Caustic Ingestion Research Articles

Management of Accidental Ingestions of Caustic Products in Emergency Departments in Dakar : About 31 Cases

Background: Caustics are corrosive substances whose ingestion causes tissue damage that can range from mucosal irritation to total necrosis or even perforation of the affected digestive or bronchial segment. Ingestion is often accidental in children and a real public health problem in low and middle income countries, particularly in Africa.
 Aims: The main objective of this study was to describe the epidemiological, diagnostic, therapeutic and scalable aspects of accidental ingestions of caustics in the medical emergency department of the National Children's Hospital Center Albert Royer (NCHCAR) in Dakar.
 Methods: This is a descriptive and analytical study over a 12-month period, from March 2020 to February 2021. The study population was children aged 0 to 15 years who were seen in consultation or hospitalized following a caustic product ingestion.
 Results: During the study period, we included 31 children for accidental ingestion of caustics out of a total of 900 hospitalized children, i.e., a hospital frequency of 3.44% (31/900). The mean age of the children was 21.29±13.10 months and the extremes were 8 and 60 months. The age group [12-18 months] was the most represented (25.81%). Boys were predominant (51.61%) with a sex ratio of 1.07. Sodium hypochlorite (bleaching water) was the main product ingested (64.52%); caustic soda concerned 22.58% of children. More than half (77.45%) of the children were symptomatic with mainly digestive signs including oral ulcerations (41.93%) and vomiting (38.71%). The oesogastroduodenal fibroscopy performed in 19 of the 31 children (61.29%) was normal in 14 children (73.68%). Five children had endoscopic lesions of which 2 cases were stage I and 3 cases stage IIa of the Zargar classification. Initial management was exclusively medical with antisecretory drugs (70.97%), analgesics (38.71%) and corticosteroids (35.48%). The evolution was favorable for the majority of patients. One child presented a dysphagia to solids after 4 weeks of evolution treated by endoscopic dilatation. 
 Conclusion: Accidental ingestions of caustics are frequent in emergency departments. They generally affect children under 24 months of age. The management is medical in the uncomplicated forms which are more and more predominant. Prevention is based on education and awareness of the dangers of caustic products.

CT appearances of gastric injury due to caustic ingestion and associated findings (a study of 30 cases).

The mortality and morbidity of acute caustic gastric injuries are high. The spectrum of gastric injury due to caustic ingestion varies from hyperemia, erosion, and extensive ulcers to mucosal necrosis. Severe transmural necrosis can be associated with fistulous complications in the acute and subacute phases and stricture formation in the chronic phase. Due to these important clinical implications, timely diagnosis and appropriate management of gastric caustic injury are crucial, and endoscopy plays a pivotal role. However, critically ill patients or those with overt peritonitis and shock cannot undergo endoscopy. Thoraco-abdominal computed tomography (CT) is preferable to endoscopy as it avoids the risk of esophageal perforation and allows the evaluation of the entire gastrointestinal tract, as well as of the surrounding organs. With the advantage of not being invasive, CT scan has a promising role in the early evaluation of caustic injury. It has an increasing role in the emergency setting with good accuracy in identifying patients who are likely to benefit from surgery. In this pictorial essay, we present the CT spectrum of caustic injury of stomach and associated thoraco-abdominal injuries, with clinical follow-up.

ŒSOPHAGE NOIR : A PROPOS D’UN CAS AVEC REVUE DE LA LITTERATURE

Abstract Introduction: The black esophagus or acute esophageal necrosis is a condition of poorly understood etiology. Aim: reporter a clinical case followed by a review of the literature Clinical observation: 69-year-old patient, hypertensive, who was treated with concomitant radiotherapy, followed by abdominoperineal amputation for adenocarcinoma of the lower rectum with sphincter involvement. The patient suddenly presented on the 15th postoperative day with hematemesis of moderate abundance. Extensive necrosis of the middle and lower thirds of the esophagus without gastric or duodenal involvement was demonstrated on fibroscopy. There was no history of caustic ingestion or esophagogastric reflux. There was no transmural necrosis on the cervicothoraco-abdominal CT scan. A 7-day fast and parenteral nutrition were instituted, as well as treatment with double-dose proton pump inhibitors and an isogroup blood transfusion. The evolution was favorable with almost total disappearance of the necrosis on fibroscopy control one week later. Conclusion: Black esophagus or acute esophageal necrosis is a rare condition, most often discovered in a postoperative context. Opponents of the proton pump and resting the stomach remain effective means in their management. Keywords: acute esophageal necrosis, black esophagus.

Social factors behind rising trends of intentional ingestions of caustic agents in adult population of Pakistan. A study from tertiary health care center, Islamabad.

Objective To evaluate factors associated with rising trends of intentional ingestion of caustic agents for suicidal attempts in Pakistan. Study Design: Cross Sectional, Observational study. Setting: Tertiary Health Care Center of Islamabad. Period: January 2019 to December 2020. Material & Methods: One hundred subjects with intentional ingestion of caustic ingestion treated in Gastroenterology unit were interviewed on a written questioner after their recovery and informed consent. Non-probability purposive was sampling method used. Results: Out of 100 patients 63% were female, mean age was 28.81 years and 58% had suicidal intension. Disturbed marital/ family life was main factor behind suicidal attempts. (P= 0.025). Conclusion: factors like female gender, younger age, poor socioeconomic status and disturbed marital/ family life in study group had statistically significant association with suicidal intentions.

Reconstruction of the upper gastrointestinal tract using intra-thoracic Roux-en-Y technique after caustic agent ingestion: a case report from Aleppo, Syria

BackgroundCaustic substance ingestion is a high-risk medical emergency associated with high mortality and morbidity. To date, there are several treatment options with no standard method of care.Case presentationWe report a case of a corrosive agent ingestion complicated with third-degree burns and severe stenosis of the esophagus and gastric outlet. After failure of conservative treatment, the patient underwent jejunostomy placement for nutritional support followed by transhiatal esophagectomy with gastric pull-up and intra-thoracic Roux-en-Y gastroenterostomy with good outcomes. The patient recovered from the procedure and has been tolerating oral intake very well with significant weight gain.ConclusionWe put a new technique for treating severe gastrointestinal injuries caused by corrosive agent ingestion that resulted in both esophageal and gastric outlet strictures. These rare complex cases requires difficult treatment decisions. We believe that this technique provides many benefits for such cases and might be a feasible alternative for colon interposition.

Performance of computed tomography and its reliability for the diagnosis of transmural gastrointestional necrosis in a setting of acute ingestion of predominantly strong acid substances in adults

Objectives Computed tomography has become a critical component in evaluating adult patients with acute caustic ingestions and an alternative to endoscopy for detecting transmural gastrointestinal necrosis. This study assessed the performance and reliability of computed tomography findings of transmural gastrointestinal necrosis, given that the presence of the disease potentially signifies the need for surgery. Methods A retrospective database search was performed to identify consecutive adult patients with acute caustic ingestions who had computed tomography with endoscopy or surgery within 72 h of admission. Eight physicians reinterpreted computed tomography in two separate rounds. Diagnostic performance utilized eight rounds of radiologists' reinterpretations against reference endoscopic or surgical grades. Intra- and interobserver agreements were calculated. Results Seventeen patients (mean age, 45.6 years; 9 men; 46 esophageal and 34 gastric segments; 16 ingested strong acid substances) met the inclusion criteria. Eight patients (10 esophageal and 13 gastric segments) had transmural gastrointestinal necrosis. The highly differentiating findings between those with and without transmural gastrointestinal necrosis were esophageal wall thickening (100% vs. 42%, P = 0.001; 100% sensitive), gastric abnormal wall enhancement and fat stranding (100% vs. 57%, P = 0.006; 100% sensitive), and gastric absent wall enhancement (46% vs. 5%, P = 0.007; 100% specific). The intra- and interobserver percentage agreements were 47–100%, and 54–100%, which increased to 53–100%, and 60–100%, respectively, when considering only radiologists’ reinterpretations. Conclusions In a very small sample of adults who primarily ingested acid, contrast-enhanced computed tomography performed well when interpreted by a panel of radiologists.

A144 BLACK ESOPHAGUS: A PEDIATRIC PRESENTATION OF ACUTE ESOPHAGEAL NECROSIS AND MANAGEMENT OF ITS COMPLICATIONS

Abstract Background Acute esophageal necrosis (AEN), or "Black Esophagus", is a rare diagnosis in children with adult literature citing high mortality. We present a pediatric case of this unusual condition. Purpose To report the rare presentation of AEN in a child and the response to intensive endoscopic management. Method Chart and literature review of AEN presentation and management. Result(s) A 13-year-old male who presented with a one-day history of severe chest pain, worsened with swallowing, followed by coffee ground emesis. No caustic ingestion. A nasogastric (NG) tube was placed and 2L of coffee-ground aspirate drained. The patient was an ex-preterm infant (25 weeks) who presented at age 2 years with an antral ulcer that developed into an antral stricture. This resolved with successive endoscopic dilatation with no recurrence after 5 years, off acid suppression. Physical exam showed BMI 99th %ile and palpated epigastric tenderness. CT-angiogram showed diffuse circumferential thickening of the esophagus and impressive gastric dilatation. A contrast study showed stasis of contrast in the esophageal lumen. Upper endoscopy revealed a thick, white membrane followed by circumferential black mucosa in the mid to distal esophagus. Previous antral stricture was noted with easy scope passage. Biopsies were negative for fungus, bacteria, HSV, CMV and parvovirus. Inflammatory infiltrate (mainly neutrophils and scattered histocytes with occasional lymphocytes) was noted in the esophagus. Necrotic tissue was identified and a diagnosis of AEN was made. The patient remained NPO, on TPN, and morphine was used for pain control. He responded well to this, along with high dose PPI. He tolerated clear fluids and oral sucralfate. Repeat scope one week later showed resolved necrosis with remaining oedematous white plaques and an unchanged antral stricture. 10 days later he developed severe dysphagia and a 15.5 cm long 6 mm diameter distal esophageal stricture was identified. This was managed by serial balloon dilatations. Due to frequent need for dilatations, endoscopic triamcinolone injections were used in several procedures as an adjunct therapy. A total of 80 mg of triamcinolone per session was injected along the length of the stricture in 4 aliquots in five out of nine endoscopic dilations in the last seven months. The most recent procedure successfully dilated the esophagus to 18mm. Currently, the patient is now tolerating a soft oral diet and remains on PPI therapy. Image Conclusion(s) AEN is very rare in children with no literature describing the endoscopic management of AEN related stenotic complications. We report the case of this unique presentation in a teenager, resulting in severe, long-segment esophageal stenosis. Intensive endoscopic therapeutic management has resulted in a positive clinical outcome allowing oral nutrition without any stenting or surgical interventions. Early recognition and active endoscopic management likely contributed to the positive outcome. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Management of esophageal perforations and postoperative leaks

: Esophageal perforations and postoperative leaks are challenging and life-threatening conditions, with a not well-defined management, yet. Perforation is defined as a full-thickness tear in the esophageal wall due to a trauma on the esophageal lumen or to a sudden increase of endoluminal pressure, like in spontaneous perforations. The most frequent causes are: iatrogenic injuries, spontaneous perforations, foreign body or caustic ingestion, trauma, tumors etc. The onset of symptoms varies depending on the location of perforation (cervical, intrathoracic or intraabdominal), the degree of tissue destruction and extension of contamination of surrounding organs, the cause, the timing of diagnosis and the presence of underlying esophageal disorders. Post-operative esophageal leaks have a different origin but a quite similar clinical presentation and treatment to esophageal perforations. The higher reported incidence is after cervical esophagogastric anastomosis, followed by intrathoracic anastomosis (above all after trans-hiatal one). It is already proven that short diagnostic timing and correct treatment can reduce mortality of 50%. Recent evidence also shows how better outcomes are achieved when the management is multidisciplinary, led by an expert team, and individualized treatments are adopted, involving all available modalities (medical, endoscopic and surgical). The purpose of this article is to review current standard practice, expert opinions and outcomes in the management of esophageal perforations and postoperative leaks.

Oral mucosal burn in a neonate due to accidental wart medicine intake

Caustic ingestion is a problem frequently encountered in children younger than five years of age and mostly in developing countries. It may result in eusophagial, laryngeal, orophanryngeal and oral lesions. An 18 day-old-girl brought to emergency room because she was mistakenly given her fathers’s wart medicine instead of her daily vitamin D medicine. There were severe hyperemia and erosions at her lips, oral mucosa and oropharynx. Her oral nutrition was stopped and intravenous protone pump inhibitor drug has initiated. There were no evidence of gastrointestinal perforation at her abdomen X-ray. Her laboratory test results were completely normal. Endoscopic evaluation was not planned at early period because of her severe oral mucosal lesions. She recieved intravenous methylprednisolone for three days.. An eusophagogastroduedonoscopy was performed on day seven and reported to be normal. She has fully recovered without any sequalea. In this article, incorrect drug use and caustic exposure which are one of the most common household accidents were discussed over a newborn case.

Procedural and Surgical Interventions for Esophageal Stricture Secondary to Caustic Ingestion in Children

BackgroundEsophageal injury after caustic ingestion can vary in severity and may result in significant long-term morbidity due to stricture development. The optimal management remains unknown. We aim to determine the incidence of esophageal stricture due to caustic ingestion and quantify current procedural and operative management strategies. MethodsThe Pediatric Health Information System (PHIS) was utilized to identify patients 0–18 years old who experienced caustic ingestion from January 2007–September 2015 and developed subsequent esophageal stricture until December 2021. Post-injury procedural and operative management was identified utilizing ICD-9/10 procedure codes for esophagogastroduodenoscopy (EGD), esophageal dilation, gastrostomy tube placement, fundoplication, tracheostomy, and major esophageal surgery. Results1,588 patients from 40 hospitals experienced caustic ingestion of which 56.6% were male, 32.5% non-Hispanic White, and the median age at time of injury was 2.2 years (IQR: 1.4,4.8). Median length of initial admission was 1.0 day (IQR: 1.0, 3.0). 171/1,588 (10.8%) developed esophageal stricture. Among those who developed stricture, 144 (84.2%) underwent at least 1 additional EGD, 138 (80.7%) underwent dilation, 70 (40.9%) underwent gastrostomy tube, 6 (3.5%) underwent fundoplication, 10 (5.8%) underwent tracheostomy, and 40 (23.4%) underwent major esophageal surgery. Patients underwent a median of 9 dilations (IQR 3, 20). Major surgery was performed at a median of 208 (IQR: 74, 480) days after caustic ingestion. ConclusionMany patients with esophageal stricture after caustic ingestion will require multiple procedural interventions and potentially major surgery. These patients may benefit from early multi-disciplinary care coordination and the development of a best-practice treatment algorithm. Level of evidenceIII.

Esophageal burn Zargar IIIA and placement of percutaneous gastrostomy in preschool patient secondary to caustic ingestion: clinical case report and literature review

Esophageal burn Zargar IIIA and placement of percutaneous gastrostomy in preschool patient secondary to caustic ingestion: clinical case report and literature review

A Retrospective Study of the Severity of Injury following Potassium Permanganate Ingestion in Teenagers and Adults in KwaZulu Natal, South Africa

Introduction: Potassium Permanganate (KMnO4) is an uncommon cause of caustic ingestion in teenagers and adults; only case reports are found in the recent literature. At Ngwelezana Hospital in South Africa, KMnO4 ingestion is not an uncommon indication for admission. KMnO4 is readily available as used in most households and recommended for medicinal purposes by traditional health practitioners. Aim: To ascertain the reasons for KMnO4 ingestion, the extent and severity of injury as determined by upper gastro-intestinal studies, and patient outcomes in comparison with the available global literature. Methods: We performed a retrospective study of 26 teenage and adult patients, admitted to our adult wards following KMnO4 ingestion. Data collected on patient demographics, reason for KMnO4 ingestion, and quantity ingested. Oral inspection and upper gastro-intestinal study findings recorded with grading (Zargar) of corrosive injury to oesophagus and stomach. Patients’ outcome and duration of hospital stay documented. Results: There were 73% females and 27% males, with an average age of 23 years. Reasons for ingestion included parasuicide (84%), accidental ingestion (8%), and for relief of abdominal pain (8%). The vast majority (96%) swallowed KMnO4 in solution rather than in solid form. The volume and concentration of KMnO4 taken was difficult to quantify. Oral discoloration, oedema, and ulceration were found in 58%. Gastro-intestinal endoscopy was performed in 92%; abnormalities were demonstrated in 68% (oesophageal injury 14%, oesophageal and gastric injuries 14%, gastric injury alone 41%). Oesophageal injuries: n = 6; Zargar grade 1—83%, Zargar grade 2A—17%. Gastric injuries: n = 12; Zargar grade 1—42%, Zargar grade 2A—33%, Zargar grade 2B—25%. Average hospital stay was 2.9 days (range 2–8 days). There were no mortalities and no complications at 6 weeks. Conclusion: KMnO4 ingestion by teenagers and adults is not uncommon in our setting, mostly related to suicide attempts and most often taken in liquid form. KMnO4 was possibly of a low concentration as no systemic complications were noted and there were milder gastric and oesophageal injuries as compared to case reports from elsewhere of mucosal necrosis following ingestion of KMnO4.

Caustic oesophageal stricture treated by instrumental dilatation: A review of 6 years of practice at the pediatric university hospital charles de gaulle of Ouagadougou.

Oesophageal stricture is one of the most important and redoubtable complications following caustic ingestions in children. Instrumental dilatation is usually considered the first line of treatment. This study aims to evaluate the outcomes of caustic stenosis treatment when using Lerut dilatators. This is a descriptive retrospective study from May 2014 to April 2020. All children under 15 years hospitalised in our department for caustic oesophageal stricture and had a gastrostomy and oesophageal dilatation with insertion of an endless wire were included. A total of 83 patients were included. The sex ratio was 2.2. The mean age was 4 years. The mean time from caustic ingestion to presentation was 90 days. Oesophageal stricture was mostly caused by caustic soda (n = 41) and potash (n = 15). We performed in total 469 dilatations and had only three oesophageal perforations. After a mean follow-up of 17 months, we had 60.2% good results (n = 50) and 7.2% (n = 6) failures. The mortality rate was 13.2% (n = 11). The results of the dilations by Lerut dilatators give encouraging results in our department. It is easy to perform and its complications remain rare. Mortality could be reduced by adequate nutritional support.

Catastrophic Upper Gastrointestinal Tract Complications Following Corrosive Ingestion

Ingestion of caustic substances, either acidic or alkali, is a well-known cause of significant mortality and morbidity in the pediatric and adult populations. According to the pH, physical form, amount, and rate of ingestion of these substances, a wide range of immediate as well as possible subsequent chronic complications can result. Some patients may have minimal to mild symptoms. However, others can present with moderate or even serious symptoms, in the form of dysphagia, odynophagia, hoarseness, and epigastric pain. Herein we present a case of a 26-year-old male patient with a history of Nitric acid ingestion. He initially complained of severe chest and abdominal pain, associated with hematemesis, dysphagia, odynophagia, hypersalivation, and inability to tolerate oral intake. Initial Esophagogastroduodenoscopy (EGD) showed diffuse mucosal ulceration reaching the second part of the duodenum. Multiple subsequent EGDs revealed more extensive damage and subsequent esophageal stricture and pyloric stenosis for which multiple dilatation attempts were done. The patient received extensive supportive management during his hospitalization course, but the damage was severe enough that he was referred for surgical management. Such catastrophic sequels of caustic ingestion are still encountered, especially in developing countries. We present this case looking forward to raising awareness about this dangerous phenomenon and highlighting the significance of immediate identification and grading of the injury.

Colon patch esophagoplasty for esophageal strictures refractory to multi-modal treatment revisited.

Esophageal strictures due to caustic ingestion (CI) may require repeat esophageal dilations and dilation adjuvants, including local anti-fibrinogenic injection therapy, stent placement, and radial stricture incisions. Refractory strictures require surgical intervention. Pedicled colon patch esophagoplasty (CPE) may avoid the morbidity associated with total esophageal replacement, although reports of its use are limited. Indications and outcomes for CPE in patients undergoing repeat esophageal stricture dilations following caustic ingestion are described according to our local experience and literature reports. A retrospective review of indications for surgical management of esophageal strictures to tertiary pediatric surgical services between 2015 and 2020 focused on patients undergoing CPE. English-language literature (PubMed, Google Scholar, and Scopus) describing CPE was also reviewed. Eight (12%) out of 65 patients with esophageal strictures requiring 7 or more esophageal dilations with poor response underwent surgical stricture management over a 6year period, which included stricture resection and re-anastomosis in 2 patients, total esophageal replacement with colon graft in 2 patients, gastric pull-up in 1 patient, and CPE in 3 patients. The patients undergoing CPE were aged 3-8years and had 17 to more than 25 dilations following caustic ingestion over a 2-5year period. One patient had a 4cm stricture; the other 2 had strictures 7cm in length. A transverse colon patch based on the middle and left colic vessels was utilized in all three, with the vascular pedicle placed retrogastrically via the esophageal hiatus and the patch inlay esophagoplasty concluded via right thoracotomy. Post-operative contrast studies showed near-normal anatomy, and the patients could tolerate full oral diets. During a 9-36month follow-up period, only 2 patients required dilations of a proximal anastomotic stricture at 1 and 5months postoperatively. One patient required additional proximal stricturoplasty with advancement of the original graft across the stricture via a cervical surgical approach. Colon patch esophagoplasty to restore esophageal luminal continuity and allow a normal diet should be considered for refractory esophageal strictures. CPE had excellent functional outcomes in our 3 patients and should be considered in selected cases instead of total esophageal replacement.

A challenging upper digestive tract continuity restoration after recurrent esophago-colonic anastomosis complications

BackgroundAcute and chronic complications in esophago-colonic anastomosis have a significant impact in the postoperative course of patients with colonic transposition. Evidence about their management is poor and surgical treatment is mostly based on tailored approaches, so each new experience could be useful to improve knowledge about this peculiar condition. We report a unique case of an esophago-colonic resection and re-anastomosis without sternal approximation after recurrent anastomosis failure and strictures.Case presentationA 69-year-old woman was referred to our hospital for worsening dysphagia. The patient had undergone esophago-gastrectomy with right colon interposition 12 years prior due to caustic ingestion. The esophago-colonic anastomosis was initially complicated by an enterocutaneous fistula, which was treated with anastomosis resection and left colon transposition. This was then further complicated by dehiscence and sternal infection treated with resection of the distal portion of the sternum and a new colo-jejunal anastomosis. Finally, a chronic anastomotic stricture occurred, refractory to endoscopic dilatation and prothesis positioning. We planned a new colonic-esophageal resection and re-anastomosis. The main technical challenges were addressing the adhesions resulting from previous surgery and mobilizing an adequate length of the intestinal tract to allow conduit continuity restoration. Blood supply was assessed through Indocyanine Green Fluorescence. To avoid compression of the digestive conduit sternal margins were not re-approximated, and the transposed tube was covered and protected using both pectoralis major muscles flap. We decided to avoid the use of any prosthetic material to reduce the risk of infection. The patient was able to resume oral food intake on the 12th day postoperatively after a barium swallowing test showed an adequate conduit caliber.ConclusionEsophago-colonic anastomosis complications represent a life-threatening condition. Therefore, reports and sharing of knowledge are important to improve expertise in management of these conditions.

TRISMUS AND ORAL CAVITY STENOSIS AFTER CAUSTIC INGESTION: SURGICAL MANAGEMENT

Caustic ingestion in general is a Medical and a Surgical emergency and may be life threatening. The effects and clinical features are often dependent on the chemical nature of the compound ingested and, it's strength. Common scenario is usually a child or a mentally retarted person who gains access to caustic or corrosive substances usually used in household and mistakenly ingests it considering it palatable. The general signs and symptoms are burns and tissue disintegration coupled with necrosis. These changes are pronounced in oral cavity, oesophagus, and stomach. Long lasting complications are Peptic Ulcers, Esophagitis, Esopahgeal Strictures, Oral submucous brosis, Trismus, Stenosis, and abnormal tissue healing. We present a clinical report of a 7-year-old Male child who had a history of acid ingestion in early childhood and the surgical repair of the defect.

Caustic ingestion in Tunisian children: Endoscopic findings, complications and predictors of severe injuries in a cohort of 1059 patients

Background and aimsThe ingestion of caustic substances remains a serious medical problem in Tunisian children. This study was conducted to describe the epidemiological, clinical, and endoscopic findings of caustic ingestion in Tunisian children, and to indentify predictive factors of severe esophageal and gastric injuries. Patients and methodsA retrospective review of all children referred to a tertiary pediatric center for caustic ingestion who underwent esophago-gastro-duodenoscopy was conducted. Severe esophageal and gastric injuries were defined as Grade 2b, 3a, 3b, and 4 using the Zargar classification. We conducted multivariate logistic regression analysis to identify predictive factors for severe esophageal and gastric caustic injuries. ResultsWe analyzed 1059 diagnostic procedures performed for caustic ingestion. The mean age was 41.4± 31.9 months. The most frequently ingested caustic substance was household bleach followed by caustic soda granules. Endoscopy showed severe esophageal and gastric lesions, respectively, in 122 (11.5%) and 56 (5.3%) cases. Predictive factors of severe esophageal injuries were: alkaline ingestion (p<0.001; OR: 17.9; 95% CI: 8.4–38.1) and the presence of symptoms after caustic ingestion (p=0.02; OR: 2.4; 95% CI: 1.1–5.4). The occurrence of complications was significantly associated with the presence of severe gastric lesions at the initial procedure (p=0.046; OR: 2.3;95% CI: 0.9– .3). ConclusionEsophago-gastro-duodenoscopy should always be performed for symptomatic children, asymptomatic children who have ingested an alkaline product, and asymptomatic children under the age of 6 years.

S2806 Biliary Stenting of Caustic Proximal Esophageal Stricture Complicated by Fistula From Prior Dilation

Introduction: Caustic ingestions can lead to recalcitrant strictures of the upper esophagus. Endoscopic treatment options include dilations and/or covered esophageal stents; however, a stricture at a high anatomic location renders traditional stenting difficult. Dilation has the risk of perforation and fistula development. We present a patient with complex, proximal and distal esophageal strictures from caustic ingestion who was managed surgically then salvaged endoscopically using biliary stents. Case Description/Methods: A 28-year-old woman with a history of caustic ingestion of bleach and was found to have airway injuries, severe proximal digestive tract injuries, and transmural gastric necrosis. She underwent a total gastrectomy and cervical esophagostomy followed by Roux esophagojejunostomy and stepwise reconstruction. She then had esophageal strictures initially treated with Savary dilation complicated by perforation and fistula formation between upper stricture and pleura. Endoscopy revealed a 3-mm lumen at the upper esophageal sphincter (UES)(Figure). Initial contrast injection revealed no passage into esophagus, with contrast passing to pleura. XP gastroscope was used to pass a guidewire through the proximal stricture and into the esophagus. A 10mm x 6cm biliary fully covered self-expanding metal stent (FCSEMS; Gore Viabil Biliary Endoprosthesis) was deployed across the stricture, covering the fistula. The patient subsequently had repeated endoscopies for stent migration and to reach the distal stricture for stenting. Discussion: Esophageal stents are not typically placed across the UES due to foreign body sensation. In this case, the anatomic location of the stricture and presence of fistula required stenting across the UES. We chose a biliary FCSEMS that had anti-migratory features (flanges and conformability) and did not foreshorten. Despite these measures, the stent did migrate multiple times requiring re-intervention over a period of months, eventually allowing access to the distal esophageal stricture after upper esophageal remodeling around the shape of the stent. At the time of presentation to advanced endoscopy, colonic interposition was a less preferred option due to lack of healthy pharyngeal or esophageal tissue for anastomosis. Through the use of biliary stents in the esophagus, we were able to simultaneously treat a difficult stricture and fistula, allowing eventual access to a distal stricture for endoscopic treatment.Figure 1.: Endoscopic and fluoroscopic imaging showing (A) proximal esophageal stricture from caustic ingestion, (B) contrast injection showing stricture with fistula to pleura prior to stenting, (C) contrast injection through biliary FCSEMS deployed across proximal stricture without evidence of leak, and (D) proximal endoscopic view of the biliary FCSEMS above the arytenoid and close to endotracheal tube in subsequent endoscopy.

S2876 To the Duodenum, and Beyond! Using the BougieCap for Duodenal Stricture Dilation

Introduction: Benign duodenal strictures are typically caused by peptic ulcer disease, caustic ingestion, surgical anastomoses, or inflammatory bowel disease. Treatment of benign strictures usually involves endoscopic dilation using through-the-scope (TTS) balloon dilators with or without fluoroscopy. TTS balloon dilators allow visualization during dilation, but they do not provide haptic feedback. The BougieCap dilator is a newer device that attaches to the endoscope and allows direct visual and haptic feedback during dilation. While it is generally used for dilation of esophageal strictures, this report describes its use for dilation of a benign duodenal stricture. Case Description/Methods: A 75-year-old male with stage IV non-small cell lung cancer on immunotherapy was found to have biliary dilation on imaging. He subsequently underwent endoscopic ultrasound which incidentally revealed a duodenal stricture at the junction of the first and second portions of the duodenum. The stricture was unable to be traversed with the linear echoendoscope or an adult upper endoscope. TTS balloon dilation from 8 to 12 mm was performed, however, the adult upper endoscope was still unable to traverse the stricture. Biopsies of the stricture were obtained and were negative for malignancy and gastric biopsies did not reveal any evidence of Helicobacter pylori infection. Approximately 4 months later, the patient developed progressive nausea and vomiting. Upper endoscopy again showed the duodenal stricture which was unable to be traversed. The decision was made to use the BougieCap device for dilation. The stricture was then sequentially dilated from 10 to 12 mm using the BougieCap with direct visualization of mucosal disruption during dilation as expected (Figure). The adult upper endoscope was then able to traverse the stricture easily. There were no procedural complications or adverse effects and the patient reported improvement in his symptoms. Discussion: Benign duodenal strictures are typically treated with endoscopic dilation using TTS balloon dilators, although this method is limited by the lack of haptic feedback or complete visualization in some cases. In this case, TTS balloon dilation was ineffective for initial stricture dilation, thus the BougieCap was used for more precise dilation under direct visualization. While the BougieCap is generally used for esophageal stricture dilation, it may also serve as a safe and effective method to dilate refractory benign duodenal strictures.Figure 1.: Endoscopic image of BougieCap dilation of the duodenal stricture.