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Management of Corrosive Ingestion

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1 Management of Corrosive Ingestion
Joint Hospital Grand Round United Christian Hospital Dr WN Fong

2 Background

3 Introduction Accidental - 80% children
Intentional - adolescents and adults Extensive damage to aerodigestive tract  Perforation  Death Alkaline > Acid Management is complicated ( young, psychotic, suicidal and alcoholic)

4 Corrosive Agent Alkaline corrosives – pH ≧12 Acid corrosive – pH <2
Granular, paste and liquid Drain and over cleanser Washing detergents Cosmetic and soaps Button batteries Acid corrosive – pH <2 Toilet bowl cleansers (sulfuric, HCl) Antirust (HOCl, oxalic) Battery fluid (sulfuric) Swimming pool and slate cleanser (HCl)

5 Corrosive Agent Mild Alkaline – pH 10.8 to 11.4 Sodium carbonate
Ammonium hydroxide Bleaches ( sodium and calcium hypochlorid and hydrogen peroxide)

6 Pathogenesis and Pathology
Degree of injury Agent Concentration Quantity Physical state Duration of exposure

7 Alkali Liquefaction necrosis (potent solvent x lipoprotein lining) Thrombosis of adjacent vessels Heat production Acid Coagulation necrosis Eschar formation

8 Anatomical Cricopharyngeal area Aortic arch Tracheal bifurcation
Lower esophageal sphincter Antrum (fasting) / body (after meal)

9 Consequence Short Term Long Term Mild mucosal erythema Ulceration
Hemorrhage Perforation (during first 2 weeks) Long Term Stricture formation Gastric outlet obstruction Shortening of esophagus altered LES Change in esophagus motility  GERD which accelerate stricture formation CA esophagus

10 Clinical Features Oropharyngeal pain Dysphagia with drooling saliva
Hoarsiness and stridor Dysphagia/ odynophagia Retrosternal chest pain, radiate to back Hematemesis Cervical emphysema mediastinitis Epigastric pain Retching Emesis of tissue, blood or coff ee ground material peritonitis Tachypnea, Shock Metabolic acidosis coagulopathy

11 Management Acute Phase Airway Fluid resuscitation
Assess the severity of injury Emergency surgery Controversies : neutralization, use of steriod/ antibiotics

12 Endoscopy Radiography
Evaluation of Injury Endoscopy Radiography

13 Endoscopy Laryngoscopy Potential airway obstruction OGD Gold standard
Within hrs Should be avoid from D5 – D15 (risk of perforation) Classification (I, IIa, IIb and III)

14 Classification of corrosive injury
Degree of Injury Depth Endoscopic Findings I Superficial mucosal injury Mucosal hyperemia & edema IIA Partial thickness injury – patchy Mucosal sloughing Superficial ulcers IIB Partial thickness injury - circumferential Deep ulcerations III Transmural injury Periesophageal and/or perigastric extension Eschar formation Full thickness necrosis Brownish black or gray ulcers

15 Radiography Plain X-ray CXR AXR
Contrast radiography ie water-soluble or thin barium Double contrast CT if evidence of duodenum abnormality

16 Role of Surgery Acute Phase – emergency measure
Evidence of perforation Shock, acidosis, coagulopathy and who ingested large amount of corrosive 3rd degree burn on endoscopy Early surgical intervention may improve outcome in grade 3 injury. Gastrointest Endosc. 91;37:

17 Controversy

18 Neutralization Absolute Contraindicate Relative Contraindicate
Gastric lavage Induce vomiting Relative Contraindicate Milk and water Activated charcoal Exothermic reaction and obscure subsequent endoscopy

19 Steriod Animal study – decrease stricture formation
Human study – inconclusive Review of 13 publications – Howell Am J Emerg Med 1992;10:421-5 Stricture significantly reduced in those with advance injury receiving steriod RCT – Anderson KD N Eng J Med 1990;323: steriod do not prevent stricture Recommend dose 30-40mg methyl prednisolone or dexamethasone 1mg/kg/day Duration : > 3 weeks

20 Antibiotics No clear data support its use No RCT in human avaliable
Consensus : Antibiotics should be given in patient treated with steriod Otherwise antibiotics is not advocated

21 Acid Suppression Esophageal shortening altered LES
Esophageal dysmotility  GERD – accelerate stricture formation

22 Flowchart – Managment of caustic ingestion
Deterioration  Laparoscopy

23 United Christian Hospital July 03’ – June 04’
Case Series United Christian Hospital July 03’ – June 04’

24 Patient Endoscopic grade Intervention Outcome 1 2 3 4 Tracheostomy
OGD N Good 2 Grade 2 Steriod Y good 3 Grade 3 trachesotomy Transhiatal esophagectomy + total gastrectomy + feeding j + esophagostomy Plan for esophageal reconstruction with colonic interposition 4 Grade 2b Total gastrectomy + feeding j + esophagostomy OGD – no stricture ( 2 months) Reconstruction : esophago-jejunostomy

25 Patient Endoscopic grade Intervention Outcome 5 6 Tracheostomy Grade 3
OGD Trachesotomy Transhiatal esophagectomy + esophagostomy Total gastrectomy Whipple operation Splenectomy Y Death 6 Grade 4 Total gastrectomy + esophagostomy, duodenostomy Plan for reconstruction in QMH 6/12 later

26 Bring Home Message Airway Early endoscopy is indicated
Surgery ?? Magnitude of surgery ?? Early surgical intervention may decrease mortality

27 Thank You

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