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

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Presentation on theme: "Management of Corrosive Ingestion Joint Hospital Grand Round United Christian Hospital Dr WN Fong."— Presentation transcript:

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 Extensive damage to aerodigestive tract  Perforation  Death Alkaline > Acid Alkaline > Acid Management is complicated ( young, psychotic, suicidal and alcoholic) Management is complicated ( young, psychotic, suicidal and alcoholic)

4 Corrosive Agent Alkaline corrosives – pH ≧ 12 Alkaline corrosives – pH ≧ 12 Granular, paste and liquid Granular, paste and liquid Drain and over cleanser Drain and over cleanser Washing detergents Washing detergents Cosmetic and soaps Cosmetic and soaps Button batteries 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 Mild Alkaline – pH 10.8 to 11.4 Sodium carbonate Sodium carbonate Ammonium hydroxide Ammonium hydroxide Bleaches ( sodium and calcium hypochlorid and hydrogen peroxide) Bleaches ( sodium and calcium hypochlorid and hydrogen peroxide)

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

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

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

9 Consequence Short Term Short Term Mild mucosal erythema Mild mucosal erythema Ulceration Ulceration Hemorrhage Hemorrhage Perforation (during first 2 weeks) 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 Oropharyngeal pain Dysphagia with drooling saliva Dysphagia with drooling saliva Hoarsiness and stridor Hoarsiness and stridor Dysphagia/ odynophagia Dysphagia/ odynophagia Retrosternal chest pain, radiate to back Retrosternal chest pain, radiate to back Hematemesis Hematemesis Cervical emphysema Cervical emphysema mediastinitis mediastinitis Epigastric pain Retching Emesis of tissue, blood or coff ee ground material peritonitis Tachypnea, Shock Metabolic acidosis coagulopathy

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

12 Evaluation of Injury EndoscopyRadiography

13 Endoscopy Laryngoscopy Laryngoscopy Potential airway obstruction Potential airway obstruction OGD OGD Gold standard Gold standard Within hrs Within hrs Should be avoid from D5 – D15 (risk of perforation) Should be avoid from D5 – D15 (risk of perforation) Classification (I, IIa, IIb and III) 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 Plain X-ray CXR CXR AXR AXR Contrast radiography ie water-soluble or thin barium Contrast radiography ie water-soluble or thin barium Double contrast CT if evidence of duodenum abnormality Double contrast CT if evidence of duodenum abnormality

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

17 Controversy

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

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

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

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

22 Flowchart – Managment of caustic ingestion Discharge Follow up Deterioration  Laparoscopy

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

24 Patie nt Endosc opic grade Interventio n Tracheost omy Outcome 1 Grade 1OGDNGood 2 Grade 2OGD Tracheostomy Steriod Ygood 3 Grade 3OGD trachesotomy Transhiatal esophagectomy + total gastrectomy + feeding j + esophagostomy YPlan for esophageal reconstruction with colonic interposition 4 Grade 2bOGD Tracheostomy Total gastrectomy + feeding j + esophagostomy YOGD – no stricture ( 2 months) Reconstruction : esophago-jejunostomy

25 Patie nt Endosc opic gradeIntervention Tracheos tomy Outcome 5 Grade 3OGD Trachesotomy Transhiatal esophagectomy + esophagostomy Total gastrectomy Whipple operation Splenectomy YDeath 6 Grade 4 OGD Total gastrectomy + esophagostomy, duodenostomy Y Plan for reconstruction in QMH 6/12 later

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

27 Thank You


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