Transcript PEBJC Virtual Colonoscopy

Management of
Corrosive Ingestion
Joint Hospital Grand Round
United Christian Hospital
Dr WN Fong
Background
Introduction
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Accidental - 80% children
Intentional - adolescents and adults
Extensive damage to aerodigestive tract
 Perforation
 Death
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Alkaline > Acid
Management is complicated ( young, psychotic,
suicidal and alcoholic)
Corrosive Agent
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Alkaline corrosives – pH
≧12
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Acid corrosive – pH <2
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Granular, paste and liquid
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Drain and over cleanser
Washing detergents
Cosmetic and soaps
Button batteries
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Toilet bowl cleansers
(sulfuric, HCl)
Antirust (HOCl, oxalic)
Battery fluid (sulfuric)
Swimming pool and slate
cleanser (HCl)
Corrosive Agent
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Mild Alkaline – pH 10.8 to 11.4
Sodium carbonate
 Ammonium hydroxide
 Bleaches ( sodium and calcium hypochlorid and
hydrogen peroxide)
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Pathogenesis and Pathology
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Degree of injury
Agent
 Concentration
 Quantity
 Physical state
 Duration of exposure
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Alkali
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Liquefaction necrosis
(potent solvent x
lipoprotein lining)
Thrombosis of adjacent
vessels
Heat production
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Acid
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Coagulation necrosis
Eschar formation
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Anatomical
Cricopharyngeal area
 Aortic arch
 Tracheal bifurcation
 Lower esophageal sphincter
 Antrum (fasting) / body (after meal)
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Consequence
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Short Term
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Mild mucosal erythema
Ulceration
Hemorrhage
Perforation (during first 2
weeks)
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Long Term
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Stricture formation
Gastric outlet obstruction
Shortening of esophagus
altered LES
Change in esophagus
motility
 GERD which accelerate
stricture formation
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CA esophagus
Clinical Features
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Oropharyngeal pain
Dysphagia with drooling
saliva
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Hoarsiness and stridor
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Dysphagia/ odynophagia
Retrosternal chest pain,
radiate to back
Hematemesis
Cervical emphysema
mediastinitis
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Epigastric pain
Retching
Emesis of tissue, blood or
coff ee ground material
peritonitis
Tachypnea,
Shock
Metabolic acidosis
coagulopathy
Management
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Acute Phase
Airway
 Fluid resuscitation
 Assess the severity of injury
 Emergency surgery
 Controversies : neutralization, use of steriod/
antibiotics
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Evaluation of Injury
Endoscopy
Radiography
Endoscopy
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Laryngoscopy
 Potential airway obstruction
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OGD
 Gold standard
 Within 12-24 hrs
 Should be avoid from D5 – D15 (risk of
perforation)
 Classification (I, IIa, IIb and III)
Classification of corrosive injury
Degree of Injury
I
Depth
Endoscopic
Findings
Superficial mucosal injury Mucosal hyperemia &
edema
IIA
Partial thickness injury –
patchy
Mucosal sloughing
Superficial ulcers
IIB
Partial thickness injury -
Deep ulcerations
III
Transmural injury
Periesophageal and/or
perigastric extension
circumferential
Eschar formation
Full thickness necrosis
Brownish black or gray
ulcers
Radiography
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Plain X-ray
CXR
 AXR
 Contrast radiography ie water-soluble or thin barium
 Double contrast CT if evidence of duodenum
abnormality
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Role of Surgery
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Acute Phase – emergency measure
Evidence of perforation
 Shock, acidosis, coagulopathy and who ingested large
amount of corrosive
 3rd degree burn on endoscopy
 Early surgical intervention may improve outcome in
grade 3 injury. Gastrointest Endosc. 91;37:165-169
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Controversy
Neutralization
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Absolute Contraindicate
Gastric lavage
 Induce vomiting
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Relative Contraindicate
Milk and water
 Activated charcoal
 Exothermic reaction and
 obscure subsequent endoscopy
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Steriod
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Animal study – decrease stricture formation
Human study – inconclusive
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Review of 13 publications – Howell
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Stricture significantly reduced in those with advance injury receiving
steriod
RCT – Anderson KD
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Am J Emerg Med 1992;10:421-5
N Eng J Med 1990;323:637-640
steriod do not prevent stricture
Recommend dose
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30-40mg methyl prednisolone or dexamethasone 1mg/kg/day
Duration : > 3 weeks
Antibiotics
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No clear data support its use
No RCT in human avaliable
Consensus :
Antibiotics should be given in patient treated with
steriod
 Otherwise antibiotics is not advocated
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Acid Suppression
Esophageal shortening
 altered LES
 Esophageal dysmotility
 GERD – accelerate stricture formation
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Flowchart – Managment of caustic ingestion
Acute
Caustic Ingestion
Severe Injury
Unknown agent
Suicidal intent
Mild Exposure
Bleach
Detergent
Airway evaluation
Resuscitation
Plain films
Perforation
Immediate
Resection
Symptoms
No Symptoms
No Perforation
Deterioration
 Laparoscopy
Discharge
Follow up
Full thickness
(grade IIb or III)
Mild injury
Grade I – 24hrs obs
Grade II – 28hrs obs
TPN
Antibiotics
 Steriod
NPO or
Clear fluid
Case Series
United Christian Hospital
July 03’ – June 04’
Patie Endosco Intervention
pic
nt
grade
Grade 1
OGD
1
Tracheosto Outcome
my
N
Good
2
Grade 2
OGD
Tracheostomy
Steriod
Y
good
3
Grade 3
OGD
trachesotomy
Transhiatal esophagectomy
+ total gastrectomy +
feeding j + esophagostomy
Y
Plan for esophageal reconstruction with
colonic interposition
4
Grade 2b
OGD
Tracheostomy
Total gastrectomy + feeding
j + esophagostomy
Y
OGD – no stricture ( 2 months)
Reconstruction : esophago-jejunostomy
Patien Endosco Intervention
t
pic
grade
Grade 3
OGD
5
Trachesotomy
Tracheosto Outcome
my
Y
Death
Y
Plan for reconstruction in QMH
6/12 later
Transhiatal esophagectomy +
esophagostomy
Total gastrectomy
Whipple operation
Splenectomy
6
Grade 4
OGD
Total gastrectomy + esophagostomy,
duodenostomy
Bring Home Message
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Airway
Early endoscopy is indicated
Surgery ??
 Magnitude of surgery ??
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Early surgical intervention may decrease
mortality
Thank You