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

Background

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)

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)

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

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

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

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

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

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

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

Endoscopy Radiography Evaluation of Injury Endoscopy Radiography

Endoscopy Laryngoscopy Potential airway obstruction OGD Gold standard Within 12-24 hrs Should be avoid from D5 – D15 (risk of perforation) Classification (I, IIa, IIb and III)

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

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

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;37:165-169

Controversy

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

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;323:637-640 steriod do not prevent stricture Recommend dose 30-40mg methyl prednisolone or dexamethasone 1mg/kg/day Duration : > 3 weeks

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

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

Flowchart – Managment of caustic ingestion Deterioration  Laparoscopy

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

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

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

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

Thank You