diseases of the esophagus can alter this mechanism either by causing anatomical damage that obstructs the lumen of the organ (e.g., peptic, or eosinophilic stricture) or by generating severe motility disorders that impair the progression of the alimentary bolus (e.g., severe dysphagia of neurological origin or achalasia). In all cases, nutrient assimilation may be compromised. In some cases (e.g., ingestion of corrosive agents), a hypercatabolic state is generated, which increases resting energy expenditure. This manuscript reviews current clinical guidelines on the dietary and nutritional management of esophageal disorders such as severe oropharyngeal dysphagia, achalasia, eosinophilic esophagitis, lesions by caustics, and gastroesophageal reflux disease and its complications (Barrett's esophagus and adenocarcinoma). The importance of nutritional support in improving outcomes is also highlighted.

[Complications of upper gastrointestinal foreign body in children and related risk factors]

OBJECTIVE

To study the complications of upper gastrointestinal foreign body in children and related risk factors.

METHODS

Clinical data were collected from 772 children with upper gastrointestinal foreign bodies who were treated at the outpatient service or were hospitalized from January 2014 to December 2018. A multivariate logistic regression analysis was used to investigate the risk factors for the development of complications in children with upper gastrointestinal foreign bodies.

RESILTS

The upper gastrointestinal foreign bodies were taken out by electronic endoscopy for the 772 children. There were 414 boys and 358 girls, with a median age of 2.8 years. Children under 3 years old accounted for 59.5%. The foreign bodies were mainly observed in the esophagus (57.5%) and the stomach (28.9%), with a retention time of ≤24 hours in 465 children (60.2%) and >24 hours in 307 children (39.8%). The types of upper gastrointestinal foreign bodies mainly included round metal foreign bodies (37.2%), long foreign bodies (24.7%), sharp foreign bodies (16.2%), batteries (14.4%), corrosive substances (4.8%), and magnets (2.7%). As for the severity of complications, 47.7% (368 children) had mild complications, 12.7% (98 children) had serious complications, and 39.6% (306 children) had no complications. The logistic regression analysis showed that an age of <3 years, underlying diseases, location of foreign body, type of foreign body, and a retention time of >24 hours were risk factors for the development of complications in these children (OR=2.141, 7.373, 6.658, 8.892, and 6.376 respectively, P<0.05).

CONCLUSIONS

An understanding of the above high-risk factors for the complications of upper gastrointestinal foreign bodies is helpful to choose appropriate intervention methods and thus reduce the incidence of serious complications.

[Complications of upper gastrointestinal foreign body in children and related risk factors]

OBJECTIVE

To study the complications of upper gastrointestinal foreign body in children and related risk factors.

METHODS

Clinical data were collected from 772 children with upper gastrointestinal foreign bodies who were treated at the outpatient service or were hospitalized from January 2014 to December 2018. A multivariate logistic regression analysis was used to investigate the risk factors for the development of complications in children with upper gastrointestinal foreign bodies.

RESILTS

The upper gastrointestinal foreign bodies were taken out by electronic endoscopy for the 772 children. There were 414 boys and 358 girls, with a median age of 2.8 years. Children under 3 years old accounted for 59.5%. The foreign bodies were mainly observed in the esophagus (57.5%) and the stomach (28.9%), with a retention time of ≤24 hours in 465 children (60.2%) and >24 hours in 307 children (39.8%). The types of upper gastrointestinal foreign bodies mainly included round metal foreign bodies (37.2%), long foreign bodies (24.7%), sharp foreign bodies (16.2%), batteries (14.4%), corrosive substances (4.8%), and magnets (2.7%). As for the severity of complications, 47.7% (368 children) had mild complications, 12.7% (98 children) had serious complications, and 39.6% (306 children) had no complications. The logistic regression analysis showed that an age of <3 years, underlying diseases, location of foreign body, type of foreign body, and a retention time of >24 hours were risk factors for the development of complications in these children (OR=2.141, 7.373, 6.658, 8.892, and 6.376 respectively, P<0.05).

CONCLUSIONS

An understanding of the above high-risk factors for the complications of upper gastrointestinal foreign bodies is helpful to choose appropriate intervention methods and thus reduce the incidence of serious complications.

Histopathological changes in the oesophageal mucosa in Egyptian children with corrosive strictures: A single-centre vast experience

BACKGROUND

The caustic ingestion continues to be a major problem worldwide especially in developing countries. The long-term complications include stricture and increased life time risk of oesophageal carcinoma. Patients suffered from corrosive induced oesophageal strictures have more than a 1000-fold risk of developing carcinoma of the oesophagus.

AIM

To determine the possibility of oesophageal mucosal dysplasia after prolonged dilatation in post corrosive stricture.

METHODS

This observational study was conducted at the Paediatric Endoscopy Unit in Cairo University Children’s Hospital. It included children of both sexes older than 2 years of age who had an established diagnosis of post-corrosive oesophageal stricture and repeated endoscopic dilatation sessions for more than 6 mo. All patients were biopsied at the stricture site after 6 mo of endoscopic dilatation. A histopathological examination of an oesophageal mucosal biopsy was performed for the detection of chronic oesophagitis, inflammatory cellular infiltration and dysplasia.

RESULTS

The mean age of the enrolled children was 5.9 ± 2.6 years; 90% of the patients had ingested an alkaline corrosive substance (potash). The total number of endoscopic dilatation sessions were ranging from 16 to 100 with mean number of sessions was 37.2 ± 14.9. Histopathological examination of the specimens showed that 85% of patients had evidence of chronic oesophagitis (group A) in the form of basal cell hyperplasia, hyperkeratosis and subepithelial fibrosis. Thirteen percent of the patients had evidence of reactive atypia (group B) in the form of severe neutrophilic intraepithelial inflammatory cellular infiltration, and 2 patients (2%) had mild squamous dysplasia (group C); we rebiopsied these two patients 6 mo after the initial pathological assessment, guided by chromoendoscopy by Lugol's iodine.

CONCLUSION

The histopathology of oesophageal mucosal biopsies in post-corrosive patients demonstrates evidence of chronic oesophagitis, intraepithelial inflammatory cellular infiltration and dysplasia. Dysplasia is one of the complications of post-corrosive oesophageal stricture.