Transcript Think before you drink

Joint Hospital Surgical Grand Round
Dr. WH She
Queen Mary Hospital
52/M
 Bipolar and delusional disorder
 Drank unknown amount of self made cocktail
 Strong acidic solution, pH < 2
 Coca Cola
 Complained of dysponea and epigastric pain
 Physical examination
 Tachycardia
 Tenderness and guarding over epigastrium
 Resuscitated and intubated
 Blood results
 Metabolic acidosis (pH 7.2, HCO3 -13 mmol/L, base
excess -14 mmol/L)
 Acute renal failure (201 umol/L)
 Raised AST level (252 U/L)
 Chest X-ray – no abnormality detected
 Upper endoscopy
 Gangrenous appearance of the esophageal and gastric
mucosa, distally to duodenum
Laparotomy
 Findings
 Full thickness gangrene of stomach with fundal
perforation
 Esophagus

Mucosal gangrene, spare muscle and adventitia
 Duodenum


1st part gangrenous changes
Some involvement of 2nd part
 Patches fat necrosis at pancreatic tail
 Proximal jejunum normal
 Procedures
 Total gastrectomy, distal exclusion of esophagus, feeding
jejunostomy and tracheostomy
 Post operative period
 Remained critical and septic
 Further laparotomies
 Findings


Pancreatic necrosis
Perforated esophageal and duodenal stumps
 Procedures


Pancreatic necrosectomy
Esophageal drain and controlled duodenostomy
Caustic ingestion
 Accidental
 Usually in children
 Intentional
 Usually adults
 Higher concentration
 Larger amount
 More severe
Gumaste VV et al. Am J Gastroenterol 1992
Schaffer SB et al. J La State Med Soc 2000
Satar S et al. Am J Ther 2004
Mckenzie LB et al. Pediatrics 2010
 pH < 3 or > 11
 Extent of injury
 Type of agent
 Concentration
 Quantity
 Physical form
 Duration of contact
Acid
 Lick the esophagus and bite the pyloric antrum
 Coagulation necrosis
 Eschar formation, prevent deeper tissue penetration
Estrera A et al. Ann Thorac Surg 1986
Gumaste VV et al. Am J Gastroenterol 1992
Ertekin C et al. Hepatogastroenterology 2004
Acid
 Pool in stomach
 Pyloric spasm
 Gastric perforation and stricture
Schaffer SB et al. J La state Med Soc 2000
Kochhar R. et al. J Gastroenterol Hepatol 2004
Tohda G et al. Surg Endosc 2008
 Example
 Hydrochloric acid, sulphuric acid
 Toilet bowl cleaners or swimming pool cleaners
Alkaline
 Highly viscous, longer duration of contact
 More uniformly severe mucosal injury to esophagus
 Liquid form
 More distal injuries
 Solid form
 Adhere to mucosa of mouth, upper airway and
esophagus
 Spare stomach
Schaffer SB et al. J La State Med Soc 2000
Alkaline
 Liquefactive necrosis
 Denaturation of proteins and collagen
 Sponification of fats
 Dehydration of tissues
 Thrombosis of blood vessels
 Example
 Drain cleaners
 Hair relaxers
 Detergents
 Disk batteries
Schaffer Sb et al. J La State Med Soc 2000
Ertekin C et al. Hepatogastroenterology 2004
Acute problems
 Laryngeal spasm, edema
 Perforation
 Upper gastrointestinal bleeding
 Acute pancreatitis
 Death
 Tracheoesophageal fistula
 Aorto-enteric fistula
Chronic problems
 Esophageal stricture
 Gastric outlet obstruction
 Esophageal carcinoma
Management
 Resuscitation
 Endoscopy
 Conservative management
 Operative management
Zwischenberger JB et al. Am J Respir Crit Care Med 2001
Endoscopy
 Classification by Zargar
0
Normal findings
1
Edema, hyperaemia of mucosa
2a
Friability, blisters, haemorrhaging, erosions, whitish
membranes, exudates, and superficial ulcerations
2b
Deep discrete or circumferential ulcerations in addition to
grade 2a
3a
Small scattered areas of multiple ulcerations and area of
necrosis (brown-black or grayish discoloration)
3b
Extensive necrosis
Zargar SA et al. Gastroenterology 1989
Zargar SA et al.Gastrointest Endosc 1991
Zargar SA et al. Am J Gastroenterol 1992
Grade 1
Grade 2a
Grade 2b
Grade 3
Endoscopy
 Timing of upper endoscopy
 No consensus yet
 Early endoscopy
 First 24 hours


Assess the severity and extent of injury
Risk of perforation
Ramasamy K et al. J Clin Gastroenterol 2003
Tohda G Et al. Surg Endosc 2008
Cheng HT et al. BMC Gastroenterol 2008
Celik B et al. Dis Esophagus 2009
Endoscopy
 Unable to assess the depth of lesion
 Despite concomitant use of endoscopic ultrasound
Kirsh MM et al. Ann Thorac Surg 1976
Chiu HM et al. Gastrointest Endosc 2004
Three phases of tissue injury from
alkaline ingestion
Phase Tissue injury
Onset
Duration
Inflammatory response
1
Acute necrosis 1-4days
1-4days
Coagulation of intracellular
proteins inflammation
2
Ulceration
and
granulation
3-5days
3-12days
Tissue sloughing
Granulation of ulcerated tissue
bed
3
Cicatrization
and scarring
3 weeks
1-6months Adhesion formation scarring
Conservative management
 Clinically stable without peritonitis
 Usually for Zargar’s grade I and II
 Grade III injury in the absence of clinical and
biological signs of severity
 Low mortality rate
Zerbib P et al. Ann Surg 2011
Operative management
 Clinically unstable or signs of perforation
 Aim
 Resect the necrotic tissues
 Prevent extension of the injury to the adjacent organs


Delayed presentation or operation
Massive ingestion of strong corrosive agents
Cattan P et al. Ann Surg 2000
 Esophago-gastrectomy, cervical esophagostomy and
feeding jejunostomy
 High mortality rate
 Pancreatoduodenectomy
 Extensive duodenal necrosis
 Reconstruction
 Stable, and survive from complications
Sarfati E et al. Br J Surg 1987
Cattan P et al. Ann Surg 2000
Use of nasogastric tube
 Controversial
 For
 Decrease incidence of stricture formation and allowed
nutritional support
Ramasamy K et al. J Clin Gastroenterol 2003
Atabek C et al. J Pediatr Surg 2007
Use of nasogastric tube
 Against
 Long term indwelling N/G insertion would cause long
strictures of the esophagus
Gumaste VV et al. Am J Gastroenterol 1992
Ramasamy K et al. J Clin Gastroenterol 2003
Use of steroid
 Debatable
 For
 Decrease strictures
 Dosage matters
Howell JM et al. Am J Emerg Med 1992
Mamede RC et al. Dis Esophagus 2002
Pelclova D et al. Toxicol Rev 2005
Use of steroid
 Against
 Risk of the use of steroids
 Randomized trial
 No difference
 Small sample size
Anderson KD et al. N Engl J Med 1990
 Meta-analyses
 No difference
Pelclova D et al. Toxicol Rev 2005
 19% (steroid treated group) vs 40% rate of stricture
Ramasamy K et al. J Clin Gastroenterol 2003
Outcome
 Depends on
 Amount of caustic substances ingested
 Severity of injury
 Clinical status
Our patient
 Unknown amount of caustic substances ingestion
 Clinically unstable
 Metabolic acidosis
 Acute renal failure
 Endoscopic Zargar’s grade IIIb
 Upper airway injury
 Esophageal necrosis
 Gastric perforation
 Duodenal involvement
 Poor biochemical predicting factors
 pH < 7.2
 Base deficit > 16 mmol/L
 Two fold increase of serum AST
Chou SH et al. World J Surg 2010
Conclusions
 Difficult to manage
 High morbidities and mortality
 Early recognition of the type, amount and duration of
caustic ingestion
 Decision on appropriate investigations and treatments
Acknowledgement
 Prof. S Law
 Dr. D Tong