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Faculty of surgery
Songkhla hospital
1. Alkalis:
 Cleaning agents (NaOH), drain openers, bleaches, toilet bowel
cleaners, and detergents…
2. Acids
 Toilet bowel cleaners ( sulfuric, hydrochloric ), anti rust
compounds ( hydrochloric, oxalic, hydrofluoric ), swimming
pool cleaners ( hydrofluoric )
Alkalis
 PH > 7
 Tasteless, odorless →larger
amounts
 liquefaction necrosis => direct
extension, deeper injuries
 Esophageal injury is common
 In stomach, partial neutralization
by gastric acid may result limited
injury
 Duodenal injury is less common
Acid
 PH < 7
 Pungent odor and noxious
taste
 coagulation necrosis =>
formation of a coagulum
layer : limit the depth of
injury
 Less esophageal injury
 More gastric injury
 As the acid toward the
pylorus, pylorospasm
impairs emptying into the
duodenum
 Corrosive properties of the ingested substance
 Amount, concentration, and physical form
(solid or liquid) of the agent
 Duration of contact with the mucosa
1. Vary widely
 Hoarseness, stridor, dyspnea => Airway evaluation
 Perforation: (During first 2 weeks)
 Retro-sternal or back pain
 Localized abdominal tenderness, rebound, rigidity,
Psoas sign, obturator sign
 Massive hematemesis
 Dysphagia, odynophagia, drooling, nausea, vomiting
2. Early signs and symptoms may not correlate with the severity
and extent of tissue injury
3. Oropharyngeal burns (-) :10-30% esophageal burns(+)
Oropharyngeal burns (+) : 70% esophageal burns(-)
 Avoid:
 The use of emetics: re-exposes
 Neutralizing agents: thermal injury
 Gastric lavage: may induce retching
and vomiting which can compound
injury
 Primary survey
 Keep NPO
 IV fluids administer
 Gastric acid suppression with intravenous PPI
 Adequate pain relief with intravenous narcotics
 Airway evaluation - laryngoscopy
 R/O perforation - Plain films of chest and abdomen
 Observation for Clinical signs of
perforation, mediastinitis, or peritonitis
 Broad spectrum antibiotics - given for patients with Grade
3 caustic injury or high suspicion for esophageal perforation.
 Endoscope
1. Timing:
 No later than 24 hours
 Usually avoided from 5-15 days
2. Purpose:
 Grading, manage appropriately
3. Risk of perforation:
 Low, under adequate sedation
4. Extent:
 Advance until a circumferential second or third degree burn is
seen
 To first part of duodenum
 Grade 0: Normal
 Grade 1: Mucosal edema and hyperemia
 Grade 2A: Superficial ulcers, bleeding, exudates
=> Excellent prognosis
 Grade 2B: Deep focal or circumferential ulcers
 Grade 3A: Focal necrosis
=> Develop strictures: 70-100%
 Grade 3B: Extensive necrosis
=> Early mortality rate: 65%
Corrosive ingestion
a
(Gr.IIa)
b
(Gr.IIb)
C
(Gr.IIIa)
d
(Gr.IIIb)
1. Patients with mild or no injury
○ may be discharged.
2. Patients with grade 1 or 2A injury
○ require no therapy.
○ a liquid diet may be initiated
○ advanced to a regular diet in 24 to 48 hours.
3. Patients with grade 2B or 3 injuries
○ should have nasoenteric tube feeding initiated after 24
hours.
○ oral liquids are allowed after the first 48 hours if the
patient is able to swallow saliva.
○ steroids ???.
*Patients with grade 3 injuries should be carefully
observed for signs of perforation over at least a one-week.
Prophylactic esophageal stenting is not recommended.
 In animal studies: incidence of stricture formation
 In human studies: Inconclusive so far
 NEJM. 1990:
 Prospective study over an 18-year period
 No benefit
 Related only to the severity of the corrosive
injury
 Toxicol Rev. 2005:
 1991-2004 in the
English, German, French, Spanish
 No benefit
 Clinical signs of perforation, mediastinitis, or peritonitis are
indications for emergency surgery.
 Esophagectomy may be required for patients with severe
strictures.
 Minimally invasive esophagectomy approach may be preferred
because it is associated with a decreased hospital stay
compared with standard esophagectomy.
 The most important factors to guarantee a successful outcome
for surgery are good vascular supply and absence of tension at
the anastomosis.
 If the stomach is damaged as well as the esophagus, a colonic
interposition can be used to create a new conduit.
 The prognosis is variable and depends upon
the grade of esophageal injury and the
underlying medical condition of the patient.
 Most deaths are due to the sequelae of
perforation and mediastinitis.
Esophageal stricture
Esophageal carcinoma
1. Stricture formation
 one-third of patients suffered caustic esophageal injury develop
esophageal strictures
 Primarily in those with grade 2B or 3 injury
 Peak incidence: two months
 Occur as early as two weeks or as late as years after ingestion
 Barium swallow examination is useful in the evaluation
Corrosive ingestion
1. Endoscopic dilatation
 The goal: dilate the esophageal lumen to 15 mm
 Perforation rate: 0.5%
 Special consideration:
 Long, eccentric strictures: risk of perforation increased
 Thick-walled strictures: recur rapidly
 Multiple sessions: elective esophageal resection
2. Intraluminal stent
 Temporary placement of a self-expanding plastic stent
 Successful in case reports
3. Surgery
 Esophagectomy with colonic interposition
 Gastric transposition: high leak rate
 Perform 6 months later
Corrosive ingestion
2. Esophageal carcinoma
 Incidence: 1000 to 3000-fold increase
 3% have history of caustic ingestion
 Mean latency: 41 years (13-71years)
 Scar carcinoma:
 Less distensible => dysphagia presents earlier
 Lymphatic spread and direct extension
 Endoscope surveillance
 Begin 15-20 years after ingestion
 The time interval : No more than every 1-3 years
Corrosive ingestion
Corrosive ingestion
 Severity depend upon: the amount, concentration, physical form
and the duration of contact with the mucosa.
 The absence of oropharyngeal burns does not preclude the
presence of esophageal or gastric injury.
 The use of emetics, neutralizing agents, or nasogastric intubation to
remove remaining caustic material is contraindicated.
 Gastrointestinal endoscopy should be performed in first 24 hours.
 Endoscopy is contraindicated if hemodynamic instability, evidence
of perforation, severe respiratory distress, or severe oropharyngeal
or glottic edema and necrosis.
 Clinical signs of perforation, mediastinitis or peritonitis are
indications for emergency surgery.
 Long-term complications include esophageal strictures and
esophageal squamous cell carcinoma. Endoscopic surveillance for
cancer is recommended at 15-20 years after ingestion.

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Corrosive ingestion

  • 2. 1. Alkalis:  Cleaning agents (NaOH), drain openers, bleaches, toilet bowel cleaners, and detergents… 2. Acids  Toilet bowel cleaners ( sulfuric, hydrochloric ), anti rust compounds ( hydrochloric, oxalic, hydrofluoric ), swimming pool cleaners ( hydrofluoric )
  • 3. Alkalis  PH > 7  Tasteless, odorless →larger amounts  liquefaction necrosis => direct extension, deeper injuries  Esophageal injury is common  In stomach, partial neutralization by gastric acid may result limited injury  Duodenal injury is less common Acid  PH < 7  Pungent odor and noxious taste  coagulation necrosis => formation of a coagulum layer : limit the depth of injury  Less esophageal injury  More gastric injury  As the acid toward the pylorus, pylorospasm impairs emptying into the duodenum
  • 4.  Corrosive properties of the ingested substance  Amount, concentration, and physical form (solid or liquid) of the agent  Duration of contact with the mucosa
  • 5. 1. Vary widely  Hoarseness, stridor, dyspnea => Airway evaluation  Perforation: (During first 2 weeks)  Retro-sternal or back pain  Localized abdominal tenderness, rebound, rigidity, Psoas sign, obturator sign  Massive hematemesis  Dysphagia, odynophagia, drooling, nausea, vomiting 2. Early signs and symptoms may not correlate with the severity and extent of tissue injury 3. Oropharyngeal burns (-) :10-30% esophageal burns(+) Oropharyngeal burns (+) : 70% esophageal burns(-)
  • 6.  Avoid:  The use of emetics: re-exposes  Neutralizing agents: thermal injury  Gastric lavage: may induce retching and vomiting which can compound injury
  • 7.  Primary survey  Keep NPO  IV fluids administer  Gastric acid suppression with intravenous PPI  Adequate pain relief with intravenous narcotics  Airway evaluation - laryngoscopy  R/O perforation - Plain films of chest and abdomen  Observation for Clinical signs of perforation, mediastinitis, or peritonitis  Broad spectrum antibiotics - given for patients with Grade 3 caustic injury or high suspicion for esophageal perforation.  Endoscope
  • 8. 1. Timing:  No later than 24 hours  Usually avoided from 5-15 days 2. Purpose:  Grading, manage appropriately 3. Risk of perforation:  Low, under adequate sedation 4. Extent:  Advance until a circumferential second or third degree burn is seen  To first part of duodenum
  • 9.  Grade 0: Normal  Grade 1: Mucosal edema and hyperemia  Grade 2A: Superficial ulcers, bleeding, exudates => Excellent prognosis  Grade 2B: Deep focal or circumferential ulcers  Grade 3A: Focal necrosis => Develop strictures: 70-100%  Grade 3B: Extensive necrosis => Early mortality rate: 65%
  • 12. 1. Patients with mild or no injury ○ may be discharged. 2. Patients with grade 1 or 2A injury ○ require no therapy. ○ a liquid diet may be initiated ○ advanced to a regular diet in 24 to 48 hours. 3. Patients with grade 2B or 3 injuries ○ should have nasoenteric tube feeding initiated after 24 hours. ○ oral liquids are allowed after the first 48 hours if the patient is able to swallow saliva. ○ steroids ???. *Patients with grade 3 injuries should be carefully observed for signs of perforation over at least a one-week. Prophylactic esophageal stenting is not recommended.
  • 13.  In animal studies: incidence of stricture formation  In human studies: Inconclusive so far  NEJM. 1990:  Prospective study over an 18-year period  No benefit  Related only to the severity of the corrosive injury  Toxicol Rev. 2005:  1991-2004 in the English, German, French, Spanish  No benefit
  • 14.  Clinical signs of perforation, mediastinitis, or peritonitis are indications for emergency surgery.  Esophagectomy may be required for patients with severe strictures.  Minimally invasive esophagectomy approach may be preferred because it is associated with a decreased hospital stay compared with standard esophagectomy.  The most important factors to guarantee a successful outcome for surgery are good vascular supply and absence of tension at the anastomosis.  If the stomach is damaged as well as the esophagus, a colonic interposition can be used to create a new conduit.
  • 15.  The prognosis is variable and depends upon the grade of esophageal injury and the underlying medical condition of the patient.  Most deaths are due to the sequelae of perforation and mediastinitis.
  • 17. 1. Stricture formation  one-third of patients suffered caustic esophageal injury develop esophageal strictures  Primarily in those with grade 2B or 3 injury  Peak incidence: two months  Occur as early as two weeks or as late as years after ingestion  Barium swallow examination is useful in the evaluation
  • 19. 1. Endoscopic dilatation  The goal: dilate the esophageal lumen to 15 mm  Perforation rate: 0.5%  Special consideration:  Long, eccentric strictures: risk of perforation increased  Thick-walled strictures: recur rapidly  Multiple sessions: elective esophageal resection 2. Intraluminal stent  Temporary placement of a self-expanding plastic stent  Successful in case reports 3. Surgery  Esophagectomy with colonic interposition  Gastric transposition: high leak rate  Perform 6 months later
  • 21. 2. Esophageal carcinoma  Incidence: 1000 to 3000-fold increase  3% have history of caustic ingestion  Mean latency: 41 years (13-71years)  Scar carcinoma:  Less distensible => dysphagia presents earlier  Lymphatic spread and direct extension  Endoscope surveillance  Begin 15-20 years after ingestion  The time interval : No more than every 1-3 years
  • 24.  Severity depend upon: the amount, concentration, physical form and the duration of contact with the mucosa.  The absence of oropharyngeal burns does not preclude the presence of esophageal or gastric injury.  The use of emetics, neutralizing agents, or nasogastric intubation to remove remaining caustic material is contraindicated.  Gastrointestinal endoscopy should be performed in first 24 hours.  Endoscopy is contraindicated if hemodynamic instability, evidence of perforation, severe respiratory distress, or severe oropharyngeal or glottic edema and necrosis.  Clinical signs of perforation, mediastinitis or peritonitis are indications for emergency surgery.  Long-term complications include esophageal strictures and esophageal squamous cell carcinoma. Endoscopic surveillance for cancer is recommended at 15-20 years after ingestion.