Ingestion of caustic hair relaxer: is endoscopy necessary?

Caustic Ingestion in Children: 1 Year Experience in 3 Italian Referral Centers

OBJECTIVES

Despite the efforts to reduce the exposure to corrosive household products, caustic ingestion in children is currently a significant medical problem. The aims of the present study were to evaluate the clinical consequences of caustic ingestion and to identify prognostic factors that could concur in driving both diagnostic and therapeutic management.

METHODS

All consecutive children referred for ingestion of a caustic substance from June 2017 to June 2018 were enrolled. Medical records, laboratory and endoscopic findings were reviewed and analyzed.

RESULTS

We enrolled 44 children with caustic ingestion. Alkaline agents were ingested by 26 of 44 (59.1%) patients, whereas acid agents were ingested by 18 of 44 patients (40.9%). Alkaline rather than acid agents were associated with a worse endoscopic score (r: 0.45) and a higher probability of early esophageal stricture occurrence (r: 0.38). The specific risk of the presence of severe esophageal lesions rose progressively with increasing number of symptoms whereas no esophageal injury was found in asymptomatic patients.

CONCLUSIONS

Our data suggest that endoscopic evaluation is mandatory in symptomatic patients to direct therapeutic management, but it could be avoided in asymptomatic patients after accidental ingestion, particularly if the ingestion is only suspected and patients have no oropharyngeal burns.

Clinical and anthropological perspectives on chemical relaxing of afro-textured hair

The culturally engrained practice of 'relaxing' afro-textured hair has been linked with hair and scalp disorders. Herein, we discuss the evolution of human hair types, focusing in particular on afro-textured hair. We explore the biological features of this hair type, and discuss the different methods employed to straighten afro-textured hair, focusing in particular on chemical straightening. We also examine clinical, anthropological, and psychological issues associated with this latter practice. Examples of common scalp pathologies associated with chronic hair relaxing, such as alopecia, hair breakage, caustic burns and irritant contact dermatitis, are also highlighted. The data presented herein should enable clinicians to engage in culturally appropriate discussions with their patients about issues of appearance and conformity.

Conservative therapeutic approach to corrosive poisonings in adults

INTRODUCTION

In this study, we assess the effectiveness of a conservative therapeutic treatment of acute corrosive poisonings in adults, and we define therapeutic protocols based on clinical and endoscopic criteria.

METHODS

We analyzed clinical records of patients with acute corrosive poisonings who were hospitalized and treated at the Toxicology Clinic at the University of Skopje, Republic of Macedonia, during a 5-year period (2006-2010). A total of 481 patients' records with cases of acute corrosive poisonings were analyzed. There were 317 female (65.9 %) and 164 male (34.1 %) patients. The purpose of the therapy in the cases of acute corrosive poisonings is to prevent perforation as well as progressive fibrosis and stenosis of the esophagus and stomach. Therapeutic approach mainly consists of proton pump inhibitors, H(2) blockers, antibiotics, and intensive hyperalimentation. There are different opinions regarding conservative treatment of acute corrosive poisonings in adults.

CONCLUSION

Based on our study of corrosive poisonings of adults, we propose a list of optimal treatment recommendations.

Predictability of outcome of caustic ingestion by esophagogastroduodenoscopy in children

AIM: To assess the necessity of esophagogastroduodenoscopy (EGD) to predict the outcome of caustic ingestion in children.

METHODS: The study included 206 children who underwent EGD because of ingestion of caustic substances between January 2005 and August 2010. Retrospective analysis of data of the patients was performed.

RESULTS: The male/female ratio was 1.6 and mean age was 38.1 ± 28.8 mo. The caustic substances were acidic in 72 (34.9%) cases, alkaline in 56 (27.2%), liquid household bleach in 62 (30.1%), and unknown in 16 (7.8%). Fifty-seven (27.7%) patients were symptom-free. Significant clinical findings were observed in 149 (72.3%) patients. Upper gastrointestinal endoscopy findings of esophageal injury were grade 0 in 86 (41.7%) patients, grade 1 in 49 (23.8%), grade 2a in 42 (20.4%), grade 2b in 28 (13.6%), and grade 3a in 1 (0.5%) patient. 35 patients with grade 2a, 2b, and 3a injuries underwent esophageal dilation at second week of ingestion. Esophageal stricture, which necessitated a regular dilation program developed in 13 of the aforementioned 35 patients. There is no statistically significant difference in the rate of development of esophageal stricture between the patients who ingested acidic (15.3%) and alkaline (8.9%) substances (P = 0.32). Severe gastric injury was detected in 38 (18.5%) patients. The rate of development of gastric injury was significantly higher in the acidic group (14%) than in the alkaline group (2.9%) (P = 0.001). Out of 149 patients with clinical findings, 49 (32.9%) patients had no esophageal injury and 117 (78.5%) patients had no gastric lesion. Esophageal and severe gastric injuries were detected in 20 (35.1%) and 8 (14%) of patients with no clinical findings respectively. Pyloric stenosis developed in 6 patients. Pyloric obstruction improved with balloon dilation in 2 patients. Mean hospitalization time were 1.2 ± 0.5 d for grade 0 and 2.3 ± 5 d for grade 1 and 6.3 ± 6.2 d for grade 2a and 15.8 ± 18.6 d for grade 2b. It was significantly longer for patients with grade 2a and 2b injuries (P = 0.000).

CONCLUSION: Endoscopy is an effective technique for determining the presence of esophageal and gastric damage and to avoid unnecessary treatment in patients with no or mild injury.

Conservative management of caustic substance ingestion in a pediatric department setting, short-term and long-term outcome

Patients with caustic substance ingestion are usually referred to surgery departments where endoscopic evaluation is the first step towards appropriate treatment. The aim of this study was to evaluate the safety and efficacy of conservative management of caustic substance ingestion in a pediatric department setting following a standard protocol including endoscopy in selected cases and conservative treatment based on clinical and endoscopy criteria. In this single center observational study, all children admitted for caustic substance ingestion to a pediatric department over an 8-year-period were managed according to a standard protocol that included endoscopy within 24 hours, if the endoscopy criteria were met, and conservative treatment as judged appropriate according to endoscopic classification. Patients were followed up for 8-10 years. Of the 24 patients (age 4/12 to 6 years) admitted, 14 met the endoscopy criteria. Grade II and III esophageal burns were found in 10/14 patients, and they were treated with H2-blockers, antibiotics, corticosteroids, and nutritional support (parenteral in 8/10). Patients with grade II or III esophageal burns necessitated prolonged hospitalization (x ± standard deviation, 23 ± 3 days; range, 21-30 days). Complications included esophageal strictures (n = 1), treated successfully with dilatations, and bleeding (n = 1) treated conservatively. During the 8- to 10-year follow-up all patients were recorded being well. Based on the study findings it is concluded that conservative management of children with caustic substance ingestion using a standard protocol, including endoscopy as indicated, is feasible within the pediatric department, and conservative treatment on demand is safe and effective in preventing short-term and long-term complications.

Caustic ingestion in children: is endoscopy always indicated? The results of an Italian multicenter observational study

BACKGROUND

The ingestion of caustic substances can represent a serious medical problem in children.

OBJECTIVE

Whether or not an urgent endoscopy should be performed is still a matter of debate, particularly in asymptomatic patients.

DESIGN

We conducted a multicenter observational study to investigate the predictive value of signs and symptoms in detecting severe esophageal lesions.

SETTING AND PATIENTS

The records of 162 children who presented with accidental caustic substance ingestion were analyzed.

INTERVENTIONS

Signs and symptoms were divided into minor (oral and/or oropharyngeal lesions and vomiting) and major (dyspnea, dysphagia, drooling, and hematemesis). An endoscopy was performed in all patients within 12 to 24 hours of the substance being ingested.

MAIN OUTCOME MEASUREMENTS

The types of substance ingested, signs and symptoms, age, sex, and severity of esophageal injury were correlated.

RESULTS

Mild esophageal lesions were identified in 143 of 162 patients (88.3%), and severe (third degree) esophageal lesions in 19 patients (11.7%). The risk of severe esophageal lesions without signs and/or symptoms was very low (odds ratio [OR] 0.13 [95% CI, 0.02-0.62], P = .002). Indeed, the presence of 3 or more symptoms is an important predictor of severe esophageal lesions (OR 11.97 [95% CI, 3.49-42.04], P = .0001). Multivariate analysis showed that the presence of symptoms is the most significant predictor of severe esophageal lesions (OR 2.3 [95% CI, 1.57-3.38], P = .001).

CONCLUSIONS

The results demonstrated that the incidence of patients with third-degree lesions without any early symptoms and/or signs is very low, and an endoscopy could be avoided. The risk of severe damage increases proportionally with the number of signs and symptoms, and an endoscopy is always mandatory in symptomatic patients.

Ethnic cosmetic products

Based both on actual differences in the hair and skin and on cultural desire, people of color do have special considerations for cosmetic products. As the experts in hair and skin, it is incumbent on dermatologists to understand the needs of a diverse patient base, to be knowledgeable about the products that patients need and desire, and to be aware of possible adverse effects related to product use or misuse. Further research is needed both to continue to understand the needs of the hair and skin of people of color and to understand the effects of products on ethnic hair and skin.

Corrosive ingestion in adults

Ingestion of a corrosive substance can produce severe injury to the gastrointestinal tract and can even result in death. The degree and extent of damage depends on several factors like the type of substance, the morphologic form of the agent, the quantity, and the intent. In the acute stage, perforation and necrosis may occur. Long-term complications include stricture formation in the esophagus, antral stenosis and the development of esophageal carcinoma. Endoscopy should be attempted and can be safely performed in most cases to assess the extent of damage. Procedure-related perforation is rare. Stricture formation is more common in patients with second and third degree burns. Corticosteroids may help prevent stricture formation. Esophageal carcinoma may develop beginning 30 to 40 years after the time of injury.

Endoscopic treatment of upper airway and digestive tract lesions caused by caustic agents

We present our experience in the endoscopic management of upper aerodigestive tract lesions caused by caustic agents. Between 1985 and 2000, 112 patients with upper airway and digestive tract lesions due to caustic agents were treated at the Airways Endoscopic Surgery Unit of Padua Hospital: 44 were male and 68 were female, and the median age was 42.6 years. A retrospective statistical analysis of our case series was made to evaluate the factors that most influenced the severity of injuries and the outcome of treatment. All of the patients underwent videoendoscopic assessment. In 79 cases, the patients came under our observation in the acute phase, whereas 33 presented a picture of chronic lesions. Acute lesions were classified into 3 grades. All acute grade 1 lesions healed spontaneously. In the 32 patients with grade 2 lesions, endoscopic treatment based on removal of necrotic tissue, dilations, and cleansing of abnormal fibrin adhesions resolved the disease in 30 cases (94%). Nine patients (43%) with acute grade 3 lesions developed severe chronic lesions that required subsequent treatments. Rigid endoscopy with diode laser-assisted radial lysis was performed in 32 patients with chronic cicatricial lesions and was successful in 30 cases (94%). We reiterate the need for a standardized multidisciplinary protocol for treating lesions caused by caustic agents and emphasize the essential role of airway and digestive canal videoendoscopy in the diagnosis and treatment of both the acute lesions and chronic cicatricial sequelae.

Hair relaxers: a benign caustic ingestion?

BACKGROUND

Despite federally legislated safety regulations, caustic ingestions remain a significant problem in the pediatric population. The current standard of care for caustic ingestion includes upper gastrointestinal endoscopy in most cases. Hair relaxers are a common caustic ingestion at our institution, yet few data have been published describing the clinical or endoscopic outcome. We explored the relative frequency of hair relaxer ingestion, the incidence of associated upper gastrointestinal injury, and the adverse clinical sequelae resulting from these ingestions.

METHODS

Consecutive caustic ingestions admitted to our institution between January 1990 and January 2001 were identified. The data were collected through retrospective physician chart review, were analyzed, and were pooled with the existing literature to evaluate for the presence of esophageal injury.

RESULTS

96 charts were reviewed, 29 (30%) of which were hair relaxer ingestions that underwent esophagogastroduodenoscopy; these ingestions served as our study cohort. The median age of the cohort was 14.0 months and patients were evenly divided in gender. The most common symptoms at presentation were drooling and emesis. At endoscopy, lip and oropharyngeal mucosa were most commonly affected. While six patients (20.7%) had Grade I esophageal mucosal injury and five patients (17.2%) had Grade I gastric mucosal injury, none had greater than Grade I mucosal damage. No adverse clinical events were identified. When our data were combined with all previously published cohort data, the findings were similar and no adverse clinical outcomes were reported.

CONCLUSIONS

Hair relaxer is the most common childhood caustic ingestion presenting to our large metropolitan tertiary care center. Symptoms are common at presentation. However, despite the high pH of these products, no clinically significant esophageal or gastric mucosal injuries and no long-term sequelae were identified.

Is esophagogastroduodenoscopy necessary in all caustic ingestions?

BACKGROUND

It is unclear whether symptoms alone can identify patients with caustic ingestion who will benefit from esophagogastroduodenoscopy (EGD). The published data are contradictory. The purpose of the current study was to determine the relationship between initial symptoms and EGD findings in patients with caustic ingestion.

METHODS

Chart review of all caustic ingestions who underwent EGD during a 4-year period (December 1993 through November 1997).

RESULTS

Twenty-eight patients (15 girls; mean age, 2.7 years (range, 0.92-13.33) underwent EGD after caustic ingestion. Fourteen percent (4/28) of patients were asymptomatic, and findings on endoscopy were normal. Another 57% (16/28) had normal endoscopic findings, although all were symptomatic. Twenty-nine percent (8/28) of patients had esophageal injury on EGD, and all were symptomatic. Esophageal injury was graded as 1 (mucosal erythema), 2 (superficial burns; noncircumferential) or 3 (deep burns; circumferential). The injury was grade 1 in three of eight patients and grade 2 in two; all had one symptom each. Grade 3 injury was found in three of eight patients: two had two symptoms (drooling and vomiting, drooling and stridor), and one had one symptom (dysphagia). All patients with grade 3 injury subsequently underwent esophageal dilations. Follow-up information was secured for two of the three patients with grade 1 injury and both patients with grade 2 injury at 34.3 months (range, 24-50) after the ingestion, and all were asymptomatic. Of the 20 patients with absence of esophageal mucosal damage, follow-up data were available for 15 patients at 37.2 months (range, 7-63) after the event and all were well.

CONCLUSIONS

All patients with clinically significant injury (grades 2 and 3) were symptomatic at initial assessment. No single symptom or combination of symptoms could identify all patients with esophageal injury. All asymptomatic patients had normal findings on endoscopic examinations. Esophagogastroduodenoscopy seems unnecessary in asymptomatic patients with alleged caustic ingestion. A larger, prospective study would be necessary to unequivocally answer this clinically important question.