Corrosive substances ingestion: a review

Global trends and research hotspots in esophageal strictures: A bibliometric study

BACKGROUND

Esophageal stricture is a prevalent condition affecting the digestive system, primarily marked by dysphagia and the obstruction of food passage through the esophagus. This narrowing of the esophageal lumen can significantly impact a person's ability to eat and drink comfortably, often leading to a decrease in nutritional intake and quality of life.

AIM

To explore the current research status and future trends of esophageal stricture through bibliometric analysis.

METHODS

Literature on esophageal stricture from 2004 to 2023 was retrieved from the Web of Science Core Collection. Statistical analysis was performed using Excel, VOSviewer, CiteSpace, and RStudio. This study provides data on annual production trends, countries/regions, influential authors, institutions, journals, references, and keywords.

RESULTS

The study included 1485 publications written by 7469 authors from 1692 institutions across 66 countries/regions, published in 417 journals. The United States, China, and Japan are the major contributors to this field, with many quality papers. Song Ho-young, Diseases of the Esophagus, Gastrointestinal Endoscopy, and Mayo Clinic are the top authors, journals, co-cited journals, and institutions, respectively. The most frequent keywords are stent, endoscopy, management, etiology, and prevention; regenerative medicine, endoscopic injection, and autologous tissue transplantation are the latest research frontiers. These keywords reflect continuous advancements in technical innovation, treatment strategies, preventive measures in the esophageal stricture research field, and a sustained focus on improving patient prognosis. In contrast, the basic sciences were underrepresented.

CONCLUSION

This study provides an insightful analysis of the developments in the field of esophageal stricture over the past twenty years, with stent placement is currently a hot research topic.

Postmortem tissue alterations induced by corrosive substances - a scoping review

INTRODUCTION

The method of dissolving a body to conceal crimes, a practice dating back to ancient times, has recently captured the interest of scientists and the film industry. Real-life cases inspired by media portrayals underscore the importance of understanding this process, which aims to prevent identification or locate the body. Historical and contemporary examples highlight the use of substances like caustic potash and various acids. Although scientific studies on this topic are limited, this scoping review explores the use of corrosive substances for concealing crimes by dissolving remains and aims to provide an overview of the current global extension of this phenomenon, addressing a gap in scholarly literature.

METHODS

A systematic literature search was performed according to PRISMA-ScR guidelines. The search strategy included PubMed, Google Scholar, gray literature, and general Google searches for cases in international media. Articles were eligible if they discussed the effects of corrosive substances on tissue with the intent to alter or destroy, excluding those focused on living individuals or for non-forensic purposes. Results were categorized into academic and gray literature, further divided by species studied.

RESULTS

A total of 280 results were found in PubMed and 966 in Google Scholar. No reviews were found. Additional searches led to 79 records, with 37 excluded due to duplication or updates. Ultimately, 83 studies were included in the review, documenting key elements such as study purpose, sample details, substances used, and findings. The effects of various corrosive agents were revealed, including alkaline substances such as lime, potassium hydroxide, and sodium hydroxide, as well as acids like hydrochloric acid, sulfuric acid, nitric acid, and aqua regia.

CONCLUSIONS

Diagnosing tissue alterations caused by corrosive substances requires a multidisciplinary approach and detailed analysis. Final outcomes depend on concentration, exposure time and conditions. Techniques like microscopy, scanning electron microscopy (SEM), energy dispersive X-ray spectrometer (EDX/EDS), micro-computed tomography (micro-CT) and X-ray fluorescence (XRF) provide critical detailed results. Recreating the crime through experiments may be necessary for investigations, shedding light on the methods employed by perpetrators, reflecting the complexity of these out-of-the-ordinary cases. Further studies are crucial for interpreting these effects.

A cross-sectional study of poisoning deaths by rubber latex processing acid in Tripura, India

Background

Rubber latex processing acid poisoning is a frequently encountered phenomenon in Tripura. Formic acid is the preferred choice for coagulating rubber latex in rubber sheet manufacturing units. The objective of this study aimed to assess the epidemiological profile of poisoning deaths by rubber processing acid and to record their autopsy findings.

Methods

This was a 2-year prospective cross-sectional study of deaths by rubber processing acid ingestion, which were brought for postmortem examination in two health care institutes of Tripura. Profiles of the cases were noted from hospital records, family members, Inquest and Challan papers from police and autopsy findings. All data were entered in SPSS software version 23.0, and Pearson's correlation was used to correlate the corrosion of stomach and survival time.

Results

Of 42 cases, 30.90% were between the ages of 41 and 50 years, and the majority were rubber tappers (69.01%). Familial disharmony (52.38%) was the most common cause of acid consumption. Close proximity (within 1 km) of the rubber tapping area to the consumption spots was observed (59.52%). Overall, 97.62% of victims had corrosion of the stomach and congestion of internal organs, and the majority (66.67%) died within 24 h of consumption.

Conclusion

This study emphasises the mortality brought on by rubber latex processing formic acid in areas surrounding rubber plantation. The poisoning prevention and control can be strategised in pre-exposure and exposure levels among vulnerable population based upon Information, Education and Communication model.

Predicting full-thickness necrosis in adult acute corrosive ingestion injuries in a sub-Saharan African setting

BACKGROUND

Corrosive ingestion remains an important global pathology with high morbidity and mortality. Data on the acute management of adult corrosive injuries from sub-Saharan Africa is scarce, with international investigative algorithms, relying heavily on computed tomography (CT), having limited availability in this setting.

AIM

To investigate the corrosive injury spectrum in a low-resource setting and the applicability of parameters for predicting full-thickness (FT) necrosis and mortality.

METHODS

A retrospective analysis of a prospective corrosive injury registry (March 1, 2017-October 31, 2023) was performed to include all adult patients with acute corrosive ingestion managed at a single, academic referral centre in Cape Town, South Africa. Patient demographics, corrosive ingestion details, initial investigations, management, and short-term outcomes were described using descriptive statistics while multivariate analysis with receiver operator characteristic area under the curve graphs (ROC AUC) were used to identify factors predictive of FT necrosis and 30-day mortality.

RESULTS

One-hundred patients were included, with a mean age of 32 years (SD: 11.2 years) and a male predominance (65.0%). The majority (73.0%) were intentional suicide attempts. Endoscopy on admission was the most frequent initial investigation performed (95 patients), while only 17 were assessed with CT. Seventeen patients had full thickness necrosis at surgery, of which eleven underwent emergency resection and six were palliated. Thirty-day morbidity and mortality were 27.0% and 14.0%, respectively. Patients with full thickness necrosis and those with an established perforation had a 30-day mortality of 58.8% and 91.0%, respectively. Full thickness necrosis was associated with a cumulative 2-year survival of only 17.6%. Multivariate analyses with ROC AUC showed admission endoscopy findings, CT findings, and blood gas findings (pH, base excess, lactate), to all have significant predictive value for full thickness necrosis, with endoscopy proving to have the best predictive value (AUC 0.850). CT and endoscopy findings were the only factors predictive of early mortality, with CT performing better than endoscopy (AUC 0.798 vs 0.759).

CONCLUSION

Intentional corrosive injuries result in devastating morbidity and mortality. Locally, early endoscopy remains the mainstay of severity assessment, but referral for CT imaging should be considered especially when blood gas findings are abnormal.

Acute Gastric Necrosis Induced by Caustic Substance Ingestion: A Case Report

Ingestion of caustic substances is a common toxicological emergency, often resulting in significant morbidity and mortality. Accidental ingestion of these toxic agents is most prevalent among children, who may encounter household cleaners and other hazardous substances out of curiosity. In contrast, adults often ingest caustic agents in the context of self-harm or suicide attempts. These agents can cause extensive damage to the gastrointestinal tract, leading to serious complications, including perforation, strictures, and systemic toxicity. Both acids and alkalis are particularly dangerous, as they can create irreversible injuries depending on their concentration and duration of exposure.  In this report, we detail the case of a middle-aged man who accidentally ingested a corrosive cleaner containing hydrochloric acid. One day post-ingestion, he presented with throat pain and odynophagia, raising immediate concern for possible gastrointestinal injury. An upper gastrointestinal endoscopy was performed, which revealed findings indicative of gastric necrosis, confirming the severity of the injury. Unfortunately, the patient lost follow-up after being discharged from the hospital. This case underscores the critical importance of recognizing the type of caustic substance involved in such emergencies and highlights the need for prompt medical intervention. Immediate identification of the ingested material, combined with rapid treatment, is essential to mitigate damage and improve patient outcomes.

Corrosive induced esophageal and gastric injury: Histopathological evaluation of surgically resected specimens over a decade in a tertiary care center

BACKGROUND

Caustic ingestion is associated with long-term sequelae like esophageal stricture, gastric cicatrization, and long-term risk of dysplasia or even carcinoma. However, only a few small studies have explored histopathological aspects of caustic-induced esophageal/gastric injury.

MATERIALS AND METHODS

We retrospectively evaluated specimens of patients undergoing surgery due to caustic ingestion-related complications from 2008 to 2020. Pathological examination was conducted by two independent gastro-pathologists to evaluate the extent and depth of the caustic injury, presence or absence of tissue necrosis, type and degree of inflammation, or presence of any dysplastic cells.

RESULTS

A total of 54 patients underwent surgical exploration during the inclusion period and complete details of 39 specimens could be retrieved. The mean age of the included patients was 28.66 ± 9.31 years and 25 (64.1%) were male. The majority of patients (30; 76.9%) had a history of caustic ingestion more than three months before the surgery and the presence of long or refractory stricture was the most common indication for the surgery (20; 51.28%). In the resected specimen, a majority of patients had superficial esophageal or gastric ulcer (90.6%; 60.0%), transmural inflammation (68.8%; 65.6%), transmural fibrosis (62.5%; 34.4%), and hypertrophied muscularis mucosa (78.13%; 53.3%). However, none of the patients had dysplasia in the resected esophageal or gastric specimens.

CONCLUSION

Caustic ingestion leads to mucosal ulceration, transmural inflammation, and transmural fibrosis which might be the reason for refractory stricture in such patients.

Benzalkonium Chloride Poisoning in Pediatric Patients: Report of Case with a Severe Clinical Course and Literature Review

The use of disinfectants, particularly those containing quaternary ammonium compounds (QUACs), has dramatically escalated globally since the coronavirus disease 2019 pandemic. We report a case that highlights the risks associated with ingesting low-concentration QUAC solutions and emphasize the importance of effective management in resolving severe lesions without sequelae. A 17-month-old boy experienced severe respiratory failure after ingesting a disinfectant containing benzalkonium chloride (BAC). The child was initially treated at a local emergency department and was subsequently transferred to a pediatric poison center. Upon evaluation, the child was found to have grade III-A corrosive esophageal lesions and chemical pneumonitis. Several complications, including massive pneumothorax and candidemia, occurred during the clinical course of the disease. However, with timely medical intervention and appropriate supportive care, the patient completely recovered without any long-term sequelae. The properties of BAC and the comprehensive management approach may have been responsible for the patient's full recovery, despite the potentially life-threatening effects of ingesting disinfectants.

Role of N-acetylcysteine and vitamin B complex in improving outcomes of corrosive ingestion

Background

Corrosive ingestion remains a worldwide public health problem. To date, there are no specific medications with approved efficacy in reducing gastrointestinal injury progression following corrosive ingestion.

Aim

The current study assessed the efficacy of N-acetylcysteine (NAC) and vitamin B complex as adjuvant therapy in improving the outcome of patients with corrosive ingestion.

Subjects and methods

The study included 92 patients with acute corrosive ingestion admitted to Alexandria Poison Center. Patients were distributed into four equal-sized groups and managed as such; Group I received the standard treatment protocol. The other three groups received IV antioxidants in addition to the standard treatment; Group II received NAC, Group III received vitamin B complex, and Group IV received both NAC and vitamin B complex. To assess occurrence of delayed complications, barium swallow and meal were done 21 days after acute corrosive ingestion, and every patient was followed up for one year.

Results

Start of oral intake was earliest among patients in Group II, and as a result, the need for parenteral nutrition decreased significantly with a subsequent decrease in duration of hospitalization. The highest percentage of patients showing normal findings of barium swallow and meal was among the two groups that received NAC (72.7% in Group II and 77.8% in Group IV). Group IV patients who received NAC and vitamin B complex had no esophageal strictures with improved outcomes.

Conclusion

NAC and vitamin B complex enhanced recovery in the acute stage, in addition to prevention of delayed complications, especially esophageal strictures.

Highlights

Acute corrosive ingestion is associated with high morbidity because of its catastrophic presentation and lifelong complications.This study was conducted on 92 patients admitted to Alexandria Poison Center (APC).IV NAC significantly decreased the time needed for starting oral intake after acute corrosive ingestion and consequently, the need for parenteral nutrition and duration of hospitalization.No patients suffered from esophageal strictures in the group which received both IV NAC and vitamin B complex.Both NAC and vitamin B complex improved the outcome of patients after ingestion of corrosives whether acids or alkalis.

Accidental ingestion of concentrated white vinegar in Hatay children in Turkey

White vinegar which contains high concentrations (~85 %) of acetic acid is a staple ingredient used in food preparation in many Mediterranean cuisines but in small amounts. Being corrosive, it can cause ulcerative injury to the oropharynx and oesophagus and upset the stomach with resulting nausea and vomiting. This study presents 11 cases of paediatric patients (five boys and six girls, aged between 11 and 89 months) with oesophageal strictures who drank white vinegar by accident. They all received endoscopic oesophageal dilation (with a bougie) ranging from one to 28 per patient, depending on the severity of the injury. Follow-up showed uneventful healing in eight patients, who at the time of the telephone call were able to swallow solids and liquids normally. Two patients who could not be reached by telephone were found healthy by consulting the national database (e-Nabız). Unfortunately, one patient, who was discharged without any symptoms after the first dilation, suffered massive gastrointestinal bleeding 24 hours after the dilation and died. The loss of this patient shows that ingesting white vinegar can be very dangerous in children, especially if parents delay seeking medical help. We believe that controlling the production and sales of highly concentrated white vinegar and selling it in child-proof containers can help to prevent accidental ingestions by children and tragic outcomes such as the one reported here.

Suicide Attempt by a Corrosive Agent Causing Unusual Outcomes and Complications

We commonly encounter patients in the emergency department who present after a suicide attempt. The methods can vary and present unique challenges depending on the nature of the attempt. We present an unsuccessful attempt via chemical ingestion that led to severe complications involving the ingestion of drain cleaner with both highly corrosive and caustic properties. The management and presentation are discussed in great detail to further investigate the best treatment plan for both acute and chronic complications.

Review of oral and pharyngolaryngeal benign lesions detected during esophagogastroduodenoscopy

Recent advancements in endoscopy equipment have facilitated endoscopists’ detection of neoplasms in the oral cavity and pharyngolaryngeal regions. In particular, image-enhanced endoscopy using narrow band imaging or blue laser imaging play an integral role in the endoscopic diagnosis of oral and pharyngolaryngeal cancers. Despite these advancements, limited studies have focused on benign lesions that can be observed during esophagogastroduodenoscopy in the oral and pharyngolaryngeal regions. Therefore, this mini-review aimed to provide essential information on such benign lesions, along with representative endoscopic images of dental caries, cleft palate, palatal torus, bifid uvula, compression by cervical osteophytes, tonsil hyperplasia, black hairy tongue, oral candidiasis, oral and pharyngolaryngeal ulcers, pharyngeal melanosis, oral tattoos associated with dental alloys, retention cysts, papilloma, radiation-induced changes, skin flaps, vocal cord paresis, and vocal fold leukoplakia. Whilst it is imperative to seek consultation from otolaryngologists or dentists in instances where the diagnosis cannot be definitively ascertained by endoscopists, the merits of attaining foundational expertise pertaining to oral and pharyngolaryngeal lesions are unequivocal. This article will be a valuable resource for endoscopists seeking to enhance their understanding of oral and pharyngolaryngeal lesions.

Severe Intentional Corrosive (Nitric Acid) Acute Poisoning: A Case Report and Literature Review

Despite being one of the most debilitating conditions encountered in the field of toxicology, there is a lack of neutralization measures for the toxins involved in acute corrosive poisoning, and this promotes progressive contact injury of deep tissues after poisoning has occurred. Multiple controversies still surround management strategies during the acute phase of poisoning and the long-term follow-up of the patient. Here, we report a severe case of intentional poisoning with nitric acid complicated by extensive injury of the upper digestive tract, multiple stricture formation, and complete dysphagia. Serial endoscopic dilation and insertion of a jejunostomy feeding tube were necessary, and underlying psychiatric illness negatively affected the outcome of the patient. We conclude that an interdisciplinary approach is necessary to properly reduce the extent of lesions and sequelae induced by corrosion. Early endoscopic mapping of injuries is of major importance to better predict the evolution and possible complications of poisoning. Interventional and reconstructive surgical procedures may significantly improve the life expectancy and quality of life of patients following intoxication with corrosive substances.

Complex Refractory Esophageal Stricture Due to Chronic Gasoline Ingestion: A Case Report

Esophageal stricture is a narrowing of the esophageal lumen which is often characterized by impaired swallowing or dysphagia. It can be induced by inflammation, fibrosis or neoplasia which damages the mucosa and/or submucosa of the esophagus. Corrosive substance ingestion is one of the major causes of esophageal stricture, particularly in children and young adults. For instance, accidental ingestion or attempted suicide with corrosive household products is not uncommon. Gasoline is a liquid mixture of aliphatic hydrocarbons derived from the fractional distillation of petroleum, which is then combined with additives such as isooctane and aromatic hydrocarbons (e.g., toluene and benzene). Gasoline also contains several other additives including ethanol, methanol and formaldehyde, which make it a corrosive agent. Interestingly, to the best of our knowledge, the incidence of esophageal stricture caused by chronic gasoline ingestion has not been reported. In this paper, we report the case of a patient with dysphagia due to complex esophageal stricture due to chronic gasoline ingestion who underwent a series of esophago-gastro-duodenoscopy (EGD) procedures and repeated esophageal dilation.

First experience with a supercharged pedicled jejunal interposition for esophageal replacement after caustic ingestion in a middle-income Latin American country

Caustic or corrosive substance ingestion that results in severe esophageal and gastric lacerations frequently requires surgical management. The most common sequelae after an upper gastrointestinal tract caustic injury include non-responding luminal strictures, which are subject to esophageal replacement. Late corrective surgery may include esophagectomy with gastric pull-up and jejunal or colonic interpositions. Although long-segment esophageal reconstruction with jejunum is technically feasible and has demonstrated good outcomes, the complexity of the surgery has precluded the widespread use of this procedure in low- and middle-income countries. This document summarizes the most relevant aspects of caustic ingestion surgical management and describes the first Latin American experience in the reconstruction of an esophageal-gastric caustic injury using a pedicled jejunal interposition, as a viable and functional option in mid- and lower-income countries with well-established Thoracic Surgery departments and microsurgery access.

Use of Antibiotics in Poisonous Ingestions of Corrosives and Organophosphates: A Retrospective Cohort Study

The use of antibiotics following oral poisoning by corrosives and organophosphates is controversial. We assessed the clinical outcomes of using antibiotics in acute poisonous ingestion involving corrosives or organophosphates by conducting a retrospective cohort study of patients presenting to the emergency department following ingestion of corrosives or organophosphates who received either antibiotics or supportive care. The endpoints included clinical stability, length of stay (LOS), and mortality. Of 95 patients, 40 received antibiotics and 55 received supportive care. The median age was 2.1 and 2.7 years, respectively (p = 0.053). Bacterial growth was shown in only 2 of 28 cultures (both were respiratory), but with hospital-acquired organisms as it was shown ≥4 days post-admission. Clinical stability rates were 60% and 89.1% in the antibiotic and supportive care groups, respectively (p < 0.001). Median LOS was 3 vs. 0 days (p < 0.001), and no mortality was recorded. NG/G-tube placement was the only factor associated with clinical failure (OR, 20.97; 95% CI, 2.36-186.13). Antibiotic use was not associated with higher chances of clinical stability, which may suggest that their use was unnecessary. Clinicians are encouraged to use antibiotics wisely, and only in the presence of a clear indication of an infection. This study provides a basis for future prospective studies to confirm its findings.

Chemical Burn-Induced Corrosive Epiglottitis in an Elderly Patient with Major Depression

Acute epiglottitis (AE) is a potential emergency of the respiratory tract caused mainly by bacterial infection. However, nonbacterial infection causes, such as corrosive injuries, may result in death due to gastrointestinal perforation if a timely diagnosis is not available. We report the case of an elderly patient with an acute melancholic episode who encountered corrosive epiglottitis (CE) caused by accidental ingestion of hydrochloric acid and compare the features of CE and AE, including the immediate onset of symptoms, normal findings on blood tests, and endoscopy revealing pale swollen epiglottitis. This case can prove to be an important reference for clinicians for differential diagnosis, especially when treating epiglottitis in patients with psychiatric disorders and unclear expression.

Susceptibility to COVID-19 Nutrition Misinformation and Eating Behavior Change during Lockdowns: An International Web-Based Survey

To understand the susceptibility to nutrition-health misinformation related to preventing, treating, or mitigating the risk of COVID-19 during the initial lockdowns around the world, the present international web-based survey study (15 April-15 May 2020) gauged participants' (n = 3707) level of nutrition-health misinformation discernment by presenting them with 25 statements (including unfounded or unproven claims circulated at the time), alongside the influence of information sources of varying quality on the frequency of changes in their eating behavior and the extent of misinformation held, depending on the source used for such changes. Results revealed widespread misinformation about food, eating, and health practices related to COVID-19, with the 25 statements put to participants receiving up to 43% misinformed answers (e.g., 'It is safe to eat fruits and vegetables that have been washed with soap or diluted bleach'). Whereas higher quality information sources (nutrition scientists, nutrition professionals) had the biggest influence on eating behavior change, we found greater misinformation susceptibility when relying on poor quality sources for changing diet. Appropriate discernment of misinformation was weakest amongst participants who more frequently changed their eating behavior because of information from poor quality sources, suggesting disparities in the health risks/safety of the changes performed.

Clinical analysis of pipeline dredging agent poisoning: A case report

BACKGROUND

Pipeline dredging agents are new household deep cleaning products used to dredge blockages in kitchen and bathroom pipeline caused by grease, hair, vegetable residue, paper cotton fibre, and other organic substances. Pipeline dredging agents are corrosive chemicals that can cause poisoning through corrosive damage to the digestive tract; however, this has not been reported clinically. Therefore, this report emphasises that oral pipeline dredging agent poisoning can cause corrosive damage to the digestive tract and may have serious health consequences.

CASE SUMMARY

A 68-year-old man consumed liquor (200 mL) at approximately 13:00 on April 22, 2021. At approximately 16:00, his family found him unresponsive with blackened lips, blood spots in the corners of the mouth, and blood stains on the ground, as well as an empty bottle of a pipeline dredging agent. One hour later, he was admitted to the emergency department of a local hospital. Considering the empty bottle, he was suspected to have sustained severe corrosive damage to the digestive tract and was transferred to our department at 23:15 on April 22, 2021. He developed dysphagia and intermittent fever and experienced difficulty in opening his mouth throughout his hospital stay. The patient’s condition gradually stabilised. However, he suddenly developed respiratory failure on day 12, and endotracheal intubation and ventilator-assisted ventilation were performed. However, the patient died after 1.5 h despite emergency rescue efforts.

CONCLUSION

Pipeline dredging agents are highly corrosive and may cause corrosive damage to the digestive tract and asphyxia upon consumption.

Caustic Ingestion: A Risk-Based Algorithm

INTRODUCTION

Caustic ingestion management could be improved with a diagnostic approach based on risk factors. This study aimed to develop an algorithm derived from predictive factors of a poor clinical course, to evaluate its diagnostic accuracy and resource consumption, and to compare it with 2 other approaches, a radiological one based on computed tomography and a classical one based on symptoms and endoscopy.

METHODS

All patients older than 15 years presenting with caustic ingestion in our tertiary care hospital between 1995 and 2021 were prospectively included. Adverse outcome was defined as intensive care unit admission, emergency surgery, or death. Ingestion characteristics, symptoms, and laboratory and endoscopic findings were analyzed to determine the most relevant risk factors. Diagnostic accuracy and the number of examinations required were estimated and compared with the other 2 algorithms applied to our series.

RESULTS

The sample included 532 cases of caustic ingestion, 13.2% (95% confidence interval [CI]: 10.3-16.0) of which had adverse outcomes. Volume and type of caustic substance; presence of symptoms and pharyngolaryngeal involvement; and neutrophilia, acidosis, and endoscopic injury were combined to develop an algorithm that would provide the highest diagnostic odds ratio (167.2; 95% CI: 71.9-388.7). Following this approach, half of the patients (50.6%; 95% CI: 46.2-55.1) would not require any examination and, overall, the need for endoscopy (20.0%; 95% CI: 16.4-23.5) and computed tomography (16.3%; 95% CI: 13.0-19.5) would be lower than that for the other 2 algorithms.

DISCUSSION

A risk-based algorithm could improve caustic ingestion management by maintaining high diagnostic accuracy while reducing diagnostic test requirements.

Developing the minimum data set of the corrosive ingestion registry system in Iran

Background

Corrosive ingestion is still a major health problem, and its outcomes are often unpredicted. The implementation of a registry system for poisoning with corrosive substances may improve the quality of patient care and might be useful to manage this type of poisoning and its complications. Therefore, our study aimed to establish a minimum data set (MDS) for corrosive ingestion.

Methods

This was an applied study performed in 2022. First, a literature review was conducted to identify the potential data items to be included in the corrosive ingestion MDS. Then, a two-round Delphi survey was performed to attain an agreement among experts regarding the MDS content, and an additional Delphi step was used for confirming the final MDS by calculating the individual item content validity index (CVI) and content validity ratio (CVR) and by using other statistical tests.

Results

After the literature review, 285 data items were collected and sent to a two-round Delphi survey in the form of a questionnaire. In total, 75 experts participated in the Delphi stage, CVI, kappa, and CVR calculation. Finally, the MDS of the corrosive ingestion registry system was identified in two administrative and clinical sections with 21 and 152 data items, respectively.

Conclusions

The development of an MDS, as the first and most important step towards developing the corrosive ingestion registry, can become a standard basis for data collection, reporting, and analysis of corrosive ingestion. We hope this MDS will facilitate epidemiological surveys and assist policymakers by providing higher quality data capture to guide clinical practice and improve patient-centered outcomes.

Evaluation of a Diagnostic and Management Algorithm for Adult Caustic Ingestion: New Concept of Severity Stratification and Patient Categorization

Background: Caustic ingestion has gained increasing attention worldwide. However, the insight into whether to use esophagogastroduodenoscopy (EGD) or computed tomography (CT) for first-line investigation remains controversial. This study aimed to evaluate a diagnostic and management algorithm that combines EGD and CT for rapid triage. Methods: We established an algorithm for our hospital in 2013, aiming to maximize the benefits and minimize the limitations of EGD and CT. Then, we retrospectively analyzed the 163 enrolled patients treated between 2014 and 2019 and categorized them into 4 groups: A = 3 (1.8%): with perforation signs and directly confirmed by CT, B = 10 (6.1%): clinically suspected perforation but not initially proven by CT, C = 91 (55.8%): initial perforation less favored but with EGD grade ≥ 2b or GI/systemic complications, and D = 59 (36.2%): clinically stable with EGD grade ≤ 2a, according to initial signs/symptoms and EGD/CT grading. The morbidity and mortality of each group were analyzed. The predictive values of EGD and CT were examined by logistic regression analyses and receiver operating characteristic (ROC) curves. Results: The outcomes of such algorithm were reported. CT was imperative for patients with toxic signs and suspected perforation. For non-emergent operations, additional EGD was safe and helpful in identifying surgical necessity. For patients with an initially low perforation risk, EGD alone sufficiently determined admission necessity. Among inpatients, EGD provided excellent discrimination for predicting the risk for signs/symptoms’ deterioration. Routine additional CT was only beneficial for those with deteriorating signs/symptoms. Conclusions: According to the analyses, initial signs/symptoms help to choose EGD or CT as the first-line investigative tool in caustic patients. CT is necessary for seriously injured patients, but it cannot replace EGD for moderate/mild injuries. The severity stratification and patient categorization help to simplify complex scenarios, accelerate decision-making, and prevent unnecessary intervention/therapy. External validation in a larger sample size is further indicated for this algorithm.

Outcomes of Gastric Conduit in Corrosive Esophageal Stricture: a Systematic Review and Meta-analysis

BACKGROUND

Gastric conduit has emerged as the preferred treatment option for both esophageal bypass and replacement for corrosive stricture of the esophagus. There is a lack of consensus and a dearth of published literature regarding the short- and long-term complications of using a gastric conduit. This meta-analysis aims to evaluate the outcomes, morbidity, and complications associated with it.

METHODS

MEDLINE, Cochrane Library, and Google Scholar (January 1960 to May 2020) were systematically searched for all studies reporting short- and/or long-term outcomes and complications following the use of a gastric conduit for corrosive esophageal stricture.

RESULTS

Seven observational studies involving 489 patients (53.2% males, mean age ranging from 22.1 to 41 years) who had ingested a corrosive substance (acid in 74.8%, alkali in 20.7%, and unknown in the rest) were analyzed. Gastric pull-up was performed in 56.03% (274/489) of patients. Median blood loss in the procedure was 187.5 ml with a mean operative duration of 298.75 ± 55.73 min. The overall pooled prevalence rate of anastomotic leak was 14.4% [95% CI (6.2-24.0); p < 0.05, I² = 67.38], and anastomotic stricture was 27.2% [95% CI (13-42.8); p < 0.001, I² = 80.11]. Recurrent dysphagia according to pooled prevalence estimates occurred in 14.4% patients [95% CI (5.4-25.1); p < 0.05, I² = 69.1] and 90-day mortality in 4.8% patients [95% CI (1.5-9.1%); I² = 31.1, p = 0.202]. The dreaded complication of conduit necrosis had a pooled prevalence of 1.3% [95% CI (0.1-3.4%); I² = 0, p = 0.734].

CONCLUSION

The stomach can be safely used as the conduit of choice in corrosive strictures with an acceptable rate of complications, postoperative morbidity, and mortality.

Profiling of inflammatory cytokines in patients with caustic gastrointestinal tract injury

INTRODUCTION

Study of inflammatory cytokines in patients with caustic gastrointestinal tract injury is sketchy. This study investigated the cytokine profiling of patients with caustic substance ingestion, and analyzed the differences between patients with severe and mild injury.

METHODS

This prospective, cross-sectional study enrolled 22 patients admitted to Chang Gung Memorial Hospital between March and October 2018. All patients underwent esophagogastroduodenoscopy in 24 hours. Patients were categorized into two subgroups, as mild (<2b, n = 11) or severe (≥2b, n = 11) group.

RESULTS

The neutrophil count was higher in severe than mild group (P = 0.032). Patients in mild and severe groups exhibited significantly higher circulating inflammatory cytokines than healthy control, including interleukin (IL)-2, IL-5, IL-8, IL-9, IL-12, IL-13, interferon-gamma inducible protein-10, macrophage inflammatory protein-1 beta, regulated upon activation, normal T cell expressed and presumably secreted and tumor necrosis factor-alpha. Furthermore, the levels of IL-2 and tumor necrosis factor-alpha were significantly higher in patients with severe group than mild group. Although there was no difference in cumulative survival between both groups (P = 0.147), the severe group received more operations (P = 0.035) and suffered more gastrointestinal complications (P = 0.035) than mild group.

CONCLUSION

Caustic substance ingestion produces mucosal damages and leads to excessive neutrophils and inflammatory cytokines in peripheral blood.

Corrosive upper gastrointestinal strictures in children: Difficulties and dilemmas

Children constitute 80% of all corrosive ingestion cases. The majority of this burden is contributed by developing countries. Accidental ingestion is common in younger children (< 5 years) while suicidal ingestion is more common in adolescents. The severity of injury depends on nature of corrosive (alkali or acid), pH, amount of ingestion and site of exposure. There are multiple doubts and dilemmas which exist in management of both acute ingestion and chronic complications. Acute ingestion leads to skin, respiratory tract or upper gastrointestinal damage which may range from trivial to life threatening complications. Esophagogastroduodenoscopy is an important early investigation to decide for further course of management. The use of steroids for prevention of stricture is a debatable issue. Upper gastrointestinal stricture is a common long-term sequelae of severe corrosive injury which usually develops after three weeks of ingestion. The cornerstone of management of esophageal strictures is endoscopic bougie or balloon dilatations. In case of resistant strictures, newer adjunctive therapies like intralesional steroids, mitomycin and stents can be utilized along with endoscopic dilatation. Surgery is the final resort for strictures resistant to endoscopic dilatations and adjunctive therapies. There is no consensus on best esophageal replacement conduit. Pyloric strictures require balloon dilatation , failure of which requires surgery. Patients with post-corrosive strictures should be kept in long term follow-up due to significantly increased risk of carcinoma. Despite all the endoscopic and surgical options available, management of corrosive stricture in children is a daunting task due to high chances of recurrence, perforation and complications related to poor nutrition and surgery.

Intestinal perforation associated with chlorine dioxide ingestion: an adult chronic consumer during COVID-19 pandemic

COVID-19 pandemic is one of the most devastating worldwide crises in recent years. During this pandemic, people have been exposed to products that have not been proven to be safe and effective against COVID-19. We present an adult chronic consumer of chlorine dioxide, in which a fatal outcome is described. This case demonstrates that for people searching products to protect themselves from COVID-19, unregulated access to industrial disinfectants represents a dangerous alternative. To date, there is no scientific evidence to uphold the use of chlorine dioxide or chlorine derivatives as preventive or therapeutic agents against COVID-19. Researchers and general population must take into consideration the fatal possible consequences of not following communications and warnings from health authorities and government institutions.

The Ominous Ouzo Party - A Case Series of Four Patients with Accidental Alkali Ingestion

BACKGROUND

Ingestion of alkaline fluids is a common problem, which can lead to perforations, strictures and malignancy. We present a rare case series of several patients who accidentally ingested the same alkaline substance in different doses.

METHODS

We investigated four patients with accidental ingestion of dishwashing liquid. All patients underwent gastroscopy within 24h after inpatient admission. Gastroesophageal lesions were classified according to the Zargar classification for corrosive ingestions.

RESULTS

Esophagogastric lesions were predominantly found at the distal esophagus and the small curvature of the stomach. The severity of these lesions ranged from mild erosions (Zargar 2A) to marked necrosis (Zargar 3A). Our data suggest that the degree of these lesions correlated with the amount of ingested toxin and duration of the inpatient stay. However, a low symptom severity or inconspicuous otolaryngologic examination did not exclude severe gastroesophageal lesions.

CONCLUSION

Our data suggest that the severity of gastroesophageal lesions correlates with the amount of ingested alkaline substance. Symptom burden and an otolaryngologic examination are not sufficiently predictive for the severity of gastroesophageal lesions. The composition and quantity of the swallowed liquid should be determined.

Poisoning among the elderly

OBJECTIVES

Poisonings continue to be an important public health problem. Herein, we analyzed the epidemiology of poisonings in elderly individuals.

METHODS

Retrospective cohort study conducted between 2011 and 2019 in a university hospital. We analyzed demographic variables, type of poison involved, suicidal or accidental nature of the poisoning, and the probability of admission, or death to the hospital.

RESULTS

A total of 880 (6.1%) of the 14,300 poisonings treated in the same period occurred in people over 65 years of age. The most numerous group were individuals between 65-69 years-old (39%), followed by the group of 70-75 years-old (20%), being men 57%. In 88% of the cases a single poison participated, being by frequency alcohol (51.6%), drugs (29.5%), and household or industrial products (12.8%). Alcohol intoxication predominated in men up to 75 years of age, and above this age drug or suicidal intoxication predominated, mainly in women. A total of 145 (16%) subjects were hospitalized, the drugs most frequently implicated being digoxin and benzodiazepines. The probability of hospital admission was associated with intoxication by metformin, digoxin, lithium or with the age of the patient (OR per year = 1.03; 95% CI: 1.0-1.06). A total of 19 patients died (2.16%), mainly due to suicidal caustic ingestion (OR = 5.7: 95% CI: 1.4-23.6) or by drugs, directly related to metformin (OR = 10.1; 95% CI: 2.4-42.4).

CONCLUSIONS

The prevalence of poisoning in the elderly is not negligible, and physicians should have a high index of suspicion in a complex situation.

Suicidal acid ingestion leading to gastric outlet obstruction treated by early definitive surgery-case report

Chemical ingestions can cause acute injury to the oesophagus, stomach, pylorus, duodenum and sometimes other organs after ingestion of corrosives, but it may be as late as 1 year after ingestion. A 30-year-old male patient presented to the emergency department with sudden epigastric abdominal pain after flash material ingestion. Computed tomography of abdomen showed signs of small bowel obstruction associated with segmental small bowel ischaemic changes. Postoperatively, patient developed an intolerance to oral intake with upper gastrointestinal scope showing sever stricture at the distal gastric lumen and pylorus. The patient was taken to the operation where gastrojejunostomy and brown procedure was done. Corrosive gastric injury treatment depends on the degree of gastric involvement, related oesophageal strictures and the patient’s general health. Early surgery offers very satisfactory and physiological results, whereas avoiding gastric resection or bypass provides very satisfactory and physiological outcomes.

Poisoning among the elderly

OBJECTIVES

Poisonings continue to be an important public health problem. Herein, we analyzed the epidemiology of poisonings in elderly individuals.

METHODS

Retrospective cohort study conducted between 2011 and 2019 in a university hospital. We analyzed demographic variables, type of poison involved, suicidal or accidental nature of the poisoning, and the probability of admission, or death to the hospital.

RESULTS

A total of 880 (6.1%) of the 14,300 poisonings treated in the same period occurred in people over 65 years of age. The most numerous group were individuals between 65-69 years-old (39%), followed by the group of 70-75 years-old (20%), being men 57%. In 88% of the cases a single poison participated, being by frequency alcohol (51.6%), drugs (29.5%), and household or industrial products (12.8%). Alcohol intoxication predominated in men up to 75 years of age, and above this age drug or suicidal intoxication predominated, mainly in women. A total of 145 (16%) subjects were hospitalized, the drugs most frequently implicated being digoxin and benzodiazepines. The probability of hospital admission was associated with intoxication by metformin, digoxin, lithium or with the age of the patient (OR per year = 1.03; 95% CI: 1.0-1.06). A total of 19 patients died (2.16%), mainly due to suicidal caustic ingestion (OR = 5.7: 95% CI: 1.4-23.6) or by drugs, directly related to metformin (OR = 10.1; 95% CI: 2.4-42.4).

CONCLUSIONS

The prevalence of poisoning in the elderly is not negligible, and physicians should have a high index of suspicion in a complex situation.

A new perspective of the risk of caustic substance ingestion: the outcomes of 468 patients in one North Taiwan medical center within 20 years

INTRODUCTION

Caustic substance ingestion is frequently life-threatening, and its pathological mechanisms of tissue damage are well documented. However, few studies have assessed the combined effects of pH and the ingested dose on patient outcomes. Additionally, the miscellaneous chemical properties are not immediately available for providing predictive insights to physicians. This study aimed to provide a new perspective of the risk assessment of caustic substance ingestion based on the pH and dose.

METHODS

The retrospective study analyzed adults treated for caustic substance ingestion at Chang Gung Memorial Hospital between January 1999 and December 2018. Uniformly strict inclusion/exclusion criteria and a double-checked process during chart review were adopted. All patients underwent urgent esophagogastroduodenoscopy (EGD) within 24 h. Caustic mucosal damage was graded using Zargar's modified endoscopic classification. The pH and ingested dose of caustic substances were clearly recorded. Statistical analyses were conducted using IBM SPSS, version 22.

RESULTS

Based on the 468 enrolled cases, the pH and dose were valuable predictors of the extent of gastrointestinal tract injury, commonly encountered complications, and long-term overall survival outcomes. Risks of mortality and perforation were dose-dependent for acids and pH-dependent for alkalis. The severe EGD findings (grade ≥ 2b) in this study were pH-dependent for both substances and additionally dose-dependent for acids.

CONCLUSION

Combining pH and dose, we proposed a new perspective for the risk assessment of caustic substance ingestion. Such findings may provide predictive insights for resolving clinical uncertainty before the availability of examination results. "Large doses of acids" and "high pH of alkalis" deserve special attention. This new perspective with a retrospective nature requires further validation.

The Association Between Caustic Ingestion and Psychiatric Comorbidity Based on 396 Adults Within 20 Years

Purpose

High prevalence of psychiatric comorbidities (PCs) has been widely documented in caustic substance ingestion cases. However, their effect on the clinical features and prognostic outcomes remains unclear due to the paucity of discussion. We report on detailed clinical courses with long-term multifaceted outcomes and review the association between caustic ingestion and each specific PC.

Patients and Methods

The retrospective chart review included 396 adults (median follow-up, 16.6 months) with and 377 without (control group) PCs treated between 1999 and 2018 at Chang Gung Memorial Hospital. All PCs were diagnosed/confirmed by psychiatrists through face-to-face interviews.

Results

The PCs predicted serious esophagogastroduodenoscopy grading, higher rates of admission/surgery/intensive care unit stay, increments of systemic/gastrointestinal complications, and poorer 5-year overall survival rates. The poor survival among patients with PCs was highly consistent with their baseline characteristics. Significantly advanced age, more non-PCs, alcoholism, illicit drug abuse, and baseline unhealthy status resulted in statistically higher risks of severe complications and limited recovery.

Conclusion

PCs changed clinical patterns and had critical roles in the survival outcomes of caustic injury victims. Clinical awareness achieves benefit by limiting injuries in mild cases or allowing emergent interventions in severe cases. Future studies based on worldwide populations are essential for realizing geographic differences.