Management of Management of Corrosive Corrosive IngestionIngestion

Joint Hospital Grand RoundJoint Hospital Grand RoundUnited Christian HospitalUnited Christian Hospital

Dr WN FongDr WN Fong

BackgroundBackground

IntroductionIntroductionAccidental - 80% children Accidental - 80% children Intentional - adolescents and adultsIntentional - adolescents and adults

Extensive damage to aerodigestive tract Extensive damage to aerodigestive tract PerforationPerforation DeathDeath

Alkaline > AcidAlkaline > Acid Management is complicated ( young, pManagement is complicated ( young, psychotic, suicidal and alcoholic)sychotic, suicidal and alcoholic)

Corrosive AgentCorrosive Agent Alkaline corrosives Alkaline corrosives

– pH – pH ≧12≧12 Granular, paste and Granular, paste and

liquidliquid Drain and over Drain and over

cleansercleanser Washing detergentsWashing detergents Cosmetic and soapsCosmetic and soaps Button batteriesButton batteries

Acid corrosive – pH Acid corrosive – pH <2<2 Toilet bowl cleanserToilet bowl cleansers (sulfuric, HCl)s (sulfuric, HCl) Antirust (HOCl, oxaliAntirust (HOCl, oxalic)c) Battery fluid (sulfuriBattery fluid (sulfuric)c) Swimming pool and Swimming pool and slate cleanser (HCl)slate cleanser (HCl)

Corrosive AgentCorrosive Agent Mild Alkaline – pH 10.8 to 11.4Mild Alkaline – pH 10.8 to 11.4

Sodium carbonateSodium carbonate Ammonium hydroxideAmmonium hydroxide Bleaches ( sodium and calcium hypochlorBleaches ( sodium and calcium hypochlorid and hydrogen peroxide)id and hydrogen peroxide)

Pathogenesis and Pathogenesis and PathologyPathology

Degree of injuryDegree of injury AgentAgent ConcentrationConcentration QuantityQuantity Physical statePhysical state Duration of exposureDuration of exposure

AlkaliAlkali Liquefaction Liquefaction

necrosis (potent necrosis (potent solvent x solvent x lipoprotein lining)lipoprotein lining)

Thrombosis of Thrombosis of adjacent vesselsadjacent vessels

Heat productionHeat production

AcidAcid Coagulation necrosisCoagulation necrosis Eschar formationEschar formation

AnatomicalAnatomical Cricopharyngeal areaCricopharyngeal area Aortic archAortic arch Tracheal bifurcationTracheal bifurcation Lower esophageal sphincterLower esophageal sphincter Antrum (fasting) / body (after meal)Antrum (fasting) / body (after meal)

ConsequenceConsequence Short TermShort Term

Mild mucosal erytheMild mucosal erythemama UlcerationUlceration HemorrhageHemorrhage Perforation (during fPerforation (during first 2 weeks)irst 2 weeks)

Long TermLong Term Stricture formationStricture formation Gastric outlet Gastric outlet

obstructionobstruction Shortening of Shortening of

esophagus altered esophagus altered LESLES

Change in esophagus Change in esophagus motilitymotility GERD which accelerate GERD which accelerate

stricture formationstricture formation CA esophagusCA esophagus

Clinical FeaturesClinical Features Oropharyngeal painOropharyngeal pain Dysphagia with drooling Dysphagia with drooling salivasaliva Hoarsiness and stridorHoarsiness and stridor Dysphagia/ odynophagiDysphagia/ odynophagiaa Retrosternal chest pain, Retrosternal chest pain, radiate to backradiate to back HematemesisHematemesis Cervical emphysemaCervical emphysema mediastinitismediastinitis

Epigastric painEpigastric pain RetchingRetching Emesis of tissue, blood Emesis of tissue, blood or coff ee ground materor coff ee ground materialial peritonitisperitonitis Tachypnea, Tachypnea, ShockShock Metabolic acidosisMetabolic acidosis coagulopathycoagulopathy

Management Management

Acute PhaseAcute Phase AirwayAirway Fluid resuscitationFluid resuscitation Assess the severity of injuryAssess the severity of injury Emergency surgeryEmergency surgery Controversies : neutralization, use of steriControversies : neutralization, use of steriod/ antibioticsod/ antibiotics

Evaluation of Evaluation of InjuryInjuryEndoscopy Endoscopy

RadiographyRadiography

EndoscopyEndoscopy LaryngoscopyLaryngoscopy

Potential airway obstructionPotential airway obstruction OGDOGD

Gold standardGold standard Within 12-24 hrsWithin 12-24 hrs Should be avoid from D5 – D15 (risk Should be avoid from D5 – D15 (risk of perforation)of perforation) Classification (I, IIa, IIb and III)Classification (I, IIa, IIb and III)

Classification of Classification of corrosive injurycorrosive injury

Degree of Degree of InjuryInjury

DepthDepth Endoscopic FinEndoscopic FindingsdingsII Superficial mucosal Superficial mucosal

injuryinjuryMucosal hyperemia Mucosal hyperemia & edema& edema

IIAIIA Partial thickness Partial thickness injury – injury – patchypatchy

Mucosal sloughingMucosal sloughingSuperficial ulcersSuperficial ulcers

IIBIIB Partial thickness Partial thickness injury - injury - circumferentialcircumferential

Deep ulcerationsDeep ulcerations

IIIIII Transmural injuryTransmural injuryPeriesophageal and/Periesophageal and/or perigastric extensor perigastric extensionion

Eschar formationEschar formationFull thickness necroFull thickness necrosissisBrownish black or gBrownish black or gray ulcersray ulcers

RadiographyRadiography Plain X-rayPlain X-ray

CXRCXR AXRAXR Contrast radiography ie water-soluble or tContrast radiography ie water-soluble or thin bariumhin barium Double contrast CT if evidence of duodenDouble contrast CT if evidence of duodenum abnormalityum abnormality

Role of SurgeryRole of Surgery Acute Phase – emergency measureAcute Phase – emergency measure

Evidence of perforationEvidence of perforation Shock, acidosis, coagulopathy and who inShock, acidosis, coagulopathy and who ingested large amount of corrosivegested large amount of corrosive 33rdrd degree burn on endoscopy degree burn on endoscopy Early surgical intervention may improve oEarly surgical intervention may improve outcome in grade 3 injury. utcome in grade 3 injury. Gastrointest Endosc. 91;37:Gastrointest Endosc. 91;37:165-169165-169

ControversyControversy

NeutralizationNeutralization Absolute ContraindicateAbsolute Contraindicate

Gastric lavage Gastric lavage Induce vomitingInduce vomiting

Relative ContraindicateRelative Contraindicate Milk and waterMilk and water Activated charcoalActivated charcoal Exothermic reaction and Exothermic reaction and obscure subsequent endoscopyobscure subsequent endoscopy

SteriodSteriod Animal study – decrease stricture formationAnimal study – decrease stricture formation Human study – inconclusive Human study – inconclusive

Review of 13 publications – Review of 13 publications – Howell Howell Am J Emerg Med 1992;Am J Emerg Med 1992;10:421-510:421-5 Stricture significantly reduced in those with advance injuStricture significantly reduced in those with advance injury receiving steriodry receiving steriod

RCT – RCT – Anderson KDAnderson KD N Eng J Med 1990;323:637-640N Eng J Med 1990;323:637-640 steriod do not prevent stricturesteriod do not prevent stricture

Recommend doseRecommend dose 30-40mg methyl prednisolone or dexamethasone 1mg/kg/30-40mg methyl prednisolone or dexamethasone 1mg/kg/dayday Duration : > 3 weeksDuration : > 3 weeks

AntibioticsAntibiotics No clear data support its useNo clear data support its use No RCT in human avaliableNo RCT in human avaliable Consensus : Consensus :

Antibiotics should be given in patient treaAntibiotics should be given in patient treated with steriodted with steriod Otherwise antibiotics is not advocatedOtherwise antibiotics is not advocated

Acid SuppressionAcid Suppression Esophageal shortening Esophageal shortening altered LESaltered LES Esophageal dysmotilityEsophageal dysmotility GERD – accelerate stricture formationGERD – accelerate stricture formation

Flowchart – Managment of caustic ingestionFlowchart – Managment of caustic ingestionAcute

Caustic Ingestion

Severe InjuryUnknown agentSuicidal intent

Mild ExposureBleach

Detergent

No PerforationPerforation

Airway evaluationResuscitation

Plain films No SymptomsSymptoms

Mild injuryGrade I – 24hrs obsGrade II – 28hrs obsFull thickness(grade IIb or III)

TPNAntibiotics Steriod

NPO orClear fluid

ImmediateResection

DischargeFollow up

Deterioration Laparoscopy

Case SeriesCase SeriesUnited Christian HospitalUnited Christian Hospital

July 03’ – June 04’July 03’ – June 04’

PatiePatientnt

EndoscEndoscopicopicgradegrade

InterventioInterventionn

TracheostTracheostomyomy OutcomeOutcome

1 1 Grade 1 OGD N Good

2 2 Grade 2 OGDTracheostomySteriod

Y good

3 3 Grade 3 OGDtrachesotomyTranshiatal esophagectomy + total gastrectomy + feeding j + esophagostomy

Y Plan for esophageal reconstruction with colonic interposition

4 4 Grade 2b OGDTracheostomyTotal gastrectomy + feeding j + esophagostomy

Y OGD – no stricture ( 2 months)Reconstruction : esophago-jejunostomy

PatiePatientnt

EndoscEndoscopic opic gradegrade

InterventionIntervention TracheostTracheostomyomy OutcomeOutcome

55 Grade 3 OGDTrachesotomyTranshiatal esophagectomy + esophagostomyTotal gastrectomyWhipple operationSplenectomy

Y Death

66 Grade 4Grade 4 OGDOGDTotal gastrectomy + esophagoTotal gastrectomy + esophagostomy, duodenostomystomy, duodenostomy

YY Plan for reconstruction Plan for reconstruction in QMH 6/12 laterin QMH 6/12 later

Bring Home MessageBring Home Message AirwayAirway Early endoscopy is indicatedEarly endoscopy is indicated

Surgery ??Surgery ?? Magnitude of surgery ??Magnitude of surgery ??

Early surgical intervention may decreaEarly surgical intervention may decrease mortalityse mortality

Thank YouThank You