History Of Caustic Ingestion Research Articles

Early topical mitomycin-C prevents stricture formation in children with caustic ingestion.

Stricture formation is the most common remote complication of caustic ingestion. The aim of this study was evaluation of the efficacy of early topical endoscopic application of mitomycin C (MMC) in prevention of stricture formation after corrosive ingestion in children. We enrolled 78 children with a history of caustic ingestion within 48 h in a prospective, randomised-controlled study. Only 61 children completed the study and were classified into two groups: group A and B. After initial stabilisation, patients in group A (n = 30) received topical application of MMC within the initial 48 h while patients in group B (n = 31) only received conventional management. Follow-up endoscopic dilatation was done every 2 weeks to patients in either group until no need for further dilatation. The barium study, which was done on the third week, revealed that all the patients (100%) on conservative management (group B) had strictures while only nine patients (30%) in group A had strictures (P < 0.001). The median number of dilatations required for patients in group B was 26 (min. = 23 and max. = 32) while in group A, it was 0 (min. = 0 and max. = 7) (P < 0.001). The success of early MMC application was complete response in 26 patients (86.7%), partial response in 3 patients (10%) and no response in 1 patient (3.3%). On the other side, conventional therapy with endoscopic dilatation achieved complete response in 11 patients (35.5%). Early topical MMC application proved its efficacy and safety in prevention of scar and stricture formation in children following caustic ingestion.

Black Duodenum and Black Esophagus

Purpose: Acute esophageal necrosis (AEN) or ‘black esophagus' is characteristically described as diffuse, circumferential, black appearance of the esophagus that stops abruptly at the gastroesophageal junction (GEJ). AEN commonly presents with symptoms of hematemesis, melena or coffee-ground emesis in about 90% of the cases. We describe the first case in the literature of AEN associated with duodenal necrosis (black duodenum) in a patient who presented with a pulmonary embolism without these classic characteristic symptoms. An 80-year-old male ex-smoker with a past medical history of hypertension was admitted to our hospital with symptoms of worsening shortness of breath, left sided back pain, nausea and non-bloody, non-bilious vomiting. He denied abdominal pain, chest pain, fever, chills, dysphagia, odynophagia, or history of caustic ingestion. The patient was tachycardiac, mildly hypoxic on room air and had normal abdominal and rectal examination. Pertinent laboratory results included a white blood cell count of 17.8/μl with 82% neutrophils and hemoglobin of 14.4 g/dl. Computed Tomography angiogram revealed bilateral pulmonary emboli, diffuse esophageal and proximal duodenal thickening. Esophagogastroduodenoscopy (EGD) revealed black discoloration with underlying friable hemorrhagic tissue from the mid-esophagus up to the distal esophagus and a normal appearing GEJ and stomach. The duodenal bulb and the proximal aspect of the second portion of duodenum had a black discoloration similar in appearance to the involved segment of the esophagus. Biopsies of the black mucosa from the esophagus and the duodenum revealed necrosis. The patient was discharged home on warfarin and proton pump inhibitor (PPI). A follow-up EGD one week later revealed a normal esophagus and a normal duodenum. Conclusion: This is the only case of AEN described in the literature associated with a pulmonary embolism (PE) and duodenal necrosis. AEN and duodenal necrosis may have been secondary to hypoxia from the PE, explaining the complete rapid improvement with anticoagulation therapy. Given our case, we suggest that a lower threshold for a diagnosis of pulmonary embolism should be considered in a patient with AEN in an appropriate clinical setting.Figure: [1331] Figure 1. Black esophagus and black duodenum.

An unusual case of dysphagia

A 50-year-old homosexual man presented progressive ysphagia, odynophagia, heartburn and weight loss of 5 kg ithin 2 months. The pain was directly related to the intake of olid food, resulting in a bolus feeling. He reported no chronic eartburn or previous history of caustic ingestion. Physical examnation revealed pain in the upper abdominal quadrant without bdominal masses. Laboratory investigations indicated a normal ull blood count and tumour markers. A CT scan showed a focal hickening of the wall of the distal oesophagus. An oesophagogastroduodenoscopy (EGD) was performed and howed an initial stricture with friable mucosa and shallow ulcertions at the distal third of the oesophagus (Fig. 1). No obstacle as observed that prevented the advancement of the instrument. t endoscopic ultrasonography (EUS) scanning, the oesophageal all was thickened up to 7.5 mm with normal stratification and the ubmucosal layer had a heterogeneous structure with a “salt and epper” appearance (Fig. 2A). After injection of a second-generation ontrast agent (Sonovue®), the submucosal layer showed a rapid nd protracted contrast enhancement (Fig. 2B), thus with a postontrast feature typical for an inflammatory condition. Moreover, he muscular layer was normal. Endoscopic biopsy performed at the ulcer sites revealed nclusion bodies suggestive of Cytomegalovirus (CMV) infection. mmune staining showed Cytomegalovirus-positive cells. This pathological finding prompted an HIV test, which proved ositive. Esophagitis is the second most common gastrointestinal anifestation of cytomegalovirus infection after colitis in the mmunocompromised patient. Common endoscopic pathological ndings is well-circumscribed ulcerations. Oesophageal complicaions such as bleeding, tracheo-oesophageal fistula and stricture re uncommon [1].

Management of pyloric stricture in children: endoscopic balloon dilatation and surgery

Surgical correction is the most preferred treatment modality in pyloric stricture (PS). Recently a few studies reported the experience of balloon dilation in children with PS. This study was designed to present our experiences of the management of the patients with PS with balloon dilation and corrective surgery. The records of 14 patients who were treated with the diagnosis of PS between August 2003 and August 2011 were reviewed retrospectively. There were nine boys and five girls (mean age, 3.4 ± 1.7 years). The history of caustic ingestion was detected in eight patients; six of them were admitted on the day of ingestion. Two patients were admitted with nonbilious vomiting more than 2 weeks after ingestion. Four patients did not have a remarkable medical history, including caustic ingestion. They admitted with the complaint of nonbilious vomiting. PS was detected during endoscopy in two patients who had a diagnosis of peptic ulcer disease. PS was shown by barium meal study in all patients. Endoscopy was performed in all patients. Endoscopic balloon dilation was tried in 12 patients. Overall eight patients required surgical procedures for PS. The complaints were resolved by endoscopic balloon dilation of pylorus in the remaining six patients. Although endoscopic balloon dilatation for benign PS in adults is a generally accepted method of treatment, there is less experience with endoscopic balloon dilatation for PS in children. PS due to benign disorders can be effectively and successfully treated through endoscopic balloon dilatation in suitable patients. In patients with successful pyloric balloon dilatation, surgery can be avoided.

Verrucous carcinoma of the esophagus: a complex diagnosis

We present the case of a 71-year-old woman with complicated gastroesophageal reflux disease with a peptic stricture located 30 cm from the incisors. There was no history of caustic ingestion or alcohol, or use of tobacco. Following four attempts at endoscopic dilation, a self-expanding, removable plastic stent had been placed previously. After 4 months of the placement of the stent, the patient experienced progressive dysphagia, retrosternal pain, and hematemesis. Esophagogastroduodenoscopy (EGD) showed clots in the esophageal lumen. After stent removal, an exophytic mass causing partial stenosis was identified in the mid-esophagus ([Fig. 1]). Histological evaluation revealed only inflammatory changes. Endoscopic ultrasound showed invasion through the muscularis propria, with a nonspecific paraesophageal lymph node. Fine-needle aspiration cytology was also negative for malignancy. Thoracoabdominal computed tomography (CT) showed no distant lesions.

Minimally invasive management of children with caustic ingestion: less pain for patients

Management of caustic ingestion in children is still controversial. In this study, we evaluate a minimally invasive management consisting of flexible endoscopy, balloon dilatation and intralesional steroid injection in children, with a history of caustic ingestion. Between April 2002 and January 2009, 350 (206 males and 144 females) children with a history of caustic ingestion were admitted. Enteral feeding was discontinued for 24 h. Parenteral feeding was started in patients with inadequate oral intake. No patient underwent an early esophagoscopy or gastrostomy. A contrast study of upper gastrointestinal tract was performed in all patients with persistent dysphagia within 3 weeks after injury. In case of an esophageal stricture, a dilatation program was initiated. For this purpose, a flexible esophagoscopy was performed. A guidewire was placed through the narrowed segment into the stomach and a balloon dilatator was inserted with the assistance of the guidewire. Balloon dilatations were performed every 1-3 weeks. In intractable strictures, triamcinolone acetonide (TAC) was injected into the narrowed segment via flexible endoscopy. Seventeen patients (8 males, 9 females, median 3 years old) required esophageal dilatation. All of the patients completed dilatation program with complete relief of symptoms. None of the patients required any stent application nor esophageal replacement or gastrostomy. Ten patients underwent intralesional TAC injection. No patient had an esophageal perforation or any other complication related to dilatation. In all patients, the symptoms have been alleviated completely and no further dilatation was necessary after a median of five dilatation sessions (1-19 dilatations). Minimally invasive management of caustic ingestion consisting of flexible endoscopy, guidewire-assisted esophageal balloon dilatation and intralesional TAC injection without any gastrostomy or esophageal stent/placement is effective and leads to relief of dysphagia in almost all patients. This method of dilatation is also safe and iatrogenic esophageal perforation is very unlikely.

Risk Factors Affect Outcome of Esophageal Injuries Caused by Caustic Ingestion in Children

Purpose: Ingestion of caustic materials is a worldwide challenge. The study aim was to identify the factors that influence the outcome and prognosis of esophageal injuries after caustic ingestion in children. Methods: We retrospectively reviewed all files of patients with history of caustic ingestion, their endoscopy results and follow up, who were admitted at Pediatrics Gastroenterology ward of Aboozar Children's Hospital, Ahwaz, South -Western of Iran. Results: During 10 years (October 1998- 2008) a total of 81 children (mean 2.7, range 1-5 y), 46 male, with history of caustic ingestion were enrolled in our study. Ingestable alkaline were drain, pipe, oven, grill and barbecue cleaners, dish washer detergent and bleaches (Totally 61%) and acidic materials as drain openers, toilet cleaners and battery liquid (Totally 39%). The grade(G) of esophageal injury with regard of the ingested caustic materials was: GO (history of ingestion, no injury, 18.5% in bleaches ingestion), G1 (edema and erythema, no transmucosal injury, 11% in very small amount acid and dish washer ingestion), G2 a/b (transmural injury, hemorrhage, circumferential ulceration, 64% in large amount of acid ingestion and vomiting, alkaline ingestion and delay in hospital admission), G3 a/ b (scattered deep ulceration and necrotic tissue 6.5% in large amount of alkaline ingestion and vomiting and/ or delay in hospital admission). Our follow up study showed that 11 (13.5%) cases developed esophageal stricture about 3 weeks after caustic ingestion despite proper treatment including dexametasone and antibiotic (Picture). The stricture confirmed by a second endoscopy and contrast media study. All these 11 patients had grade 2+ esophageal injury. Dilatation by boogies or balloon was done for these cases and 2 of them needed further surgery treatment which 1 of them died.FigureConclusion: Caustic ingestion by children is a worldwide preventable medical problem. In this study, we found that the alkali, large amount of ingested caustic agent, delayed referral to hospital and treatment including vomiting after ingestion worsen the outcome and prognosis. Prevention is paramount.

Development of Esophageal Cancer from a Short Residual Esophagus 20 Years Following Corrosive Injury-Case Report and Treatment

Background: The chance of developing carcinoma after corrosive injury is well known. Of all the patients with esophageal carcinoma, 1-4% patients have a history of caustic ingestion. 1~3 Nearly all the reported cases in the literature occurred after ingestion of lye, but did not undergo surgical treatment in the beginning. Aim and Objectives: A 54-year-old male patient suffered from corrosive injury 20 years ago. He received operation at that time with colon interposition following nearly total esophagectomy. A stricture was found 20 years later, and biopsy from the small residual esophageal segment showed esophageal carcinoma. The residual esophagus was removed and the defect was reconstructed with free radial forearm flap. However, recurrence was found 8 months later during endoscopic examination. A difficult reconstruction for the long esophageal defect was done after tumor resection. Materials and Methods: The patient suffered from tumor recurrence in the lower neck just at the junction between the skin flap and interposition colon. This time, complete esophagectomy including the interposition colon segment and forearm flap was successful. A long esophageal defect of about 40cm from pharynx to abdomen was presented. A difficult reconstruction with tubal anterolateral thigh and tensor fascia lata fasciocutaneous free flap was done to connect the pharyx to the abdomen. Results: The patient recovered well and was able to digest well post-operatively. Esophagogram showed smooth intake without leakage 3 months later. Conclusion: We conclude that corrosive esophageal carcinoma should be suspected in patients with previous corrosive injury if there is any change in their symptoms. Early surgical intervention with the diseased esophagus can lower the rate of malignancy formation. With the improvement of the reconstruction methods, extensive resection still can be done.

Painful Swallowing After Herpes Stomatitis

A 3-year-old male was hospitalized for dehydration secondary to stomatitis. He had had poor oral intake for 2 days prior to admission, and his mother noted that the child appeared lethargic and was refusing to drink. He had vomited twice but had no hematemesis or bilious emesis. He was noted to have increased episodes of drooling at home. The child’s medical history was significant only for eczema and mild reactive airway disease that was treated with triamcinolone cream and nebulized albuterol, respectively. He had no previous symptoms of stomatitis and had no history of caustic ingestion. Family history was noncontributory. On physical exam, the patient was tachycardic with a pulse of 150 beats per minute, and his blood pressure was 121/86 mm Hg. Although he was alert, he had multiple erythematous ulcers in the oral-pharyngeal region. Serum electrolytes, blood urea nitrogen, and creatinine were normal. His blood count demonstrated a white blood cell count of 26 900 cells/mL (78% granulated neutrophils), hemoglobin 14.4 g/dL, hematocrit 41%, and platelet count of 545 000. A throat culture was negative for Group A Streptococcus, and a neck radiograph did not demonstrate abscess formation. He was given intravenous fluids to prevent dehydration, intravenous ketorolac for pain, and intravenous acyclovir for a presumed diagnosis of herpes simplex virus (HSV) stomatitis based on his clinical findings. The patient was discharged after 3 days, and at the time of discharge, his oral lesions were in various stages of healing. He returned to his primary care physician 2 weeks after hospital discharge with dysphagia, odynophagia, and a significant decrease in oral intake. He had no fever, weight loss, or diarrhea. His oral ulcers had completely resolved, and the remainder of his physical exam was within normal limits. A repeat neck radiograph demonstrated a prevertebral soft tissue prominence and distinct epiglottis and aryepiglottic folds, possibly consistent with edema. The patient was placed on a trial of lansoprazole and demonstrated no clinical improvement, so esophago gastroduodenoscopy (EGD) was performed, which revealed a narrow esophageal stricture less than 5 mm in diameter located just below the upper esophageal sphincter (Figure 1A). The endoscope could not be advanced beyond the stricture. Esophageal biopsies revealed a zone of parakeratosis, but no inflammation or giant cell formation (Figure 1B), and a culture and polymerase chain reaction testing of esophageal tissue were negative for HSV, consistent with a resolved infection. A barium esophagram demonstrated a narrowing of the upper esophagus consistent with a stricture, as well as a long segment of narrowing throughout the esophagus (Figure 2). These findings prompted serial dilation using a Savary dilator system (Cook Medical, Bloomington, IN) under fluoroscopic examination. After serial dilations, the patient had marked improvement in swallowing, and a repeat barium esophagram demonstrated a dilated esophagus. A subsequent immune workup for this child was found to be normal, and the patient recovered with good oral intake.

Ingestion of Caustic Substances: A 15‐Year Experience

The objective of this study was to analyze the circumstance, demographic features, clinical findings, and complications of caustic ingestion in relation to the type and amount of caustic substance. The authors conducted a retrospective cohort study in a tertiary medical center. The authors reviewed medical records from 1988 to 2003 of patients with a history of caustic ingestion and clinical signs of injury to the aerodigestive tract. Parameters examined included age at presentation, gender, demographic status, nature of the caustic substance ingested, amount of substance, circumstance of the event, diagnostic tools, degree of injury, and anatomic distribution of the injury, early and late complications, and requirement for ventilatory support. A total of 50 cases of caustic ingestion were identified (age range, 5 months-71 years). A biphasic distribution of the patients was noted; half were children under 5 years old and the remainder was adults. The most common caustic agent ingested was alkaline (42%) followed by acidic (32%) and chlorine bleach (26%). The most frequent cause for ingestion was accidental (67%) as opposed to attempt suicide (33%). All cases of attempted suicide occurred in adults. Most of them reported ingestion of large amounts of caustic substance. In the pediatric group, an association between the caustic agent and ethnicity was observed. Among Jewish children, alkaline cleaning agents were the most common cause (82%). Acetic acid was the most common substance ingested by the Arab children (100%). The findings of rigid esophagoscopy in 36 patients were as follows: first-degree esophageal injury in 16 (44%), second-degree in 6 (17%), third-degree in 7 (19%), fourth-degree in 6 (17%), and one (3%) was normal. Mucosal injury to the esophagus was worse in the acidic ingestion group as compared with the alkaline substance ingestion group with marginally statistically significant difference in the median degree of injury between the three types of ingested substances (P = .054). Mucosal injury to the esophagus was worse among patients who attempted suicide as compared with accidental ingestion with a statistically significant difference in the median degree of injury between the two reasons for ingestion (P = .002). Severity of injury from caustic ingestion damages depend on the type of ingested substance, which varies depending on ethnicity. Ingestion of caustic agents by children involves specific substances according to the season, cultural and religious festivals, and ethnicity. The majority of adult cases are intentional with more serious injuries and a higher rate of complications. In our series, ingestion of acidic substances and ingestion associated with suicide attempt had the most severe consequences.

Caustic Injury to the Esophagus.

The potentially catastrophic presentation and lifelong complications that result from caustic ingestion make it one of the most challenging clinical situations in gastroenterology. Patients who present with a history of caustic ingestion, particularly with a strong alkali or acid, should undergo emergent endoscopy once stabilized to assess the degree of oropharyngeal, esophageal, and gastric damage regardless of presence or lack of symptoms. Once staged, patients with moderate to severe injury should be restricted from any oral intake, placed on intravenous fluids, and observed, provided there are no signs of perforation or transmural necrosis that require immediate esophagectomy. For those who will require lengthy periods without oral intake, feeding should be initiated through a jejunostomy tube (preferably) or through total parenteral nutrition. Patients that have survived the first several weeks of injury should be reassessed for esophageal stricture formation. Chronic strictures may require serial dilations initially to establish patency and in some patients, dilation will be needed chronically to maintain the adequate lumen diameter. More severe strictures may require esophagectomy or bypass with colon or small bowel interposition. Finally, although there is an increased incidence of esophageal carcinoma in these patients, regular endoscopic screening is not advocated.

Detection of caustic oesophageal injury with technetium 99m-labelled sucralfate

Background/Purpose: Radiolabelled sucralfate has been used to show the extent and severity of reflux oesophagitis, peptic ulceration, and inflammatory bowel disease. Endoscopy under general anaesthetic has been the preferred method to assess the injury after caustic ingestion. The aim of this study was to assess whether sucralfate has an affinity for the chemically injured oesophageal mucosa and, if so, to assess the accuracy of radiolabeled sucralfate as an indicator of presence and extent of oesophageal injury. Methods: A prospective study was conducted of 22 patients with mean age of 30 months (range, 13 to 90) admitted consecutively with a history of caustic ingestion between January 1998 and January 2000. A sucralfate-labelled scan followed by endoscopic assessment of upper gastrointestinal tract with documentation of extent and grade of injury was performed in all patients within 24 hours of admission except the first 6 who underwent scan after the endoscopy. The sucralfate was labelled by the direct stannous reduction method. Oesophageal transit was studied by recording 120 images (64 × 64 matrix size) at 1 image per second while the child swallowed 5 mL of labelled sucralfate containing 2 to 3 MBq Technetium 99m. Retention of radiolabelled oesophageal activity was considered abnormal. Results: The caustic substances ingested were household cleaners in 18, potassium permanganate in 3, and pool chlorine in 1. There were 11 scans that showed residual activity in the oesophagus, which correlated exactly with endoscopic findings. The other 11 patients had normal oesophageal mucosa, but 2 were found to be falsely positive on scanning. In 2 cases repeat sucralfate scan results correlated well with the healing process assessed endoscopically. Conclusions: The results indicate that technetium 99m sucralfate swallow is an accurate technique for assessing oesophageal injury after ingestion of caustic substances. In addition, it may be used to document healing. J Pediatr Surg 36:262-265. Copyright © 2001 by W.B. Saunders Company.

MANOMETRIC PROGRESSION OF ACHALASIA: A PEDIATRIC CASE REPORT

119 Pediatric achalasia is a neurologic disorder of unknown etiology resulting in dysphagia. Limited information is available regarding the manometric changes during the development of achalasia. We describe a 10-year old boy with clinical and radiographic manifestations of achalasia, who had a non-specific esophageal motility disorder on initial evaluation and within 6 months developed manometric evidence of achalasia. Case report: A 10-year-old male presented with 1 year history of intermittent vomiting, retrosternal pain and daily episodes of regurgitation. He had no history of caustic ingestion or family history of achalasia. Physical examination was unremarkable. Barium swallow demonstrated a dilated esophagus with distal narrowing. Abdominal and chest CT scan were normal. EGD with biopsies was entirely normal. Esophageal motility demonstrated a mean lower esophageal sphincter (LES) pressure of 26 mmHg with complete LES relaxation. 11% of the swallows induced peristalsis. Mean basal esophageal pressure was 8 mmHg above end-expiratory gastric pressure. Because the manometric study did not demonstrate the presence of classical achalasia, the LES was dilated with a mercury bougie to 46 Fr., with improvement of symptoms. On six months follow-up, he had recurrence of emesis and dysphagia. Repeat manometry demonstrated increased LES pressure with incomplete or absent relaxation in 71% of the swallows. No peristalsis was observed. Basal esophageal pressure was 18 mmHg, with decreased mean esophageal wave pressure throughout the esophagus. Diagnosis of achalasia was made, and the patient underwent pneumatic dilatation with dramatic improvement. Conclusion: Achalasia is a progressive disease, which may first present as a non-specific motility disorder. In case of esophageal dysmotility, if symptoms persist or worsen over time, repeat manometry should be done.

Caustic ingestion: controversies in management. A review of 214 cases.

Two hundred fourteen patients admitted with a history of caustic ingestion are reviewed. Sixty-five had mucosal penetrating burns. Children five years of age and under accounted for 39% of admissions, but only 8% of burns requiring treatment. Adults accounted for 48% of admissions and 81% of burns requiring treatment. Complications associated with mucosal penetrating burns occurred in 31 patients; all but one were due to lye or acids. A three year prospective study evaluating methylprednisolone in the management of caustic burns is reported. This included 24 patients with mucosal penetrating burns due to lye or acids. The results of this study, and this review as a whole, indicate that methylprednisolone is beneficial in moderately severe burns due to lye, but is not indicated for severe burns from liquid lye, or for acid burns.

Ingestion of caustic: A pediatric problem

T H F~ M A N A G E M E N T o f esophageal trauma from ingestion of caustic in the acute form has changed greatly in the past decade. Formerly one could expect a stricture rate of from 40 to 60 per cent in those patients having a history of caustic ingestion, while today the rate of stricture formation may be lowered to from 3 to 5 per cent and the frequent dilations axoided in most cases/ This paper describes our experience with this problem. The prevention of esophageal stricture is best accomplished by the use of early esophagoscopy for diagnosis, treatment with anti-inflammatory steroids and antibiotics, and serial evaluation of the esophagus until healing of the nmcosa has occurred. On the basis of these facts, the following therapeutic program has been recommended. 1. Upon admission, a history and physical examination are carried out, an airway assured, and bland neutralizing substances are used as indicated. 2. Vomiting is not induced and nasogastric tubes and lavage are avoided. 3. Anti-inflammatory steroids and anti-