Caustic Agents Research Articles

Caustic injury of upper gastrointestinal tract: 20 year experience at a tertiary referral center

Caustic ingestion can cause severe injury to upper gastrointestinal tract. There were few studies about clinical characteristics and treatments of caustic injury in Korea. We investigated the changes in clinical features of caustic injury over the past 20 years including pattern of endoscopic mucosal injury and treatment modality. This study was a retrospective review of medical records from patients with caustic injury from September 1993 through December 2012. Patients were classified into two groups based on the year when caustic ingestion occurred: patients who visited the hospital from 1993 to 2002 (early group) and patients who visited the hospital from 2003 to 2012 (late group). A total 140 patients were included (early group [n=50] vs. late group [n=90]). Annual number of caustic ingestions did not show decreasing tendency over the past 20 years. Alkali ingestion increased (20.0% vs. 65.6%, p<0.001) and cases with more than grade 2b of esophageal mucosal injury decreased (41.3% vs. 20.7%, p=0.012) in late group. There were no differences between two groups in sex, age, proportion of accidental ingestion, and systemic/gastrointestinal complications. Use of gastric lavage (p<0.01) and broad spectrum antibiotics (p=0.03) decreased in late group. However, there was no difference in use of steroid between two groups. In this study, overall caustic ingestion did not decrease and ingestion of alkali agents increased over the past 20 years. Tighter legislation on caustic agents is required and we need to be alert to the best management of caustic injury.

Endoscopic Management of Gastrointestinal Emergencies

Gastrointestinal endoscopy in the last years has become from a purely diagnostic to a largely therapeutic procedure. Endoscopic therapy has rapidly become the treatment of choice for many acute conditions including non-variceal and variceal GI bleeding, foreign body impaction, caustic agents and acute biliary and colonic obstruction, narrowing the role of surgery and interventional radiology in the acute setting. The development of new tools and techniques have reduced the rebleeding and mortality rate but the comorbidity remain an important factor that impact on the patient outcome. In this issue of Journal of Gastroenterology and Hepatology research I have brought together a group of distinguished experts in their respective fields to review the literature and share their approach to endoscopic emergencies. I asked the authors to review and update the evidence regarding their subsequent topics as well as offer some clinical and practical advice, which would be useful tool to approach the GI emergiencies. I wish to thank Dr. Sung J for the invitation to participate as editor of this edition of the Journal of Gastroenterology and Hepatology research. We’d also like to thank each of the authors contributing to this edition for their efforts on this project. We hope the readers will find this issue as informative and enjoyable to read.

Treatment of Basal Cell Carcinoma by Topical 25% Podophyllin Solution

Background: Basal cell carcinoma is the most common malignancies of the skin. Numerous modalities of treatment are available. Podophyllin is an antimitotic and caustic agent that has been used in treatment of genital warts. Objective: To test the effectiveness and safety of topical 25% podophyllin in treatment of basal cell carcinoma. Patients and Methods: Thirty eight patients with basal cell carcinoma enrolled in this open labeled interventional study that had been enrolled in Department of Dermatology-Baghdad Teaching Hospital, Baghdad, from January 2010 to October 2011. History and physical examination was performed to all patients regarding all demographics detail related to the disease. Exclusion criteria: were pregnancy, recurrent tumors, aggressive deep subtypes, morpheaic type, and size more than 2 cm2 in diameter. Biopsies for all patients were done for histopathological examination at the first visit, and after clinical cure of the lesions. Lesions were treated with 25% topical podophyllin solution once weekly for 6 weeks. Follow up after clinical cured was done every 3 months up to 18 months to recording any sign and symptom of recurrent. Results: Thirty five patients with basal cell carcinoma completed the study: 28 (80%) males and 7(20%) females with males to females ratio 4:1, their ages ranged from 30 - 87 (64.114 ± 12.68) years, and the duration of the disease ranged from 2 months to 30 years (6.88. ± 4.83) years. The size of lesions ranged from 0.8 - 1.9 (1.454 ± 0.239) cm. The total podophyllin applications number ranged from 2 - 6 (4.65 ± 1.055) sessions. The total numbers of treated lesions were 100 lesions: 64 (64%) nodular, 31(31%) pigmented, 3(3%) Basosquamous, and 2 (2%) superficial. Ninety six (96%) lesions in 32 patients showed complete cure with 2 - 6 sessions, while 4 lesions in 3 patients showed partial response with 6 sessions. Biopsy from 21 cured lesions in 21 patients showed complete clearness apart from one with residual malignant cells. All the patients did not show clinical recurrence, during the follow up period up to 18 months. Inflammatory reactions were noted in all treated lesions as redness, edema and juicy skin 36 - 72 hours after topical podophyllin applications. After 3 - 5 days, the reaction became more exaggerated and ulceration developed, ended with crust formation. No evidence of systemic side effects was seen and this had been confirmed clinically and by laboratory during the sessions and one month later. Minimal or no scarring was noticed. Conclusions: Topical 25% podophyllin solution is a new, effective therapeutic modality in treatment of basal cell carcinoma which gives 96% cure, and it is highly recommended as alternative therapy in all type of basal cell carcinoma, single and multiple and for all ages especially for elderly patients and those who have surgeries phobia.

Intercontinental comparison of caustic ingestion in children.

PurposeTo investigate the caustic ingestion in children among different continents according to demographic characteristics (core purpose), main symptoms, common caustic agents, signs and symptoms, management, treatment and complications.MethodsThis systematic review was performed by searching the databases Science Direct, ProQuest, Google Scholar, and PubMed, electronically and manually. We included studies that were published from 1980 to 2013, at University of Medical Sciences of Tabriz, Iran. A strategic search was performed with keywords including caustic, corrosive, ingestion and children, and was limited to articles in English and Persian. Statistical analysis was performed by SPSS ver. 18.ResultsOf 63 selected articles of caustic ingestion with 9,888 samples, the proportion of Africa was 3 articles (4.8%) and 95 samples (1%), America 9 articles (14.3%) and 305 sample (3%), Asia 29 articles (46%) and 2,780 samples (28.1%), Europe 17 articles (27%) and 3,002 samples (30.4%), and Oceania 5 articles (7.9%) and 3,706 samples (37.5%). The average age was in the Africa 3.07±2.02 years, America 3.17±1.83 years, Asia 3.34±1.58 years, Europe 3.58±2.09 years and Oceania 3.52±2.02 years. Sex distribution was in Africa 76 males (0.91%) and 19 females (0.23%), America 49 males (0.58%) and 41 females (0.49%), Asia 1,575 males (18.76%) and 1,087 females (12.95%), Europe 1,018 males (12.13%) and 823 females (9.8%), and Oceania 1,918 males (22.85%) and 1,788 females (21.3%). Statistical analysis of the data indicated higher consumption in Europe and Oceania in the boys with higher average age of years.ConclusionThe comparison of caustic ingestion indicated that the cause substances of caustic ingestion in children are different among continents, therefore prevention strategy and different treatment guidelines among continents will be needed.

Miralax Mix Up: A Case Report on Caustic Injury to the Esophagus

Introduction: Ingestion of caustic agents causes a variety of injuries to the esophagus making management difficult. We describe an interesting case of ingestion of an unknown caustic agent and briefly discuss the current recommendations on diagnosis and treatment. Case Report: A 68-year-old Caucasian male presented with a 2 day history of painful swallowing after drinking what he believed was Miralax with water. The patient denied any recent antibiotic or steroid use. The patient’s past medical and surgical history is significant for congestive heart failure status post defibrillator, type 2 diabetes mellitus, coronary artery disease status CABG, bipolar disorder, tobacco abuse and polysubstance abuse. On evaluation, the patient’s vital signs were within normal limits. Physical exam was remarkable for scattered white patches on the surface of the oropharynx, which revealed a denuded area when removed by scraping with a tongue blade. Labs were significant for an elevated white blood cell count of 17,500. Basic metabolic panel was within normal limits. Examination by a fiberoptic nasolaryngoscope revealed burns of the oropharynx and hypopharynx. Esophagogastroduodenoscopy (EGD) showed severe diffuse esophageal injury (Grade 2A/2B) likely related to an inadvertent caustic ingestion. Patient was treated with a proton pump inhibitor drip and broad spectrum antibiotics. After several days, the patient was able to tolerate a clear liquid diet. He continued to improve clinically and was discharged on a soft diet with crushed medications. A follow-up EGD was scheduled for 8 weeks. Discussion: Ingestion of caustic agents occurs most commonly by accident in the pediatric population and as a suicide attempt in adults. These agents include both acidic and alkali chemicals commonly found in household cleaning products, which cause tissue injury resulting in both systemic and focal injuries. Most serious and long-term complications occur in the esophagus and include esophageal ulcerations, edema, perforation, strictures, and an increased lifetime risk for carcinoma. Presenting symptoms can vary from no symptoms to life threatening symptoms depending on the extent of tissue damage. Endoscopy should ideally be performed within 24 hours of ingestion. A 6-point grading system based on endoscopy findings is often used to predict clinical outcomes and treatment plans. Treatment is mainly focused on supportive care depending on the extent of injury and often includes gastric acid suppression and broad spectrum antibiotics until the patient recovers and complications such as strictures and perforations are treated.

Distinct subcellular localization of the neuronal marker HuC/D reveals hypoxia-induced damage in enteric neurons.

Correct neuronal identification is essential to study neurons in health and disease. Although commonly used as pan-neuronal marker, HuC/D's expression pattern varies substantially between healthy and (patho)physiological conditions. This heterogenic labeling has received very little attention. We sought to investigate the subcellular HuC/D localization in enteric neurons in different conditions. The localization of neuronal RNA-binding proteins HuC/D was investigated by immunohistochemistry in the mouse myenteric plexus using different toxins and caustic agents. Preparations were also stained with Sox10 and glial fibrillary acidic protein (GFAP) antibodies to assess enteric glial cell appearance. Mechanically induced tissue damage, interference with the respiratory chain and oxygen (O2 ) deprivation increased nuclear HuC/D immunoreactivity. This effect was paralleled by a distortion of the GFAP-labeled glial network along with a loss of Sox10 expression and coincided with the activation of a non-apoptotic genetic program. Chemically induced damage and specific noxious stimuli did not induce a change in HuC/D immunoreactivity, supporting the specific nature of the nuclear HuC/D localization. HuC/D is not merely a pan-neuronal marker but its subcellular localization also reflects the condition of a neuron at the time of fixation. The functional meaning of this change in HuC/D localization is not entirely clear, but disturbance in O2 supply in combination with the support of enteric glial cells seems to play a crucial role. The molecular consequence of changes in HuC/D expression needs to be further investigated.

An Epidemiological Study of Adult Acute Poisoning in Fez: Morocco

Introduction: Acute poisoning represents a real health problem in the world. It’s a frequent cause of admission to emergency departments and in the intensive care unit. This study aims to analysis epidemiological aspects, clinics, therapeutic, outcome and the factors of mortality of poisoning in Fez, Morocco. Methods: It’s a retrospective study, concerned all patients admitted for poisoning at the intensive care unit, from January 2009 to December 2012. Results: There were 201 patients admitted for acute poisoning. The median age was 26.26 years with a female predominance (74.1%). The circumstances of poisoning were suicidal, accidental and unknown in 85%, 10% and 5% respectively. Ingestion was the major route of exposure (94.5%), followed by inhalation (5.5%). The most frequent main toxic agents were pesticides (64.17%), medication (22.38%), carbon monoxide (5.5%) and caustic agents (5.5%). The main symptoms were nausea, vomiting and abdominal pain in 117 cases (58.2%). Disorders of consciousness were reported in 62 cases (30.8%). Hemodynamic instability was associated especially with acute aluminum phosphide poisoning. Increase of Troponin Ic was observed in 23 cases (12.7%). The electrocardiogram was abnormal in 21 cases (10.4%) especially with acute aluminum phosphide and carbon monoxide poisonings. Gastric lavage was done for 158 patients (78.60%). 33 patients (16.6%) were need mechanical ventilation. 19 patients (9.5%) of aluminium phosphide poisoning were needed vasoactive. The rate of mortality was 10.9%. The aluminium phosphide poisoning was responsible for 18 (81.8%) deaths. Apart from AIP poisoning, the mortality rate was 2.18%. The statistically significant prognosis factors for death were aluminium phosphide poisoning, cardiovascular signs as shock, myocarditis, electrocardiogram abnormalities, elevated cardiac troponin levels, respiratory distress, need for mechanical ventilation and vasoactive drugs. Conclusion: This epidemiological study revealed the high mortality associated with acute poisonings, especially to aluminium phosphide. The prevention remains the best approach for reducing morbidity and mortality.

Spectrum of corrosive esophageal injury after intentional paraquat or glyphosate-surfactant herbicide ingestion

BackgroundData on the spectrum of corrosive injury to the esophagus after paraquat or glyphosate-surfactant ingestion are sparse in the literature and confined to case studies and brief reports. Therefore, this study aimed to examine the clinical features, degrees of esophageal injury, and clinical outcomes after paraquat or glyphosate herbicide ingestion, and sought to determine what association, if any, may exist between these findings.MethodsWe performed an observational study on 47 patients with paraquat or glyphosate ingestion who underwent endoscopic evaluation over a period of 11 years (2000–2011).ResultsCorrosive esophageal injuries were classified as grade 1 in 14 (glyphosate-surfactant) and three (paraquat), grade 2a in nine (glyphosate-surfactant) and 18 (paraquat), and grade 2b in one (glyphosate-surfactant) and two (paraquat) patients. No patients had grade 0, 3a, or 3b esophageal injuries. Therefore, the severity of corrosive injury was more severe in the paraquat group (P = 0.005). After toxin ingestion, systemic toxicity occurred, with rapid development of systemic complications in many cases. Neurologic complications occurred more frequently in the glyphosate-surfactant group (29.2% versus 0%, P = 0.005), although respiratory failure (4.2% versus 34.8%, P = 0.008), hepatitis (12.5% versus 52.2%, P = 0.004), and renal failure (20.8% versus 52.2%, P = 0.025) developed more frequently in the paraquat group. Patients with glyphosate poisoning had shorter hospital stays than patients with paraquat poisoning (13.3 ± 15.1 days versus 26.8 ± 10.2 days, P = 0.001). Nevertheless, there was no significant difference in mortality rate between the glyphosate-surfactant and paraquat groups (8.3% versus 13.0%, P = 0.601). We ultimately found that patients with grade 2b esophageal injury suffered from a greater incidence of respiratory (100.0% versus 5.9%, P = 0.001) and gastrointestinal (66.7% versus 11.8%, P = 0.034) complications than patients with grade 1 injury, regardless of herbicide type.ConclusionParaquat and glyphosate are mild caustic agents that produce esophageal injuries of grades 1, 2a, and 2b only. Our data also suggest a potential relationship between the degree of esophageal injury and systemic complications.

Prevention of Unintentional Injuries: A Global Role for Pediatricians

In spite of many proven ways to prevent childhood injuries, the relative prevalence of unintentional injury continues to plague the health and well-being of children worldwide. No population groups are spared, with children living in all social and economic circumstances at risk. Dr Hollwarth describes the extent of this injury pandemic. He also cites practical approaches for pediatricians to help advocate for evidence-based injury prevention policies and more consistent inclusion of anticipatory guidance in their daily practice. The simple truth is that children are much more susceptible to unintentional injuries than adults and the societal costs are unacceptably high. This column serves as a call to arms for pediatricians everywhere to work on combating this growing public health challenge. —Jay E. Berkelhamer, MD, FAAP Editor, Global Health Monthly Feature Primary care pediatricians serve as physicians for the entire family because they accompany children from infancy through adolescence, and quite often into adulthood. The pediatrician may be primarily consulted in cases of diseases, but his or her advice with regard to vaccination, healthy nutrition, and a safe environment is usually appreciated by families. Thus, pediatricians can play a significant role in injury prevention, too. Why is injury prevention important? Unintentional injuries constitute a global public health problem and are the leading cause of death in children and adolescents between the ages 5 and 18 years. More than 800 000 children younger than 18 die every year as a result of unintentional injuries.1 In the United States, this is the leading cause of death among children aged 18 and younger, claiming more than 12 000 lives annually.2 For each child who dies as a result of injury, another 553 children are treated at emergency departments, a further 11.2 children need to … Address correspondence to Michael E. Hollwarth, Univ. Prof. Dr., Department of Paediatric and Adolescent Surgery, Medical University, Auenbruggerplatz 34, A-8036 Graz, Austria. E-mail: michael.hoellwarth{at}medunigraz.at

Achieving hemostasis in dermatology-Part II: Topical hemostatic agents

Bleeding is a common occurrence during any dermatologic surgery that disrupts blood vessels. The complications of excess bleeding can include delayed wound healing, hematoma formation, infection, dehiscence, and necrosis. In part one of this review, we discussed the pre-operative, intra-operative, and post-operative management of patients undergoing dermatologic surgery. In Part two, we discuss traditional and new topical hemostatic agents used to achieve hemostasis in dermatological procedures and surgery. We will evaluate the caustic and non-caustic hemostatic agents as well as hemostatic dressings. The mechanisms of action, side effect profile, and advantages and disadvantages of the topical hemostatic agents are provided. Sources for this article were found searching the English literature in PubMed for the time period 1940 to March 2012. A thorough bibliography search was also performed and key references examined.

Endoscopic therapy in the treatment of caustic esophageal stricture: A retrospective case series study

Endoscopic procedures, such as balloon/bougie dilation and stent implantation, have gained increasing potential as the treatment of corrosive esophageal stricture. The purpose of the present retrospective case series study was to assess clinical outcomes of endoscopic therapy of esophageal strictures after caustic injury. Between January 2003 and December 2009, 13 admitted patients that developed esophageal stricture after caustic agent ingestion underwent endoscopic therapy at the First Affiliated Hospital of Nanjing Medical University. Data such as age, gender, caustic agents, site of burn, type of treatment, effectiveness and outcome of endoscopic therapy were recorded. The average follow up was 39 months with a range of 29-70 months. Successful endoscopic therapy was achieved in 12 of 13 patients (92%). Duration of stricture resolution was between 4 and 48 months (mean, 15 months). Among them, seven patients required dilations only, whereas the other five patients received both dilations and stent implantation. There were no severe complications in these patients. These data suggest that endoscopic therapy is feasible, less invasive and effective for the management of caustic esophageal stricture. After repeat dilation and stenting, patients can achieve stricture resolution in approximately 15 months and avoid surgery.

Minimally invasive repair of a late stricture in a reversed gastric tube

Ingestion of caustic agents may result in severe scarring and stricture formation of the esophagus. Reversed gastric tube esophagoplasty is an option for definitive surgical management of severe esophageal stricture refractory to medical treatment. Delayed complications from this procedure have rarely been reported. We present a case involving a patient who developed a delayed gastric stricture three decades after receiving a reversed gastric tube esophagoplasty. A historical review of the reversed gastroplasty is presented as well.

Prise en charge des enfants après ingestion de substances acides ou alcalines

In children, caustic ingestion is due to accidents at home and inadequate storage of caustic agents. In emergency, it is useful to remove the soiled clothes, rinse the affected area, and prevent vomiting and feeding. Caustic ingestion (pH<2 or>12) induces burns of the upper gastrointestinal tract requiring esophagogastro-duodenoscopy between H12 and H24. Strong alkalis cause necrosis with liquefaction of the esophagus, penetrating deeply with a high-risk of perforation. Management of these children requires a specialized care center with an intensive care unit, endoscopic equipment, and a surgical team. Esophageal stricture is the main complication; no prophylactic treatment (steroids) is effective. Strictures occur after the 3rd week, and barium swallow should be performed by the end of the 1st month. Stricture are often multiple, long, and tortuous; endoscopic dilatation is difficult with a high-rate of perforation and a low-rate of success. In situ application of mitomycin C or injection of triamcinolone could reduce the recurrence rate of stricture. In recalcitrant or recurrent strictures, it is recommended to perform an esophageal replacement using a colonic interposition or a gastric tube. Endoscopy should also be performed 15-20years after caustic ingestion to screen for early neoplastic lesions. Prevention is very important for avoiding caustic ingestions. Information and education should be given specifically to the parents of toddlers; caustic products should be stored out of reach of children and they should not be kept with food.

Endoscopic Characterization of Caustic Ingestion in Zambia

Purpose: Ingestion of caustic agents can cause severe upper gastrointestinal damage. Data from developing nations is deficient due to under-reporting and lack of or late presentation to healthcare providers. AIM: To describe endoscopic findings of caustic ingestion. Methods: We conducted a retrospective cohort study, at University Teaching Hospital (UTH), a tertiary medical center in Lusaka, Zambia. We reviewed endoscopy records from January 1999 to May 2010 and searched for any mention of caustic ingestion. Parameters examined included age at presentation, gender, nature of the caustic substance ingested (acid or alkali), accidental or intentional and anatomical distribution of injury in the gastrointestinal tract. Results: We identified 43 cases of caustic ingestion. The mean age was 24 years, ± 8.7, and predominantly male 39/43 (90%). The most common caustic agent ingested was acid (53%) followed by alkali (47%). Endoscopic findings included gastric outlet obstruction (55%), esophageal stricture (30%), gastric ulcer (21%), pyloric ulceration (16%), gastritis (14%), esophageal ulceration (9%) and duodenal ulceration (2%). There was no difference in the endoscopic findings between men and women. The type of injury sustained was also not related to the type of substance ingested (acid or alkali). Data regarding situation of ingestion (accidental or intentional) was not available on endoscopy reports. Conclusion: The most common endoscopic outcomes were gastric outlet obstruction and esophageal stricture. Early diagnosis of caustic ingestion is important to guide treatment and prevent complications. Funding should be allocated towards raising public awareness.

Acute Upper Gastrointestinal Bleed in a Patient With Underlying Malignancy

Question: A 65-year-old man with recently diagnosed abdominal B-cell lymphoma (on R-CHOP therapy) presented to the emergency department with 3 days of general malaise, dizziness, and melena. Associated symptoms included poor intake, multiple episodes of vomiting, and constipation before the onset of melena. He denied any ingestion of nonsteroidal anti-inflammatory drugs or caustic agents. Physical examination revealed a blood pressure of 94/69 mm Hg, a heart rate of 114 bpm, dry mucous membranes, and epigastric abdominal tenderness. Abdominal computed tomography without contrast showed small bowel dilatation without a definitive transition point, severe sigmoid diverticulosis, and an abdominal retroperitoneal mass. Initial laboratory investigations showed a blood urea nitrogen/creatinine ratio of 23:1, albumin of 3 g/dL (normal range, 3.5–5), stool occult blood positive, and a hemoglobin of 14.3 g/dL (normal, 13.7–17.5). On the medical floor, a stat hemoglobin in response to further vomiting and dark stools showed a 3-g drop from admission. He was transfused blood, given intravenous fluids, and placed on a proton pump inhibitor drip. An upper gastrointestinal endoscopy showed areas of blood clot with friable mucosa and circumferential eschar located in the distal esophagus (Figure A, B), which abruptly ended at the gastroesophageal junction (Figure C) with no involvement past this site nto the stomach (Figure D). Esophageal brushings showed many inflammatory cells (neutrophils and lymphocytes) without vidence of malignant cells or fungal/viral infection (not shown). An area of tissue proximal to the gastroesophageal junction was iopsied for pathology and showed loss of the epithelial layer, fibrinoid necrosis, and smooth muscle with granulation tissue (Figure , F). Histologic stain revealed no fungal organisms. What is your diagnosis? What therapeutic interventions should be taken? What complication is most associated with this disease rocess? Look on page 1120 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information n submitting your favorite image to Clinical Challenges and Images in GI.

An Uncommon Cause of Dysphagia

A 65-year-old woman presented to a north Indian tertiarycare center with progressive dysphagia, loss of appetite, and loss of weight (12 kg) over 3 months. There was no history of odynophagia, fever, intake of caustic agent, or intake of any medication known to cause pill-induced esophagitis. She was a nonsmoker and a tee-totaller. There was no significant past history or any comorbid illness. There was no family history of malignancy. On examination she had a BMI of 19.4 kg/m with no palpable lymphadenopathy or organomegaly. Her investigations showed normal renal and liver function tests. Her hemoglobin was 12.2 g% with an ESR of 46 mm/h. Her chest radiograph was normal and HIV serology was negative. She underwent an esophagogastroduodenoscopy which showed a punched-out ulcer with elevated edges at 26 cm from incisors (Fig. 1). Multiple biopsies taken from the ulcer and its edges were evaluated histologically (Fig. 2). She subsequently underwent a computed tomography of the chest (Fig. 3) and endoscopic ultrasound (Fig. 4). Questions

Puncture injection of para-toluenesulfonamide combined with chemoembolization for advanced hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is difficult to eradicate due to its resilient nature. Portal vein is often involved in tumors of large size, which exclude the patient from surgical resection and local ablative therapy, such as percutaneous ethanol injection (PEI) and radiofrequency ablation (RFA) because they were considered neither effective nor safe. Currently, there is almost no effective treatment for HCC of such condition. As a unique antitumor agent in form of lipophilic fluid for local injection, para-toluenesulfonamide (PTS) produces mild side effects while necrotizing the tumor tissues quickly and efficiently. Being largely different from both PEI and RFA therapies, PTS can disseminate itself in tumors more easily than other caustic agents, such as alcohol. So PTS may offer additional benefit to HCCs with vascular involvement. We herein describe a 70-year-old HCC patient who was treated with the combination of PTS injection and transcatheter arterial chemoembolization, resulting in a significantly improved clinical prognosis.

Effects of Thuja Occidentalis as an alternative remedy in the treatment of Papillomatosis in Cattle

Papillomatosis is a condition in farm animals and is treated by surgical excision or application of certain caustic agents. Contrary to it, two cattle with teat warts were treated by an alternative method by using the thuja occidentalis (thuja-30, a homeopathic medicine) @ 10 drops Per os twice a day for a span of 3 weeks and lead to complete recovery.

Clinical and Epidemiological Features of Acute Corrosive Poisonings

the ingestion of chemical agents, of caustic nature, represents a serious problem for clinical toxicology. If the ingestion doesn't cause death during the acute period, it will most often cause severe side effects in the upper gastrointestinal tract during the chronic phase. The purpose of this study is to show the clinical, epidemiological and socio-economical characteristics seen in acute corrosive poisonings such as ingested caustic agents, causes for abuse and most consequential complications. a ten year medical data was constructed and collected (2000-2009) from patients with acute corrosive poisonings who were hospitalized and treated in the University Clinic of toxicology and urgent internal medicine in Skopje, Republic of Macedonia. The variables included were: age, sex, type of poisonings and percentage of late post-corrosive complications. In the study, 735 patients files were analyzed, collected in a period often years. The mean age of patients is 32.9 +/- 15.6 years. Majority of patients ingested hydrochloric acid (HCl; n = 354; 48,16%). Demographic, diagnostic and therapeutic findings in acute corrosive poisonings are found to be similar to the findings observed in the referenced literature. Conclusively, women between 14 and 30 years old represent a high risk group; hydrochloric acid is the most often abused agent; and high percentage of post-corrosive complications are

The Implementation of Laparoscopy for Acute Caustic Gastrointestinal Injuries Is Limited: Reply

To the Editor, We are grateful for the clinical experience and suggestions provided by Dr. Huscher and colleagues concerning their laparoscopic management of caustic injuries to the upper gastrointestinal tract (UGI). Also, we congratulate them on their brilliant results. Minimally invasive surgery such as video-assisted thoroscopic surgery (VATS) and laparoscopy has been performed regularly in our department for more than 10 years. Total minimally invasive esophagectomy and gastric tube reconstruction for esophageal cancer with assist devices, such as the harmonic scalpel and endo-GIA stapler, have also been performed in a certain number of cases. However, the application of endoscopy in emergency surgery for patients with severe caustic UGI injuries remains a contentious issue. The operative indications in our series are listed in our article. Most of our patients underwent operation because of shock or persistent metabolic acidosis despite intensive resuscitation. As you can imagine, clinical conditions (hypotension, acidosis etc.) became even worse during the operation. The only way to save these patients is to remove the necrotic organs and tissue as soon as possible, i.e. to stop the continuous absorption of toxins, which would otherwise cause sepsis. In most cases, we finished resection within 60–90 min. We then irrigated the entire abdominal cavity, using approximately 10,000 ml of warm saline to clear all intraperitoneal soiling and thus prevent postoperative abdominal abscess. The entire anesthesia time should be as short as possible for these patients. The disadvantages of laparoscopic resection that concern us most are: (1) the instillation of carbon dioxide into the peritoneum, further compromising cardiopulmonary function and causing unpredictable intraoperative tragedy; (2) intraperitoneal spillage of gastrointestinal contents due to necrotic perforation—difficult to completely clean up through the endoscope and potentially very time consuming. The operative time achieved by Dr. Huscher was 218 ± 28 min, but is the time used for peritoneal lavage after resection taken into account? We have to point out that one of the main differences in caustic UGI injuries in Western countries and Taiwan is the caustic agent. In Taiwan, acid is the most commonly ingested agent. Unlike the localized lesions caused by ingestion of solid alkaline pellets, the low pH of acid causes diffuse injuries from the midor even upper esophagus down to the gastric body and antrum. This extent of injury greatly increases operative difficulty. We agree that laparoscopy is of value in the management of a limited number of cases of acute caustic GI injuries, provided the patient’s vital signs are stable and there is no perforation. Also, it is a valuable tool for early diagnosis of some cases with equivocal clinical conditions. For the ‘‘very sick patients,’’ as Dr. Huscher has said, what would be more important, a life-saving operation or minimally invasive surgery in order to reduce surgical trauma? Intestinal continuity was restored in two of Dr. Huscher’s young patients; what about the other 4? We appreciate this opportunity to reply to Dr. Huscher’s comments. Also we acknowledge and thank Jadzia Chou for manuscript revision. S.-H. Chou H.-P. Li Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan