Dr. Arun Aggarwal Gastroenterologist: Pediatric GI- Surgery conference

Pediatric GI- Surgery conference
Dr. Arun Aggarwal Gastroenterologist
By: Dr. Arun Aggarwal
Gastroenterologist

Caustic esophageal injury in children
• Seen most often in young children between 1-
3 years of age
• boys accounting for 50 to 62% of cases
• Most ingestions by children are accidental and
the amounts ingested tend to be small.
• The opposite is the case in adults, in whom
ingestion often is deliberate and related to
attempted suicide
Gastroenterologist

• The most common causes of caustic esophageal burns are
alkaline household cleaning products, such as oven and
drain cleaners, strong lyes that contain sodium and
potassium hydroxides, and laundry detergents and cleaning
agents with sodium phosphate, sodium carbonate, and
ammonia.
• Esophageal burns are rare with household bleaches
(sodium hypochlorite) because these have a relatively
neutral pH.
• Some caustic ingestions are caused by acid household
products including toilet bowel cleaners, battery fluids, and
muriatic (hydrochloric) acid used in swimming pools.
• Esophageal injury from acids may be attenuated compared
with alkalis, and perforation of the esophagus is less
common
Gastroenterologist

Mechanisms of injury: alkali versus
acids
• Alkalis: cause liquefaction necrosis. This type of
injury leads to early disintegration of the mucosa,
allowing deep penetration and even perforation.
• Acids or corrosives: cause coagulation necrosis.
• However, esophageal injury from acids may be
attenuated compared with alkalis because the
coagulum that forms on the mucosal surface may
limit deeper penetration of the caustic substance.
• Degree and extent of damage depends on type of
substance, morphologic form of agent, quantity,
and intent.
Gastroenterologist

Timing of tissue damage and repair
Injury Time
Acute injury Day 0
Inflammation, vascular
thrombosis
1 to 7 days
Granulation tissue (vulnerable
to perforation)
10 to 21 days
Fibrosis/stricture 3 weeks
Gastroenterologist

CLINICAL MANIFESTATIONS
• Early signs and/or symptoms may not correlate
with the severity and extent of tissue injury.
• The most common symptom is dysphagia.
• Esophageal studies during the acute phase of
injury have shown loss of motility with delayed
transit.
• Patients may also present with drooling,
retrosternal or abdominal pain, hematemesis,
and features suggesting upper airway injury such
as stridor, hoarseness, nasal flaring, and
retractions.
Gastroenterologist

• 10~30% patients with esophageal burns have
no oropharyngeal damage.
• 70% patients with oropharyngeal burns do not
have significant damage to esophagus.
• Injuries of oropharynx are not a reliable index
of damage to esophagus.
1. Gumaste VV, Dave PB. Ingestion of corrosive substances by adults. Am J Gastroenterol. 1992;87:1–5. 2. Haller
JA, Andrews HG, White JJ, et al. Pathophysiology and management of acute corrosive burns of the esophagus:
results of treatment in 285 children. J Pediatr Surg. 1971;6:578–584.
Gastroenterologist

• larynx or epiglottis: hoarseness and stridor
• Esophagus: dysphagia and odynophagia
• stomach: epigastric pain and hematemesis (or
aortoenteric fistula)
• Absence of pain not preclude significant GI
damage.
Gastroenterologist

DIAGNOSTIC EVALUATION
Gastroenterologist

• The objectives of early endoscopy are to establish the
presence or absence of esophageal and/or gastric
lesions and to determine the severity of involvement.
• Endoscopy is contraindicated in patients who are
hemodynamically unstable, have evidence of
perforation or severe respiratory distress, or exhibit
severe oropharyngeal or glottic edema and necrosis.
• Radiologic examination is valuable and essential for
follow-up to detect the presence of strictures.
However, barium studies are not reliable in detecting
acute injury or in predicting stricture formation.
Gastroenterologist

Grading of esophageal burns from
caustic injury
Injury Findings
Grade 0 Normal mucosa
Grade 1 (superficial) Superficial hyperemia and edema
Grade 2A (transmucosal) Hemorrhage, exudates, linear erosions,
blisters, shallow ulcers involving the
mucosa and submucosa
Grade 2B Circumferential burn present
Grade 3 A Deep ulceration, eschar formation with
necrosis, full-thickness injury with and
without perforation, <1/3 of esophagus
Grade 3 B > 1/3 of esophagus
Gastroenterologist

• First-degree burns are those with injury limited to
edema and erythema.
• Second-degree burns are characterized by linear
ulceration and necrotic tissue with whitish plaques.
Grade 2A are localized or partial and Grade 2B are
circumferential.
• Third-degree burns include circumferential injury with
sloughing of the mucosa.
• Some authors use third-degree burns to define patients
with perforation.
• Linear burns rarely lead to stenosis, whereas
circumferential burns frequently heal with stricture
formation
Gastroenterologist

TREATMENT
• The initial treatment: observation, with an
emphasis on preventing vomiting, choking, and
aspiration.
• The induction of vomiting is contraindicated
because vomiting may lead to additional
esophageal injury.
• use of neutralizing: not recommended.
• use of diluting agents: not recommended;
ingestion of diluting agent can induce vomiting,
potentially leading to further complications.
Gastroenterologist

• gastric lavage (x)
• induced emesis (x)
• milk and water: (?) diluting agents,
effectiveness not proven
• radiologic studies
• endoscopy
• oral intake
• prevention of strictures
Gastroenterologist

Nasogastric tube
• In patients in whom extensive circumferential burns
(Grade 2B or 3) are seen during upper endoscopy, NG
tube should be placed under direct visualization during
the endoscopic procedure.
• NG tube should not be inserted blindly because
perforation or additional injury can occur while passing
the tube.
• NG tube can provide a route for nutritional support
during the healing phase, and help maintain a lumen
during stricture formation.
• It also can serve as a guide for esophageal dilatation.
Gastroenterologist

Endoscopy
• assess oropharynx, larynx, esophagus,
stomach, and duodenum
• laryngoscopy: airway obstruction → early
intubation or tracheostomy
• No GI injury → observation, discharged,
evidence of GI injury →managed
appropriately
Gastroenterologist

Endoscopic grading
First degree
(superficial)
nonulcerative esophagitis, mild
erythema, edema of mucosa
Second degree
(transmucosal)
whitish exudate, erythema,
underlying ulceration that may
extend into the muscularis
Third degree
(transmural)
dusky or blackened transmural
tissue, deep ulcerations (may
extend into periesophageal tissue,
lumen may be obliterated)
Gastroenterologist

• performed between 24-48 hrs after injury,
allowing time to manifest most information
• wound softening after 2~3 days and lasts up
to 2 weeks (avoid endoscopy between days 5-
15, increase danger of perforation)
• endoscope should be advanced until a
circumferential 2rd degree burn or 3rd degree
burn is seen, attempts to past → increase risk
of perforation
Gastroenterologist

Corticosteroids
• Does not help protect against the development of
esophageal strictures, and may be harmful (increased
vulnerability to infection and GI bleeding).
• Corticosteroids also should not be used for acid
ingestion because esophageal strictures are less likely
and there is a greater risk of masking the clinical
features of gastric necrosis and perforation.
1. Hawkins D B, Demeter M J, Barnett TE. Caustic ingestion controversies in
management: a review of 214 cases. Laryngoscope 1980; 90: 98–109.
2. Oakes D D. Reconsidering the diagnosis and treatment of patients following
ingestion of liquid lye. J Clin Gastroenterol 1995; 21: 85–86.
Gastroenterologist

Oral Intake
• graded 1→ permit oral intake and discharged
within days
• grades 2 or 3 → nutritional support by
parenteral or NG tube (blind passage
increases risk of iatrogenic esophageal
perforation)
• Grade 2: NPO 3-5 days
• Grade 3: NPO >one week
Gastroenterologist

LATE COMPLICATIONS
Gastroenterologist

Stricture formation
• Stricture formation is the primary complication of caustic
injury, occurring in 2 to 38% of all ingestions and in 3 to 57
% of ingestions with documented esophageal burns.
• Most third-degree (circumferential) burns lead to
esophageal strictures regardless of treatment.
• Once a stricture is confirmed radiologically, esophageal
dilatation usually is required to maintain or reestablish
normal swallowing.
• All patients with significant burns and the potential for
stricture formation should be evaluated
with barium contrast studies two to three weeks post
ingestion.
• Contrast studies are not reliable in detecting acute injury or
in predicting stricture formation.
Gastroenterologist

Treatment of Strictures
• (Endoscopic) dilatation / bougination
• Surgery
– emergent surgery: perforation or shock, acidosis,
coagulation disorder with ingested large amount
of caustic agent → improve outcome
– reconstruction: colon interposition
Gastroenterologist

• A variety of dilators can be used, including mercury-
filled bougies, Maloney antegrade dilators or Tucker
dilators used in retrograde dilatation, and dilators
passed over a string or guide wire.
• Because caustic strictures appear to perforate easily,
retrograde dilatation has been considered the safest
method, although this method requires a gastrostomy
and a string for guidance.
• Balloon dilators under endoscopic control are also
commonly used in children.
• Perforation should be less likely with these instruments
because only radially directed force is exerted, and the
longitudinal shearing force with ante grade and
retrograde dilators is avoided.
Gastroenterologist

• Although esophageal dilatation may be beneficial
initially, repeated dilatations usually are needed.
• Only 33 to 48% of patients with caustic strictures
have long-term success with repeated dilatations.
• The remaining patients, who often have long
strictures, have increasing difficulty in swallowing
because of progressive obstruction.
• Many of these patients have extensive strictures
that ultimately require esophagectomy with
colon interposition within two years following
the ingestion.
Gastroenterologist

Left panel shows an esophageal stricture six weeks after lye ingestion. A
gastrostomy with retrograde string placement was performed with
multiple dilatations by string bougie. The patient was able to eat normally
for two to three weeks after each dilatation, but required monthly
dilatation. Right panel shows the stricture after two years and multiple
dilatations.
Gastroenterologist

• Mitomycin C, an inhibitor of fibroblast proliferation, has
been used in children who have required repeated
dilatations.
• Although there are no controlled trials, the application of
mitomycin C to the surface of the stenotic esophagus right
after dilatation has been reported to decrease the need for
further dilatation.
• A retrospective case series from eight institutions in
Europe, Australia and the United States described 16
patients with esophageal strictures, 10 of which were
caused by caustic ingestion. Each was treated with topical
mitomycin C following esophageal dilatation. The
treatment was successful in eliminating or reducing the
need for repeated dilatations in 82 % of the patients.
Rosseneu S, Afzal N, Yerushalmi B, et al. Topical application of mitomycin-C in oesophageal strictures. J Pediatr
Gastroenterol Nutr 2007; 44:336.
Gastroenterologist

Prevention of Strictures
• Intraluminal stent (silicone rubber) may be
helpful in selected esophageal injuries
patients (grade 2 or 3).
• long term outcome: unclear
1. Berkovits RN, Bos CE, Wijburg FA, et al. Caustic injury of the esophagus. J Laryngol Otol.
1996;110:1041–1045.
2. De Peppo F, Zaccara A, DallOglio L, et al. Stenting for caustic strictures. J Pediatr Surg.
1998;33:54–57.
Gastroenterologist

Pyloric stenosis
• Pyloric stenosis can occur with both acids and
alkalis and often is associated with esophageal
injury and strictures.
• With severe injury to the stomach, gastric
outlet obstruction may occur as early as three
weeks or as late as 10 weeks.
Gastroenterologist

Dr. Arun Aggarwal Gastroenterologist: Pediatric GI- Surgery conference

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Dr. Arun Aggarwal Gastroenterologist: Pediatric GI- Surgery conference

Similar to Dr. Arun Aggarwal Gastroenterologist: Pediatric GI- Surgery conference (20)

Recently uploaded

Recently uploaded (20)

Dr. Arun Aggarwal Gastroenterologist: Pediatric GI- Surgery conference