1. The Truth About Lye Pediatric Caustic Ingestions Amelia Simpson

2. Case Presentation- LS 2 year old girl drank out of a Gatorade bottle at her home that contained liquid lye- NaOH. Immediately had emesis and was taken to local ED  SCH. EGD showed significant esophagitis throughout the esophagus with exudates

3. Caustic Agents

4. Epidemiology Majority of caustic ingestions occur in children >50% of ingestions occur in children <6 yrs old House hold cleaning agents are most common ingested substances Males>females >13 yrs or older  intentional ingestions, female predominance 20% of ingestions result in some form of esophageal injury

5. Pathophysiology Injury depends on type of agent Strong alkalis cause liquefaction necrosis Lye = alkali agent Lye is most common cause of esophageal caustic injuries

6. Phases of Lye Injury Acute Necrotic Phase: 24-96hrs Ulceration and Granulation Phase: 3-5days Scarring Phase: 3 weeks and after

7. Diagnosis Symptoms: burning sensation, drooling, hypersalivation, difficulty swallowing, stridor, dysphonia, aphonia substernal/back pain ID offending agent if possible Laryngoscopy to evaluate airway Upper GI EGD with in first 24hrs of admission – Scope should be inserted only as far as first lesion

8. Multicenter study designed to determine if specific clinical signs and symptoms could determine severity of esophageal injury 336 ingestions 2 year prospective study and 7 poison control centers

10. Staging of Esophageal Injury

11. Initial Treatment Stabilization: NPO with IVF resuscitation Airway management/security (ABCs) Nutrition Management Surgical exploration if e/o perforation, mediastinitis, systemic Prevention of future complications: esophageal stricture/stenosis

12. Nutrition Once pt can manage own secretions begin CLD and advance as tolerated to regular – 24-48hrs If pt is unable to swallow or concern for severe injury, gastrostomy can be performed, +/- NG string Patients may require distal enteral feeds vs parenteral feeds

13. Prevention of Future Complications What immediate interventions can be done to prevent stenosis/stricture?

14. Serious caustic insult causes the esophagus to not only narrow but also shorten which alters the LES function PPI to reduce further injury as well as improve responsiveness to stenting and dilation Periodic screening by 24hr pH probe during follow up and treatment

15. Prospective randomized study over 18 year period 60 children with esophageal injury were assigned to treatment with or without corticosteroids Treatment branch received 2mg/kg /day of prednisolone and 50 amp/kg/day of ampicillin

16. Steroids made no significant difference in the development of esophageal strictures. Only correlation was severity of injury to development of stricture.

17. Follow Up Grade I-IIA injuries lead to strictures less often and can be followed clinically Grade IIB-III injuries should undergo barium esophagram or EGD 2-4 weeks after injury to evaluate for early stricture Surveillance for GERD with pH probe also can be considered

18. HD#1 taken to the OR for lap Gtube and NG string placement She tolerated her own secretions and was advanced to CLD  regular diet prior to discharge Gtube and string left in place upon discharge Case Presentation- LS

19. References Anderson KD, Rouse TM, Randolph JG: A controlled trial of corticosteroids in children with corrosive injury of the esophagus. N Engl J Med 323:637, 1990. Arevalo-Silva, C. et al. Ingestion of Caustic Substances: a 15 year experience. The Laryngoscope. 116:1422-1426. 2006. Kirsh MM et al: Treatment of caustic injuries of the esophagus: a ten year experience. Ann Surg 188:675, 1978. Mutaf O et al. Gastroesophageal reflux: a determinant in the outcome of caustic esophageal burns. J Pediatr Surg 31:1494, 1996. Zagar, SA. et al. The role of fiberoptic endoscopy in the management of corrosive ingestions and apnea. Gastrointest Endosc. 37:165-169. 1991.