Caustic ingestions in children

Early management of acute caustic ingestion in pediatrics

This review is intended to provide an overview of currently available literature related to caustic ingestion in pediatric patients, including initial management considerations in symptomatic versus asymptomatic children, timing and necessity of endoscopic evaluations, and the use of various therapeutic interventions. Further, this review provides management considerations for children presenting for evaluation following caustic ingestion based on the best available evidence. Additional research is needed to develop conclusive pediatric guidelines that meet GRADE criteria for management of caustic ingestion in children.

Epidemiological and Clinical Characteristics of Pediatric Acute Drug Intoxications: A Retrospective Analysis

BACKGROUND/OBJECTIVES

Acute drug intoxications (ADIs) are a significant concern in pediatric healthcare, contributing to both accidental and intentional morbidity. This study aimed to analyze the demographic, clinical, and therapeutic characteristics of pediatric ADI cases to identify trends and inform preventive strategies.

METHODS

This retrospective study included 120 cases of pediatric ADI admitted to the Second Pediatric Clinic of Craiova County Emergency Clinical Hospital in 2022 and 2023. The inclusion criteria encompassed children aged 0-17 years with confirmed pharmaceutical intoxications. Cases involving mixed poisonings or non-pharmaceutical substances were excluded. Clinical severity was classified using the Poisoning Severity Score (PSS). Data on demographics, substances involved, clinical presentations, interventions, and outcomes were analyzed.

RESULTS

The majority of cases occurred in females (73.3%) and urban residents (77.5%). Accidental intoxications were prevalent in children aged 1-5 years (45%), while intentional ingestions were common in adolescents (47.5%). The most frequently implicated substances included antibiotics (46.7%), benzodiazepines (20.8%), and acetaminophen (15.8%). Severity was classified as mild (44.2%), moderate (26.6%), or severe (29.2%), while treatment primarily included supportive care, intravenous fluids (62.5%), and antidotes (35.8%). Severe cases required respiratory support in 29.2% of the instances. Hospitalization duration significantly decreased from 2022 (3.8 ± 1.9 days) to 2023 (2.3 ± 0.9 days) (p < 0.05), and no fatalities were recorded.

CONCLUSIONS

Pediatric ADIs predominantly involve accidental ingestions in young children and intentional overdoses in adolescents. Targeted public health strategies, such as parental education, adolescent mental health support, and improved rural healthcare access, are essential to reduce incidence and severity. These findings underscore the need for focused prevention and optimized clinical management.

Outcomes of Colonic and Gastric Tube Transplants after Caustic Esophageal Burn in Children: A 33-Year Review

Introduction: Accidental caustic burns of the esophagus in children represent a significant global health challenge, often necessitating esophageal reconstruction. The aim of this study is to compare the efficacy and morbidity related to esophagus replacement with colonic and gastric tube transplants in a pediatric population followed for caustic stenosis. Methods: This retrospective study was conducted at a tertiary pediatric surgery unit for children treated from January 1989 to December 2022. We compared colonic and gastric tube esophageal replacement. Short term (within 30 days) and mid-term outcomes and complications were reviewed. Statistical evaluation was considered using a Chi-square test for categorical data analysis. Results: A total of 124 children with caustic esophageal burns were included. Among them, 23 (18.5%) had a gastric tube transplant for esophagus replacement and 101 (81.5%) a colonic transplant. During surgical intervention, we found a significantly higher risk of complications when using a colonic transplant (34%, p < 0.001). There was no significant statistical difference in postoperative short term and mid-term complications between the two techniques. Twenty-six (26%) of the children required a reoperation, with a higher risk in the gastric tube transplant group (p < 0.001). Endoscopic dilatation after surgery was also performed on a higher number of children who had received a gastric tube transplant (p = 0.005). Overall, 97.6% recovered full normal oral feeding. Conclusions: We found that colonic and gastric tube replacement are both good options for pediatric esophageal replacement after a caustic injury and show effectiveness over time. Gastric tube transplants carried a slightly higher risk of reoperations and a higher number of dilatations post-surgery. However, our groups are not really comparable, due to the much higher number of colonic transplants. Both surgical options have to be considered during surgery, and the choice depends on the anatomy of the patient. Our future research will focus on assessing long term quality of life and the potential risk of neoplastic complications.

Pediatric Esophageal Foreign Bodies and Caustic Ingestions

Foreign body ingestions commonly occur in children aged under 6 years. While serious complications of ingestions are rare, sharp objects, caustics, multiple magnets, and button batteries can be associated with poorer outcomes including gastrointestinal (GI) obstruction, perforation, necrosis, and fistula formation. Initial workup should include history, physical examination, and plain film radiographs that will identify radiopaque objects. Removal of the foreign body is typically warranted if the object is high risk, it is located higher up in the GI tract, the patient is symptomatic, or the object is retained for a prolonged amount of time.

Perforations from Endoscopic Dilation of Corrosive Strictures in Adults: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

Endoscopic dilation is an important therapeutic option for treatment of corrosive strictures. Its safety is unclear with variable perforation rates in previous studies. We aimed to evaluate its safety with regard to perforations and the effect of dilator type to perforation risk.

METHODS

A systematic review of published literature from inception to April 24, 2021, using PubMed and EMBASE databases was conducted. Studies in adult subjects (mean age ≥ 18 years) reporting perforation rates of endoscopic dilation of corrosive esophageal and/or gastric strictures were included. Pooled cumulative perforation rates were computed as primary outcome. Secondary outcomes included, perforation with each dilator subtypes, surgical or conservative modes of management and mortality. Random effect meta-analysis was used to estimate the frequency of each of these outcomes. Variables were reported as percentages with 95% CI.

RESULTS

A total of 712 subjects (N) who underwent 4840 dilations (n) were noted in the 15 studies that were included. Of which, eight were retrospective, while the remaining seven were prospective. On meta-analysis, the cumulative pooled perforation rate was 1% (1-2%) of the number of dilations (n%). The perforation rates with SG (1%, 0-3%) and balloon (1%, 0-5%) dilators were similar (p value < 0.01). 45/64 (59%, 11-94%) perforations were subjected to surgery while the remaining 14/64 (41%, 6-89%) was managed conservatively. Choice of management strategy was biased to the norms of the treating team. About 3/712 patients (0%, 0-2%) succumbed following perforation.

CONCLUSION

Perforation from endoscopic dilation of corrosive strictures occurs rarely, and there is no significant difference in perforation risk related to the type of dilator.

Increased risk of hepatocellular carcinoma in patients with traumatic liver injury: Real-world data from a nationwide population-based study

Hepatocellular carcinoma (HCC) is the sixth most common cancer globally, and liver is one of the most commonly injured organs after blunt abdominal trauma. The traumatic liver injury-HCC risk relationship remains unclear.We extracted data of patients with traumatic liver injury between 2000 and 2013 from Taiwan National Health Insurance Research Database (n = 15,966) and those of age-, gender-, occupation-, and index year-matched individuals without traumatic liver injury from the general population (n = 63,864). Cox proportional hazard models were employed to determine the hazard ratios (HRs) and 95% confidence intervals (CIs) for HCC occurrence in the traumatic liver injury cohort compared with that in the comparison cohort.Patients with traumatic liver injury had an increased HCC risk (adjusted HR 2.13, 95% CI 1.59-2.85); this increased risk was more pronounced within 1 year after injury (adjusted HR 8.84, 95% CI 4.29-18.2). After >1 year of injury, HCC risk remained 1.53-fold higher in patients with traumatic liver injury than in those without traumatic liver injury (95% CI 1.08-2.15).People with traumatic liver injury demonstrate a high HCC risk, particularly within the first year of the injury.

pH and specific gravity of corrosive agents as indicators in caustic injuries

BACKGROUND

Video endoscopy, which remains the diagnostic gold standard after ingestion of a corrosive substance, is performed under general anesthesia in children, requires advanced technology, and is costly. Simple and accessible methods are therefore needed to determine the need for endoscopy. The aim of this study was to evaluate the role of the pH and specific gravity of ingested substance in determining endoscopy indications after corrosive ingestion.

METHODS

This prospective study included pediatric patients who presented after ingesting a corrosive substance from June 2018 to June 2019. Relationships between the extent of damage detected by endoscopy and the patient's age, physical examination findings, and the pH and specific gravity of the causative substance were evaluated.

RESULTS

The degree of damage detected on endoscopy was significantly milder for corrosive substances with a pH between 2 and 12 (P = 0.003). In addition, pH values between 2 and 12 were significantly more common among patients without physical examination findings (P = 0.029). Specific gravity less than 1,005 was associated with mild injury detected by video-endoscopy (P = 0.011). Patients in whom severe injury was detected by endoscopy had marked findings on physical examination (P < 0.001). There was no significant relationship between physical examination findings and the specific gravity of the substance involved (P = 0.087).

CONCLUSIONS

The results of this study suggest that conservative treatment options can be used without performing endoscopy in patients who have no physical examination finding after corrosive ingestion and where the pH of the substances is between 2 and 12 and the specific gravity of the substances is less than 1,005.

Household cleaning products poisoning in a pediatric emergency center: A 10- year cross-sectional study and literature review

BACKGROUND

Poisoning by household cleaning products(HCPs) is common in children. Some HCPs are toxic and may cause severe complications. We assessed HCP poisonings treated in a pediatric emergency department(PED).

METHODS

This was a retrospective study of patients aged under 18 years with HCP poisoning admitted to the largest PED in Taiwan from 2011 to 2020 were recruited.

RESULTS

The records over a 10-year period from 103 children admitted to the PED because of HCP poisoning(70 boys [68%] and 33 girls [32%]), mean age 3.54 years(standard deviation [SD] = 3.15 years) were evaluated. Most poisonings were unintentional(99%, n = 102) and occurred at home(96%, n = 99). The HCPs included alkaline(74%, n = 76), acidic(25%, n = 26), and neutral(1%, n = 1) agents. Most were orally ingested(86%, n = 89). Panendoscopy was performed in 25 patients(24%), and the endoscopic(Zargar) grade was used to determine the severity of injury. Medications(steroids [9%, n = 9], antibiotics [10%, n = 10], or antacids [30%, n = 23]) were prescribed. Alkaline HCP ingestion induced severe esophageal injury(p = 0.04) and esophageal stricture(p = 0.04). Five patients(5%) exhibited esophageal strictures and required balloon dilation. On multivariate analysis, alkaline HCP ingestion(p = 0.04), severe esophageal caustic injury(Zargar grade ≥ 3) (p < 0.001), and medications(steroids [p < 0.001], antibiotics [p < 0.001], and antacids [p = 0.001]) were associated with esophageal stricture.

CONCLUSION

Alkaline HCP ingestion and severe esophageal caustic injury(Zargar grade ≥ 3) were associated with esophageal stricture. Physicians tended to prescribe medications(steroids, antibiotics, or antacids) for patients with severe esophageal injuries to reduce the risk of esophageal stricture. The usefulness of these medications requires further study.

Predictors of successful endoscopic management of caustic esophageal strictures in children: When to stop the dilatations?

BACKGROUND

Caustic esophageal strictures are mainly managed by endoscopic dilatations. Cases that do not respond to the dilatations eventually require an esophageal replacement. The aim of our study was to identify factors that could allow us to predict if the dilatations will be successful or not.

METHODS

We retrospectively reviewed the chart of 100 patients with caustic esophageal injuries treated at our center between 2012 and 2019. Collected data included age, gender, type of caustic substance, duration of the dilatations, length and extent of the strictures, number and time interval between dilatations, presence of gastroesophageal reflux, occurrence of esophageal perforation, and outcome of the dilatation program.

RESULTS

The patient ages ranged from 1 to 8 years old. The overall success rate was 98.2% for patients with short strictures and 81.8% for patients with long strictures (>3 cm). A long stricture, a pharyngeal extension of the stricture, the occurrence of an esophageal perforation, and the presence of gastroesophageal reflux were strong predictors of the failure of the dilatation program. The median treatment time for the patients to achieve a cure was 5 months in cases of short strictures and 17 months in cases of long strictures. Within the subgroup of patients with long strictures, a dysphagia-free period within the first year of management of 8 weeks was associated with the success of the dilatation program.

CONCLUSION

A length of more than 3 cm, pharyngeal involvement, the occurrence of esophageal perforation, and the presence of gastroesophageal reflux are predictors of failure of dilatations for the management of caustic esophageal strictures. A dysphagia-free period of 8 weeks or more within the first year of dilatations is considered a predictor of success of dilatations in patients with long strictures.

LEVEL OF EVIDENCE

Level II.

Prevention Strategies for Esophageal Cancer-An Expert Review

In the last 30 years, we have witnessed a rapid increase in the incidence and prevalence of esophageal cancer in many countries around the word. However, despite advancements in diagnostic technologies, the early detection of this cancer is rare, and its prognosis remains poor, with only about 20% of these patients surviving for 5 years. The two major forms are the esophageal squamous cell carcinoma (ESCC), which is particularly frequent in the so-called Asian belt, and the esophageal adenocarcinoma (EAC), which prevails in Western populations. This review provides a summary of the epidemiological features and risk factors associated with these tumors. Moreover, a major focus is posed on reporting and highlighting the various preventing strategies proposed by the most important international scientific societies, particularly in high-risk populations, with the final aim of detecting these lesions as early as possible and therefore favoring their definite cure. Indeed, we have conducted analysis with attention to the current primary, secondary and tertiary prevention guidelines in both ESCC and EAC, attempting to emphasize unresolved research and clinical problems related to these topics in order to improve our diagnostic strategies and management.

Alkaline substances gastroesophageal injury in young children: emphasis on Asian food preparation habits

BACKGROUND

Ingestion of alkaline substances should not be disregarded because a small amount can cause chemical burns in the esophagus, with esophageal stricture being the most common late complication.

METHODS

We enrolled children with alkaline corrosive damage receiving treatment at China Medical University Children's Hospital's emergency department between 2008 and 2018. Patients were divided into groups A (ingested causative agents other than alkaline oil), and B (ingested alkaline oil).

RESULTS

Altogether, 40 (27 [67.5%] male and 13 [32.5%] female) patients aged 7 months-7 years were enrolled. The most commonly ingested agent was alkaline oil (13 cases, 32.5%), followed by oven and drainage cleaners (8 cases, 20%), bleach (6 cases, 15%), laundry and dish cleaners (4 cases, 10%), sodium hydroxide (4 cases, 10%), sodium carbonate (2 cases, 5%), sodium phosphate (2 cases, 5%), and sodium citrate (1 case, 2.5%). High proportions of children had esophagitis (40/40, 100%), erosive gastritis (7/40, 17.5%), and gastric ulcer (6/40, 15%). The incidence of esophageal stricture was 38.4% (5/13) and 7.4% (2/27) in groups B and A, respectively. In group B, 4 children developed growth stunting or malnutrition during the first decade after onset, with reduced immunity and feelings of inferiority.

CONCLUSION

Alkaline ingestion usually results in esophageal injury that is difficult to cure. Corrosive esophageal strictures cause swallowing difficulties and growth stunting in children. Young children who ingested alkaline oil have more complications. Given that alkaline corrosive injuries are often accidental, prevention of corrosive agent ingestion is crucial.

Increase in foreign body and harmful substance ingestion and associated complications in children: a retrospective study of 1199 cases from 2005 to 2017

Background

Children with a history of caustic or foreign body ingestion (FBI) seem to be presenting more frequently to emergency departments. This study aims to elucidate the clinical presentation, diagnostic procedures, and complications associated with the ingestion of different object categories over a 13-year time period.

Methods

A structured retrospective data analysis of patients who presented between January 2005 and December 2017 to the University Medical Centre Ulm was performed. Patients up to 17 years of age with food impaction or foreign body or harmful substance ingestion were included by selection of the corresponding International Statistical Classification of Diseases and Related Health Problems (ICD10-GM) codes. Descriptive statistics, parametric or non-parametric tests, and linear regression analysis were performed.

Result

In total, 1199 patients were analysed; the mean age was 3.3 years (SD 3.12; range 7 days to 16 years), the male to female ratio was 1.15:1, and 194 (16.2%) were hospitalized. The number of patients seen annually increased from 66 in 2005 to 119 in 2017, with a rise in percentage of all emergency patients from 0.82% in 2010 to 1.34% in 2017. The majority of patients (n = 619) had no symptoms, and 244 out of 580 symptomatic patients complained of retching or vomiting. Most frequently, ingested objects were coins (18.8%). Radiopaque objects accounted for 47.6%, and sharp objects accounted for 10.5% of the ingested foreign bodies, both of which were significantly more often ingested by girls (p < 0.001 for both). Button battery ingestion was recorded for 63 patients with a significant annual increase (R2 = 0.57; β = 0.753; p = 0.003). The annual rate of complications also increased significantly (R2 = 0.42; β = 0.647; p = 0.017).

Conclusion

We found an alarming increase in the number of children who presented to our emergency department with FBI and associated complications. A standardized diagnostic and therapeutic approach may reduce and prevent serious complications. Further preventive measures within the home environment are needed to stop this trend.

MicroRNA expression profiles in the esophagus of children with caustic stenosis: A pathway towards esophageal cancer?

BACKGROUND

Eighty percent of caustic ingestions occur in children and esophageal neoplasms may develop as a late complication of such injury. The identification of biomarkers is a promising strategy to improve early diagnosis of esophageal cancer or caustic lesions that are at an increased risk of progression.

STUDY DESIGN/AIMS

This study aimed at identifying global microRNA (miRNA) expression changes in esophageal mucosa from children with caustic stenosis. The study included 27 biopsy samples from 15 patients. Samples were divided into two groups, according to the time elapsed after injury (N = 15 in Group A, with less than five years of follow-up and N = 12 in Group B, with more than five years of follow-up). miRNA expression profiles were determined in each lesion, compared with normal esophageal tissues from control group. We used the TaqMan Human MicroRNA Arrays (Thermo Fisher) platform. Furthermore, bioinformatic algorithms were used to identify miRNA target genes and biological pathways including miRNAs and their target genes potentially associated with esophageal disease.

RESULTS

Thirteen miRNAs were significantly deregulated (9 over- and 4 underexpressed) in patients from Group A. In patients from Group B, two miRNAs were over- and two were underexpressed. Of note, miR-374 and miR-574 were deregulated in Group B patients and have been linked to esophageal tumorigenesis. We identified signal transduction and transcription factor networks with genes strongly related to development and progression of esophageal cancer.

CONCLUSION

miRNAs identified here contribute to a better understanding of pathways associated with malignant transformation from caustic stenosis to neoplastic lesions. This study may serve as a basis for validation of miRNAs, including miR-374 and miR-574, as potential biomarkers of early cancer detection.

Corrosive ingestion managements in children

Corrosive (caustic) material ingestion remains a major health issue, particularly in developing countries. The management strategy after corrosive ingestion should be planned according to the signs and symptoms. The management of corrosive ingestion based on endoscopic grading, nothing by mouth, and barium studies should be abandoned. With the new management protocol, esophageal stricture can be predicted with high accuracy using the simple new prognostic DROOL score (≤ 4) rather than endoscopic grading, reduced by immediate oral feeding as soon as the patient can swallow saliva instead of nothing by mouth, diagnosed earlier (10-14 days) by fluoro-endoscopic balloon-assisted esophageal examination for patients with persistent dysphagia instead of relying on a barium study (≥ 21 days), and adequately treated by initiating balloon dilation earlier during the same anesthesia procedure. Fluoroscopically guided balloon dilatation with large balloons (18-20 mm) seems to be safe, with a low frequency of complications and a high success rate. If dilatation fails after a few months, esophagectomy and replacement surgery using the stomach should be considered. The increased risk of developing esophageal carcinoma after ingestion of corrosive substances should be kept in mind.

Conservative treatment of caustic oesophageal injuries in children: 15 years of experience in a tertiary care paediatric centre

INTRODUCTION

Endoscopic dilatation is good choice of conservative treatment for caustic digestive tract injuries in children.

AIM

To set up a strategy of management of caustic digestive tract injury based on our experience and literature review.

MATERIAL AND METHODS

We retrospectively analysed medical records of 34 paediatric patients who were admitted to the Centre of Paediatric Surgery of the Children's Hospital between 2000 and 2017. Age at presentation, gender, anatomic location, circumstances and distribution of injury, early and late complications, clinical signs, and the first aid were analysed. Upper gastrointestinal (GI) endoscopy was performed within 12-24 h after ingestion in all cases. The Zargar classification system was used to grade the severity of the injury. Fisher's exact test was used for statistical analysis, with p < 0.05 considered as the limit of statistical significance.

RESULTS

The upper GI endoscopy revealed caustic injuries in 5 (15%) and 8 (23%) patients were classified as grade IIa and IIb, respectively. Oesophageal and ventricle caustic injuries in 3 (9%) and 2 (6%) patients were classified as grade IIIa and IIIb, respectively. Thirteen patients with grade IIa and IIIb injuries suffered permanent damage and required repeated dilatation. All patients underwent stricture treatment using late or early endoscopic dilatation of the oesophagus. An average of 15 dilatation procedures were required to achieve a satisfactory lumen.

CONCLUSIONS

Our experience of 34 children revealed that endoscopic dilatation may be required as a primary treatment for oesophageal strictures.

Corrosive injury of the trachea in children

The secondary injury may present weeks to months after the initial insult and repeat bronchoscopy, and long-term follow-up is required for the respiratory complications of CSI.Ingestion of caustic fluid may cause severe tracheal stenosis. Repeated airway dilatation may be a lifesaving intervention until such point that surgery can be performed.

Endoscopic findings and outcome in caustic ingestion of acidic and alkaline agents in adults: A retrospective analysis

Caustic ingestion in adults is a rare but potentially life-threatening problem. It remains controversial whether endoscopic findings and mortality differ between acid and alkali ingestion. We compared ingestion of these agents and evaluated prediction parameters for survival and complications.Adult patients who presented with caustic ingestion were analyzed from 2005 to 2016. Mucosal injury was graded endoscopically by Zargar's score. Age, gender, intent of ingestion, caustic agents, comorbidities, management, complications, and mortality were examined.Thirty-one patients met inclusion criteria and were divided into acid (n = 10) and alkali group (n = 21). Ingestion of alkali resulted in higher grades (≥III) of esophageal (56% vs 24%, P = .01) and stomach injuries (43% vs 13%, P = .05) and was mostly done with suicidal intent (76% vs 30%, P = .003). Patients in the alkali group received more often surgical interventions, mechanical ventilation and tracheotomy. Overall complications including Zargar's-score ≥ grade III, mediastinitis, and aspiration pneumonia were higher in alkali group but all showed no statistical significance (P = .73). Mortality (acid: 1 (10%), alkali: 4 (19%), P = .52), age, gender, comorbidities, and intensive care management did not differ significantly between the groups. Chronic renal failure and mediastinitis were promising prediction parameters for mortality but did not reach statistical significance. No independent risk factors for the development of esophageal stenosis were identified.Alkaline agents caused a higher mucosal injury severity and were more often used in suicidal intent. Mediastinitis and chronic renal failure might be potential prediction parameters for survival but need to be evaluated in larger studies.

Effects of topical application of platelet-rich plasma on esophageal stricture and oxidative stress after caustic burn in rats: Is autologous treatment possible?

BACKGROUND

Caustic esophageal burn is still an important health problem in pediatric surgery. Although there are a number of experimental and clinical studies to increase the recovery of the esophagus and reduce the stenosis rate, there is no consensus on the treatment protocol. Platelet-rich plasma (PRP) is an autologous blood product, which has positive effects on wound healing, reepithelization and scar prevention. The aim of our study was to investigate the effects of PRP on stricture formation and oxidative status after caustic esophageal injury in rats.

METHODS

Twenty-one rats were divided into three groups [Sham operation (n = 8), corrosive esophageal burn with 30% NaOH (n = 6), topical PRP application after corrosive burn (n = 7)]. On the postoperative 21st day, oxidative markers were measured in the serum, and collagen accumulation and stenosis index were measured histopathologically to assess the efficacy of PRP treatment.

RESULTS

Postoperative weight was higher than preoperative weight in Sham and PRP groups, but lower in the Burn group (p < 0.05). No difference was observed between Sham and PRP groups at total antioxidant status and paraoxonase values, but a significant decrease was found in the Burn group. Group PRP had higher total oxidant status and arylesterase levels than Group Burn (p < 0.05). There was no difference in total thiol values between PRP and Sham group. Histopathological scoring for muscularis mucosa damage revealed a significant reduction in Group PRP, compared to Group Burn (p < 0.05). Esophageal wall thickness and SI were reduced, and luminal diameter was increased in Group PRP compared to Group Burn (p < 0.05).

CONCLUSION

For the first time in the literature, these results indicate that topical PRP treatment after the experimental corrosive burn has a positive effect on oxidative stress, mucosal healing and decreased stricture development. PRP may be an alternative at the clinical treatment because it can be used during diagnostic esophagoscopy.

TYPE OF STUDY

Treatment study Level I (randomized controlled trial).

Endoscopic balloon dilatation is an effective management strategy for caustic-induced gastric outlet obstruction: a 15-year single center experience

Background and study aims  There is sparse data on the endoscopic management of caustic-induced gastric outlet obstruction (GOO). The present retrospective study aimed to define the response to endoscopic balloon dilatation (EBD) in such patients and their long-term outcome. Patients and methods  The data from symptomatic patients of caustic-induced GOO who underwent EBD at our tertiary care center between January 1999 and June 2014 were retrieved. EBD was performed using wire-guided balloons in an incremental manner. Procedural success and clinical success of EBD were evaluated, including complications and long-term outcome. Results  A total of 138 patients were evaluated of whom 111 underwent EBD (mean age: 30.79 ± 11.95 years; 65 male patients; 78 patients with isolated gastric stricture; 33 patients with both esophagus plus gastric stricture). The initial balloon diameter at the start of dilatation, and the last balloon diameter were 9.6 ± 2.06 mm (6 - 15 mm) and 14.5 ± 1.6 mm (6 - 15 mm), respectively. Procedural and clinical success was achieved in 95 (85.6 %) and 108 (97.3 %) patients, respectively, requiring a mean (SD) of 5.3 (2.6) and 7.21 (3.86) sessions, respectively. Patients with isolated gastric obstruction had a better response than those with combined esophagus and gastric stricture. Minor complications such as self-limited pain or bleeding were seen in 18 (16.2 %) and 16 (14.4 %), respectively. Perforation occurred in two patients. Over a follow-up period of 98 months, there were no recurrences. Conclusion  Caustic-induced GOO can be successfully managed using EBD with 97.3 % clinical success.

Role of endoscopy in caustic injury of the esophagus

Caustic injury of the esophagus is a problematic condition challenging endoscopists worldwide. Although the caustic agents and motives are different among countries and age groups, endoscopy still plays an invaluable role in diagnosis and treatment. Endoscopy can determine the severity of caustic ingestion which is of great importance in choosing appropriate treatment. However, some aspects of endoscopy in diagnosis of caustic injury remain controversial. Whether or not all patients need endoscopy, when to perform endoscopy and how to assess the severity are just some examples of these controversies. Due to lack of randomized controlled trials, many findings and suggestions are inconclusive. Computerized tomography scan of the chest and abdomen gains popularity in assessing the severity of caustic injury and avoiding unnecessary surgery. If esophageal stricture eventually develops, endoscopic dilatation is a mainstay. Maneuvers such as steroid injection and esophageal stent may be used in a refractory stricture. Nevertheless, some patients have to undergo surgery in spite of vigorous attempts with esophageal dilatation. To date, caustic injury remains a difficult situation. This article reviews all aspects of caustic injury of the esophagus focusing on endoscopic role. Pre-endoscopic management, endoscopy and its technique in acute and late phase of caustic injury including the endoscopic management of refractory stricture, and the treatment outcomes following each endoscopic intervention are thoroughly discussed. Finally, the role of endoscopy in the long term follow-up of patients with esophageal caustic injury is addressed.

Foreign body ingestion in pediatric patients

PURPOSE OF REVIEW

The purpose of this article is to review clinical manifestations and management of common pediatric foreign body ingestions, with a particular focus on some of the current trends.

RECENT FINDINGS

Foreign body ingestion (FBI) is a problem that is frequently encountered by pediatric providers. As new toys and products enter the marketplace, there may also be new dangers from those objects not initially recognized. Some of the recent trends and findings in pediatric FBI include an increase in adolescent injury from ingestion of laundry detergent pods because of a popular game where participants are encouraged to bite or swallow the pods, and injuries associated with ingesting parts of a popular toy known as a 'Fidget Spinner'.

SUMMARY

Adverse events resulting from FBI range the entire gamut from nonexistent or minor symptoms to moderate injury and rarely may be fatal. Factors such as age, type of object ingested, anatomic location of the foreign body, and timing from ingestion to receipt of medical attention all determine the risk posed to the child and guide management decisions. Because of the constant development of products, and the potential for the emergence of new and dangerous trends among children, continued surveillance by the medical community is important in monitoring and managing injuries associated with FBI.

Achalasia and esophageal cancer: risks and links

Esophageal cancer affects more than 4,50,000 persons worldwide, and its incidence has increased in recent years. It is the eighth most common cancer across the globe. The main histologic types are esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EA), and their associated risk factors are well known. Achalasia, an idiopathic esophageal disorder that conditions aperistalsis and the absence of lower esophageal sphincter relaxation, stands out among them. The prevalence of ESCC in subjects with esophageal achalasia is 26 in every 1,000 cases, whereas the prevalence of EA is 4 in every 1,000. Patients with achalasia have a 50 times higher risk of presenting with ESCC than the general population, and the disease manifests 20-25 years after achalasia symptom onset. Multiple mechanisms are related to the development of ESCC in achalasia, and they include bacterial overgrowth, food stasis, genetic alterations, and chronic inflammation. Regarding the risk of EA in achalasia patients, most cases are associated with Barrett's esophagus, due to uncontrolled chronic acid reflux. Given that achalasia is a well-established factor for ESCC/EA, clinicians must be aware of said associations to enable the development of programs for the prevention and opportune detection of these cancers in patients with achalasia.

The effect of platelet-rich plasma on motility changes in experimental caustic esophageal burn

BACKGROUND

Besides stricture formation, diminished esophageal motility after caustic esophageal burns also plays a role in the deterioration of the clinical course. In this study, we aimed to investigate the effect of caustic burn on the esophageal contractions and the effect of platelet-rich plasma (PRP) on these changes.

METHODS

Twenty-one Wistar albino rats were divided into three groups [Sham operation (n = 8), caustic esophageal burn with NaOH (n = 6), PRP treatment after caustic burn (n = 7)]. After 3 weeks, esophagectomy was performed and contractions and EFS responses were evaluated in the organ bath.

RESULTS

KCl- and acetylcholine-induced responses were reduced in the Burn group, but increased in Sham and PRP groups (p < 0.05). EFS responses were higher in Burn group compared to the other groups. Response with L-arginine was increased in Burn group, but decreased in PRP group. There was more decrease in the contraction in Sham and PRP groups compared to the Burn group after SNP (sodium nitroprusside) incubation (p < 0.05). L-NAME (Nω-Nitro-L-arginine methyl ester) did not change the EFS responses in the Burn group, but EFS responses were decreased significantly in Sham and PRP groups (p < 0.05). EFS responses were decreased in all groups, but more in the Sham and PRP groups after Y-27632 (Rho-kinase inhibitor) incubation (p < 0.05).

CONCLUSIONS

For the first time, we demonstrated that both cholinergic and non-adrenergic non-cholinergic mechanisms are responsible for the altered motility in corrosive esophageal injury. Our results suggest that PRP treatment may be helpful in regulating the esophageal motility and decreasing altered contractions in corrosive burns. This effect may also contribute to the reduction of stricture formation, especially by reducing inappropriate contractions of the esophageal wall during the post-burn healing phase.

Surgical management of corrosive-induced gastric injury in children: 10years' experience

AIM

The purpose of this study was to report surgical management and outcome of corrosive-induced gastric injuries in children at our institute over the last decade.

PATIENTS & METHOD

Medical records of patients admitted for corrosive-induced gastric injury at the Pediatric Surgery Department of Ain Shams University between January 2007 and January 2017 were retrospectively reviewed.

RESULTS

Twenty six cases (17 boys and 9 girls) were enrolled. Mean age was 3.61±1.29. Ingested agent was acid in all the patients. Main presenting symptom was gastric output obstruction in 22 cases. The interval between corrosive ingestion and presentation ranged from one to 135days (mean=43.9±34). Surgical procedure included total gastrectomy (n=2), partial gastrectomy (n=2), augmentation gastroplasty (n=1), Billroth I (n=2), antrectomy (n=2), antroplasty (n=3), gastrojejunostomy (n=2), Heineke-Mikulicz pyloroplasty (n=9), Finney pyloroplasty (n=5), and feeding jejunostomy (n=4). Anastomotic stricture requiring a second operation developed in one patient. There were three mortalities related to the associated esophageal strictures. The mean follow-up period is 3.5years. All patients are free of symptoms and gained adequate weight.

CONCLUSION

Surgery is the mainstay of management for corrosive-induced gastric injuries with good long-term results. Surgical procedure should be tailored according to the patient's general condition and extent of gastric injury.

LEVEL OF EVIDENCE

This is a case series with no comparison group (level IV).

Halofuginone improves caustic-induced oxidative injury of esophagus in rats

BACKGROUND

The aim of this study is to evaluate the anti-inflammatory and anti-fibrotic effects of halofuginone in caustic esophageal burn injury in rats.

MATERIALS AND METHODS

Corrosive esophageal injury (CEI) was produced in male Wistar albino rats by instilling NaOH solution (1 ml, 37.5%) into the distal esophagus. Rats were decapitated on the 3rd day (early group) or 28th day (late group), and treated daily with either saline or halofuginone (100 µg/kg/day; i.p.), continued on alternate days after the third day. Histopathological evaluation and measurement of nitric oxide (NO), peroxynitrite (ONOO-) and oxygen-derived radicals by chemiluminescence (CL) were made in the distal 2 cm of the esophagus. Non-irrigated proximal esophageal samples were assessed for the levels of nuclear factor (NF)-κB, caspase-3, glutathione (GSH), malondialdehyde (MDA) and myeloperoxidase (MPO) activity.

RESULTS

GSH, MDA, NF-κB and caspase-3 levels, and MPO activity in the proximal esophagus were not different among groups. Increased number of TUNEL (+) cells in the irrigated esophagus of the early and late caustic injury groups was reduced by halofuginone treatment. High microscopic damage scores in both early and late CEI groups were decreased with halofuginone treatment. NO, ONOO- and CL levels, which were elevated in the saline-treated early CEI group, were reduced by halofuginone treatment, but reduced NO and ONOO- levels in the late period of saline-treated group were increased by halofuginone.

CONCLUSION

In addition to its anti-fibrotic effects, current findings demonstrate that halofuginone exerts antioxidant and anti-apoptotic actions and supports therapeutic potential for halofuginone in CEI-induced oxidative stress.

Dysphagia and feeding difficulties post-pediatric ingestion injury: Perspectives of the primary caregiver

PURPOSE

To explore the experiences of children with dysphagia and/or feeding difficulties post-chemical or button battery ingestion injury from the perspective of the primary caregiver.

METHOD

Five primary caregivers of children with a history of dysphagia and/or feeding difficulties post-ingestion injury (4 chemical, 1 button battery) completed the Children's Picky Eating Questionnaire (CPEQ), and participated in a semi-structured interview. Interviews explored experiences of caring for a child with dysphagia and/or feeding difficulties, impressions of services and supports, and additional impacts to the child and family. Content analysis was used to identify key themes.

RESULT

Primary caregiver report and CPEQ results confirmed all children had some degree of persisting dysphagia and/or feeding difficulties at time of interview (mean 4.13 years' post-injury). Interviews identified five key themes: 1) The initial trauma of the injury, 2) The experience of associated and ongoing medical issues, 3) Managing altered oral intake, 4) Experiences of services and support, and 5) Impacts on the child, primary caregiver, and wider family unit. All caregivers reported significant challenges and concerns, and potential areas of service improvement were highlighted.

CONCLUSION

The current data highlights specific issues experienced by primary caregivers, and poses areas for improving primary caregiver and family supports. Family-centered models of care are needed to support the whole family unit in caring for a child with dysphagia and/or feeding difficulties post-ingestion injury.

Management of Benign Esophageal Strictures in Children

Esophageal strictures are seldom in children. In many countries, accidental ingestion of corrosives is a major cause of risk for stricture formation. Therefore, their management is a challenge. Safety and long-term efficacy of esophageal dilation for benign esophageal strictures has been confirmed in children. Because most children with structures are toddlers or younger, balloon dilatation is often preferred over bouginage. There is increasing evidence that short duration administration of high doses steroids may be of benefit in some specific situation (IIb esophagitis according to Zargar classification). Mytomycin-C application needs to be further evaluated. Stenting was reported to be successful in some refractory cases.

Dysphagia and Speech-Language Pathology Involvement Following Chemical Ingestion Injury: A Review of 44 Cases Admitted to a Quaternary Australian Hospital (2008-2012)

PURPOSE

This study aimed to explore the clinical characteristics of an adult chemical ingestion population and examine the course of return to oral intake post injury and speech-language pathologist (SLP) involvement during the initial acute-care admission.

METHOD

A retrospective chart review of adults admitted to a quaternary hospital for the treatment of an acute chemical ingestion injury between 2008 and 2012 was conducted.

RESULTS

Forty-four adults (23 men, 21 women) were identified as receiving treatment for ingestion injury, of whom 18 (40.91%) required altered oral intake. Of those requiring altered oral intake, 50% were referred to SLPs. Individuals requiring altered oral intake were significantly (p < .05) older, more likely to be men, and present with more severe injuries requiring longer ICU and hospital admissions following intentional chemical ingestions than those who were able to commence a normal oral diet without any alteration or nonoral supplementation. By discharge, 15.91% (n = 7) of the total cohort had not resumed normal oral intake.

CONCLUSIONS

Return to oral intake post chemical ingestion injury can be protracted and complex. Referrals to SLPs were limited. These data may aid prognostic insight as well as provide (a) collateral information to assist discharge planning and follow-up and (b) background for evaluating the potential for SLP involvement.

Successful management of 70% acetic acid ingestion on the intensive care unit: A case report

Acetic acid is an organic acid available in concentrations from 2 to 80%. Whilst lower concentrations of 2-6% are more commonly used as the table top condiment, vinegar, much stronger solutions are regularly used in Eastern Europe as food preservatives and cleaning solutions. Oral ingestion of greater than 12% has been reported to cause haemolysis, renal failure, shock and death. Most reported cases of deliberate or accidental poisoning are from Russia and Eastern Europe in the 1980s, with very little currently in western publications. We present the case of a female patient who attempted suicide by drinking 250 ml of 70% acetic acid. Her widespread gastrointestinal injuries were managed conservatively, and despite suffering extensive upper airway and renal complications, she was successfully decannulated and discharged home after a prolonged intensive care and hospital stay.

Risk factors for symptomatic esophageal stricture after caustic ingestion-a retrospective cohort study

Esophageal stricture is a major secondary complication of ingesting caustic agents. We examined our experiences with caustic injuries with a view to finding clinical and biological risk factors of esophageal strictures secondary to caustic ingestion. Records were retrieved for 58 adults admitted consecutively to our intensive care unit for caustic ingestion. Fifty cases were managed conservatively and therefore retained for analyses. Patients were grouped according to whether they developed strictures or not during the follow-up period. Mucosal damage was assessed by emergency endoscopy. Eleven patients (22%) developed a stricture. At referral, dysphagia, epigastric pain, and hematemesis were associated with secondary stricture (respectively P = 0.047, P = 0.008, P = 0.02). A high Zargar endoscopic grade (above IIa; P = 0.02), the ingestion of strong acids or alkalis (P = 0.006), hyperleukocytosis (P = 0.02), and a low prothrombin ratio (P = 0.002) were associated with a higher risk of developing a stricture. The median delay of stricture diagnosis was 12 (8;16) days after ingestion, with extreme values from 4 to 26 days. Initial symptoms such as dysphagia or hematemesis, early endoscopy showing >IIa grade esophagitis, and certain laboratory results should draw the physician's attention to a high risk of esophageal stricture.

Caustic Ingestions and Foreign Bodies Ingestions in Pediatric Patients

Children inevitably swallow foreign material accidentally or intentionally. Each type of ingestion carries their own set of risks and complications, short and long term, some requiring immediate attention while others close monitoring. Alkalotic household cleaning products and lithium button batteries are increasingly common and damage the esophagus quickly. While many toys with rare-earth metals are banned, they are already present in many households and can cause necrosis of bowel that is between the magnets. This article reviews the incidence and assessment along with current literature to provide guidelines for management of pediatric patients with suspected caustic or foreign body ingestion.

Oral Chemical Burns Reported to the Poisons Information Centre in Erfurt, Germany, from 1997 to 2014

Devastating oral burns often followed by lifelong complications can result from ingestion of caustic substances. However, although being one of the most challenging situations in clinical practice, literature data on the epidemiology of oral burns are still scarce. Retrospective analysis of all cases of oral burns after ingestion of corrosive substances reported to the Poisons Information Centre in Erfurt, Germany, from 1997 to 2014 was performed. In total, 482 calls because of oral burns were registered, with no change in the numbers of cases during the years. In the majority of the instances (47%), toddlers were affected, followed by middle-aged adults (33%). In both age groups, the male sex prevailed. Ingestion of corrosive substances with babies, schoolchildren, adolescents, and elderly were much less frequent. In most cases (78%), the injury occurred accidentally and only in 5% of the instances in suicidal intent; 85% of the suicidal attempts were committed by middle-aged adults and 15% by elderly. Main agents involved in oral burns were cleansing agents (37%), remedies (12%), disinfectants (7%), acids or bases (6%), technical fluids (6%), cosmetics (5%), and foods (5%). Mostly, the calls came from emergency department doctors (58%), in 19% laymen were calling from home, and in 18% the calls came from a doctor's office. Most of the injuries occurred accidentally, in the domestic setting and in toddlers, and would have been preventable. Thus, a more comprehensive education of the population, especially of parents, regarding the dangers arising from household chemicals is still needed.

Is rigid endoscopy necessary with childhood corrosive ingestion? a retrospective comparative analysis of 458 cases

The aim of this study was to determine the necessity of endoscopy in cases in which a corrosive substance was ingested and to find a practical way to avoid unnecessary endoscopies for similar cases in the future. The clinical records of 458 hospitalized cases with clinical histories of corrosive substance ingestion between January 2007 and December 2013 were retrospectively reviewed. The demographics of the cases, the ingested substances, and the rigid endoscopy findings were evaluated. The three most commonly ingested corrosive agents were household bleach (22.9%), household degreaser (15.9%), and drain cleaner (13.1%). Rigid esophagoscopy was performed in 367 of the 458 cases. Corrosive agents were grouped according to their purpose of household use; eight groups were created. The degree of corrosive injury observed in the different groups was compared with the degree of injury caused by household bleach. Among the corrosive agent groups, dishwashing machine products (Gr.1), laundry products (Gr.2), liquid cleaners (Gr.3), and household bleach (Gr.4) did not cause high-grade injuries. The resulting injuries and esophagoscopy results among the above groups, whether symptomatic or not, did not differ from one another. Corrosive agents such as drain cleaner (Gr.6), household degreaser (Gr.7), and several other acidic products (Gr.8) caused high-grade injuries in the esophagus; however, lime remover/HCl (Gr.5) did not. Thus, hospitalization and rigid endoscopy seem unnecessary to assess esophageal injury in most cases, if the ingested corrosive agent fits into group 1, 2, 3, or 4 and if the patient can be easily fed. Esophagoscopy is useful to shorten the hospitalization times in cases where strong corrosive agents were ingested, such as those in groups 5, 6, 7, and 8.

Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines

This guideline refers to infants, children, and adolescents ages 0 to 18 years. The areas covered include indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; corrosive ingestion and stricture/stenosis endoscopic management; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography; and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease has been dealt with in other guidelines and are therefore not mentioned in this guideline. Training and ongoing skill maintenance are to be dealt with in an imminent sister publication to this.

Speech-language Pathology in Acute Pediatric Chemical or Button Battery Ingestion Injury

OBJECTIVES

Dysphagia is a common consequence of pediatric ingestion injury, yet there is a lack of data relating to recommencement of oral (per os; PO) intake or use of feeding therapy. We describe patterns of early PO intake, and referral to speech-language pathology (SLP) for feeding therapy, during the acute admission of a pediatric cohort postchemical or button battery ingestion injury.

METHODS

Retrospective chart review of pediatric ingestion injuries admitted to a quaternary hospital from 2008 to 2013. Clinical parameters, PO intake progression, and nature of referrals for feeding therapy during the acute admission were examined.

RESULTS

Fifty-one children (26 boys; mean age: 31.5, range 4-170 months) were identified (75% with grade II or III mucosal injuries), of whom 31 (60%) had impaired PO intake. Of these, 5 recommenced premorbid PO intake during admission. At discharge, 16 remained on modified PO intake, and 10 remained nil PO. Eight (26%) were referred to SLP for feeding therapy during acute admission, or within 4 months of discharge. Feeding therapy-referred children were more likely to have pediatric intensive care admission (PICU) (100% vs 26%), and longer hospital admission (36.1 vs 9.3 days for those not referred).

CONCLUSIONS

More than half of the cohort had impaired PO intake, and one-third were nil PO at time of discharge. Referrals for feeding therapy were limited. Our findings may provide some guidance for clinicians, patients, and their families regarding possible PO intake recovery patterns, as well as provide background for evaluating the potential for feeding therapy and SLP involvement within this population.

Surveillance of patients at high-risk of squamous cell esophageal cancer

Currently curative treatment for esophageal squamous cell cancer (ESCC) is possible only in patients with early-stage, usually asymptomatic disease. In Western countries, where the incidence of ESCC is relatively low, a screening of asymptomatic, average-risk population is untenable. In order to detect early-stage ESCC or its precursor lesions it is important to identify high-risk patients and consider endoscopic surveillance in these groups. These high-risk groups include patients after curative treatment for head and neck cancer, previous endoscopic resection of ESCC, caustic injury, and patients with tylosis or achalasia. This paper discuss the evidence and proposed method of endoscopy surveillance of these high-risk patients.

The Challenges of Dysphagia Management and Rehabilitation in Two Complex Cases Post Chemical Ingestion Injury

PURPOSE

Dysphagia is common sequelae of chemical ingestion injury, resulting from damage to critical swallowing structures. From a speech-language pathology perspective, this study outlines the physiological deficits in 2 individuals with severe injury (1 woman, acid; 1 man, alkali) and the pattern of dysphagia rehabilitation and recovery.

METHOD

A retrospective chart review of clinical and instrumental assessments was conducted to examine swallow characteristics and speech-language pathology management (compensatory and rehabilitation strategies) at multiple time points.

RESULTS

Chemical ingestion injury resulted in severe pharyngeal dysphagia for both participants, warranting speech-language pathology management. Dysphagia was characterized by poor base of tongue mobility and reduced laryngeal excursion. Decreased airway patency and protection, secondary to mucosal sloughing, widespread edema, and structural deficits necessitated tracheostomy. Recovery was complicated by physical alterations of pharyngeal and laryngeal structures (e.g., interarytenoid adhesions) and esophageal strictures. Participant 1 was discharged (Day 135) consuming a texture-modified diet; Participant 2 remained nil by mouth (Day 329).

CONCLUSIONS

Dysphagia recovery subsequent to chemical ingestion is protracted and complex. Clinical outcomes may be improved through individualized and intensive rehabilitation by speech-language pathologists.

Esophageal Cancer

Esophageal cancer carries a poor prognosis among gastrointestinal malignancies. Although esophageal squamous cell carcinoma predominates worldwide, Western nations have seen a marked rise in the incidence of esophageal adenocarcinoma that parallels the obesity epidemic. Efforts directed toward early detection have been difficult, given that dysplasia and early cancer are generally asymptomatic. However, significant advances have been made in the past 10 to 15 years that allow for endoscopic management and often cure in early stage esophageal malignancy. New diagnostic imaging technologies may provide a means by which cost-effective, early diagnosis of dysplasia allows for definitive therapy and ultimately improves the overall survival among patients.

Caustic oesophagitis in children: prevalence, the corrosive agents involved, and management from primary care through to surgery

PURPOSE OF REVIEW

Caustic substance ingestion (CSI) remains a major health issue, particularly in developing countries, where laws are not effectively enforced. This review offers a thorough analysis of the current epidemiology, clinical features, management, treatment, and long-term complications of CSI in children.

RECENT FINDINGS

Strong alkalis sold in liquid and granular forms, particularly crystalline grease cleaners (concentrated sodium hydroxide), are the principal causes of severe oesophageal damage. Currently, early endoscopy to assess the gastro-oesophageal mucosa is not considered necessary for all CSI cases. Oesophageal stricture is a major complication developing after CSI, and should be diagnosed and treated earlier, 10-14 days after CSI via commencement of a dilation program. Fluoroscopically guided oesophageal balloon dilatation seems to be safe, with a low frequency of complications and a high success rate. However, it should commence earlier than is currently the case, and should be performed gently, using balloons of gradually increasing diameter. If dilation fails after a few months, oesophageal replacement surgery should be performed.

SUMMARY

Unfortunately, neither dilatation treatment nor oesophageal bypass surgery can prevent the development of oesophageal carcinoma, the incidence of which is high after CSI. The continuing unacceptably high incidence of CSI accidents would be reduced if corrosive materials were sold in their original childproof containers, highlighting the need for preventive and adult education programmes.

Caustic ingestion injury of the upper aerodigestive tract in adults

Adult ingestion of caustic substances is an unusual but serious surgical problem, with injuries likely to be more extensive than those in the corresponding paediatric population. After initial stabilisation and airway management, clinicians are presented with a complex multisystemic problem, frequently requiring a multidisciplinary approach involving several surgical disciplines and associated therapies. A new multidisciplinary team was convened to discuss complex ingestion injury in adults and established techniques were used to bring forward a proposed treatment algorithm. An algorithm may potentially improve clinical efficacy and risk in the management of these complex patients.

Caustic ingestion management: world society of emergency surgery preliminary survey of expert opinion

Caustic material ingestion injuries (CMI) are uncommon. Only 5,000 cases are reported in the United States each year and most acute care healthcare facilities admit only a few cases annually. Accordingly, no single institution can claim extensive experience, and management protocols are most probably based on either expert opinion or literature reports. In this study, we will attempt to review opinions and practices of representatives of the board members of the World Society of Emergency Surgery and compare them to the current literature.

Therapy of caustic ingestion: new treatment considerations

PURPOSE OF REVIEW

This review will focus on therapeutic considerations and recent advances in treatment of caustic ingestion injuries.

RECENT FINDINGS

A retrospective study suggests that it may be safe to advance the endoscope beyond the first circumferential burn to allow for a more complete assessment of extent of injury. A randomized controlled prospective study suggested that a 3-day course of high-dose methylprednisolone might reduce the occurrence of esophageal stricture formation. Balloon dilatation has been shown to be as effective as other bougienage techniques with lower risk of perforations. Recent studies indicate that esophageal dilatation can be safely performed as early as 5-15 days after initial ingestion and may decrease risk for long-term stricture formation. The use of adjunctive treatment, such as topical mitomycin C and esophageal stents, shows promise in reducing the reoccurrence of stricture formation after dilatation.

SUMMARY

Caustic ingestion remains a significant problem in children, despite continued efforts to educate the public about ways to avoid this preventable accident. Because there are few good quality therapeutic trials in children, many of the current recommendations regarding treatment are based on expert opinion. Large, prospective, multicenter, controlled treatment trials are needed to identify the best protocols to prevent serious complications.

Protective effect of early placement of nasogastric tube with solid dilator on tissue damage and stricture formation after caustic esophageal burns in rabbits

BACKGROUND

The ingestion of caustic substances remains an important public health issue worldwide. Children represent 80% of the ingestion injury population globally. Accidental alkaline material accounts for most caustic ingestions. There is no conclusive evidence of tissue damage and stricture protection of a nasogastric-tube with a solid dilator in the literature, therefore it was hypothesized that early intraesophageal tube placement does not cause additional histopathologic damage and prevents strictures.

METHODS

An exploratory study on experimental caustic esophageal burns in a rabbit model was designed. In the treated group a silicone tube was placed immediately after causing the burns, while the untreated group followed the natural course of the burn. On the twenty-secondday, an esophagectomy was performed on all animals for microscopic (Histopathologic Damage Score and Stenosis Index) and macroscopic analysis.

RESULTS

Forty animals were randomly divided into two groups. The Histopathologic Damage Score was 3.7±1.1 in the treated group versus 3.9±1.2 in the untreated group (p=.9690). The Stenosis Index was 0.6±0.1 in treated rabbits versus 2.3±0.2 in untreated (p<.0001).

CONCLUSION

The early placement of an intraesophageal tube with solid dilator prevents stenosis formation and does not produce greater tissue damage.