Corrosive ingestion


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Corrosive ingestion

  1. 1. Faculty of surgerySongkhla hospital
  2. 2. 1. Alkalis: Cleaning agents (NaOH), drain openers, bleaches, toilet bowelcleaners, and detergents…2. Acids Toilet bowel cleaners ( sulfuric, hydrochloric ), anti rustcompounds ( hydrochloric, oxalic, hydrofluoric ), swimmingpool cleaners ( hydrofluoric )
  3. 3. Alkalis PH > 7 Tasteless, odorless →largeramounts liquefaction necrosis => directextension, deeper injuries Esophageal injury is common In stomach, partial neutralizationby gastric acid may result limitedinjury Duodenal injury is less commonAcid PH < 7 Pungent odor and noxioustaste coagulation necrosis =>formation of a coagulumlayer : limit the depth ofinjury Less esophageal injury More gastric injury As the acid toward thepylorus, pylorospasmimpairs emptying into theduodenum
  4. 4.  Corrosive properties of the ingested substance Amount, concentration, and physical form(solid or liquid) of the agent Duration of contact with the mucosa
  5. 5. 1. Vary widely Hoarseness, stridor, dyspnea => Airway evaluation Perforation: (During first 2 weeks) Retro-sternal or back pain Localized abdominal tenderness, rebound, rigidity,Psoas sign, obturator sign Massive hematemesis Dysphagia, odynophagia, drooling, nausea, vomiting2. Early signs and symptoms may not correlate with the severityand extent of tissue injury3. Oropharyngeal burns (-) :10-30% esophageal burns(+)Oropharyngeal burns (+) : 70% esophageal burns(-)
  6. 6.  Avoid: The use of emetics: re-exposes Neutralizing agents: thermal injury Gastric lavage: may induce retchingand vomiting which can compoundinjury
  7. 7.  Primary survey Keep NPO IV fluids administer Gastric acid suppression with intravenous PPI Adequate pain relief with intravenous narcotics Airway evaluation - laryngoscopy R/O perforation - Plain films of chest and abdomen Observation for Clinical signs ofperforation, mediastinitis, or peritonitis Broad spectrum antibiotics - given for patients with Grade3 caustic injury or high suspicion for esophageal perforation. Endoscope
  8. 8. 1. Timing: No later than 24 hours Usually avoided from 5-15 days2. Purpose: Grading, manage appropriately3. Risk of perforation: Low, under adequate sedation4. Extent: Advance until a circumferential second or third degree burn isseen To first part of duodenum
  9. 9.  Grade 0: Normal Grade 1: Mucosal edema and hyperemia Grade 2A: Superficial ulcers, bleeding, exudates=> Excellent prognosis Grade 2B: Deep focal or circumferential ulcers Grade 3A: Focal necrosis=> Develop strictures: 70-100% Grade 3B: Extensive necrosis=> Early mortality rate: 65%
  10. 10. a(Gr.IIa)b(Gr.IIb)C(Gr.IIIa)d(Gr.IIIb)
  11. 11. 1. Patients with mild or no injury○ may be discharged.2. Patients with grade 1 or 2A injury○ require no therapy.○ a liquid diet may be initiated○ advanced to a regular diet in 24 to 48 hours.3. Patients with grade 2B or 3 injuries○ should have nasoenteric tube feeding initiated after 24hours.○ oral liquids are allowed after the first 48 hours if thepatient is able to swallow saliva.○ steroids ???.*Patients with grade 3 injuries should be carefullyobserved for signs of perforation over at least a one-week.Prophylactic esophageal stenting is not recommended.
  12. 12.  In animal studies: incidence of stricture formation In human studies: Inconclusive so far NEJM. 1990: Prospective study over an 18-year period No benefit Related only to the severity of the corrosiveinjury Toxicol Rev. 2005: 1991-2004 in theEnglish, German, French, Spanish No benefit
  13. 13.  Clinical signs of perforation, mediastinitis, or peritonitis areindications for emergency surgery. Esophagectomy may be required for patients with severestrictures. Minimally invasive esophagectomy approach may be preferredbecause it is associated with a decreased hospital staycompared with standard esophagectomy. The most important factors to guarantee a successful outcomefor surgery are good vascular supply and absence of tension atthe anastomosis. If the stomach is damaged as well as the esophagus, a colonicinterposition can be used to create a new conduit.
  14. 14.  The prognosis is variable and depends uponthe grade of esophageal injury and theunderlying medical condition of the patient. Most deaths are due to the sequelae ofperforation and mediastinitis.
  15. 15. Esophageal strictureEsophageal carcinoma
  16. 16. 1. Stricture formation one-third of patients suffered caustic esophageal injury developesophageal strictures Primarily in those with grade 2B or 3 injury Peak incidence: two months Occur as early as two weeks or as late as years after ingestion Barium swallow examination is useful in the evaluation
  17. 17. 1. Endoscopic dilatation The goal: dilate the esophageal lumen to 15 mm Perforation rate: 0.5% Special consideration: Long, eccentric strictures: risk of perforation increased Thick-walled strictures: recur rapidly Multiple sessions: elective esophageal resection2. Intraluminal stent Temporary placement of a self-expanding plastic stent Successful in case reports3. Surgery Esophagectomy with colonic interposition Gastric transposition: high leak rate Perform 6 months later
  18. 18. 2. Esophageal carcinoma Incidence: 1000 to 3000-fold increase 3% have history of caustic ingestion Mean latency: 41 years (13-71years) Scar carcinoma: Less distensible => dysphagia presents earlier Lymphatic spread and direct extension Endoscope surveillance Begin 15-20 years after ingestion The time interval : No more than every 1-3 years
  19. 19.  Severity depend upon: the amount, concentration, physical formand the duration of contact with the mucosa. The absence of oropharyngeal burns does not preclude thepresence of esophageal or gastric injury. The use of emetics, neutralizing agents, or nasogastric intubation toremove remaining caustic material is contraindicated. Gastrointestinal endoscopy should be performed in first 24 hours. Endoscopy is contraindicated if hemodynamic instability, evidenceof perforation, severe respiratory distress, or severe oropharyngealor glottic edema and necrosis. Clinical signs of perforation, mediastinitis or peritonitis areindications for emergency surgery. Long-term complications include esophageal strictures andesophageal squamous cell carcinoma. Endoscopic surveillance forcancer is recommended at 15-20 years after ingestion.
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