Corroded

Gastrointestinal System


Common Types of Corrosives Ingested

In children, ingestion of corrosive material is usually accidental; this is as opposed to adults, where corrosives are usually ingested with self-harm or suicide in mind.


The ingested chemicals can either be an acid, or an alkali, both of which have high corrosive potential.


Generally, alkaline substances tend to cause more damage to the esophagus, whereas acidic substances are known to cause more injury to the stomach.


Note that drain cleaner is often alkaline in nature, with sodium hydroxide a common component.

Clinical Presentation of Corrosive Ingestion

The clinical features of corrosive ingestion depend on several factors, including the nature of the substance (i.e. acidic vs. alkaline), as well as the amount ingested, physical form (i.e. liquid or solid) , and time of presentation (early or delayed).


Solid particles adhere to the mucosa of the mouth, making them difficult to swallow, thereby diminishing the injury to the esophagus, while simultaneously increasing the damage to the upper airway and pharynx.


Conversely, liquids are easily swallowed and are most likely to damage the esophagus and stomach; liquid substances may also spill on other parts of the body and clothing, causing injury to those areas as well.

Activated Charcoal

Administration of activated charcoal is contraindicated in patients who have ingested corrosive substances, as this will interfere with subsequent upper gasotrointestinal endoscopy.

Neutralizing Corrosives

Although it may seem logical to administer an acid to neutralise the caustic effect of an ingested alkaline substance, this should never be performed.


Not only can the neutralizing substance itself cause caustic damage to the normal tissue, but the resulting exothermic reaction will cause further damage to the already injured tissue.


Gastric lavage and induced emesis is also contraindicated, as this risks re-exposure of the esophagus to the offending substance.

Endoscopy in Corrosive Ingestion

Esophagogastroduodenoscopy is considered crucial in the workup of patients who have ingested corrosives; it is usually recommended in the first 12 to 48 hours following caustic ingestion, although it is safe and reliable up to 96 hours after the injury. Gentle insufflation and great caution are mandatory during the procedure.


Although there are records of endoscopy having been performed without consequences from 5 to 15 days following corrosive ingestion, it is considered potentially hazardous after 96 hours from the time of injury, due to tissue softening and friability during the healing period.


Adequate sedation (i.e. general anesthesia in children) is compulsory, yet endotracheal intubation is strictly required only in patients with respiratory distress.

Grading of Esophageal Injury

Endoscopic classification of caustic esophageal injury plays a crucial important role in the subsequent management. The current accepted classification is as follows:


Grade 0 - Normal

Grade 1 - Superficial mucosal edema and erythema

Grade 2 - Mucosal and submucosal ulcerations

Grade 2A - Superficial ulcerations, erosions, exudates

Grade 2B - Deep discrete or circumferential ulcerations

Grade 3 - Transmural ulcerations with necrosis

Grade 3A - Focal necrosis

Grade 3B - Extensive necrosis

Grade 4 - Perforation

CT imaging for the grading of Esophageal Injury

CT imaging has increasingly achieved recognition as a modality which offers a more detailed evaluation of the degree of transmural damage to the esophageal and gastric wall, and the extent of necrosis, as compared to early endoscopy.


CT is also more sensitive than endoscopy for the assessment of threatened or established stomach perforation.

Surgery in Esophageal Chemical Burns

Currently, the decision to perform emergency surgery is mainly based on endoscopic findings.


Esophagectomy is indicated in the event of perforation (Grade 4 caustic injury); this may also be be combined with a partial gastrectomy, depending on the degree of involvement of the stomach.


Note that there are concerns about the degree of correlation between endoscopic findings and the extent of necrosis; as many as 15% of esophagectomies in patients meeting the above criteria are eventually found to be unnecessary.

Proton-pump Inhibitors

While the efficacy of proton-pump inhibitors or H2-receptor blockers in minimizing esophageal injury by suppressing acid reflux is yet to be been proven, these are widely used in the treatment of corrosive injury.

Broad-spectrum Antibiotics

Administration of broad-spectrum antibiotics is mainly advised if respiratory tract involvement is identified; this is usually combined with corticosteroid therapy.

Steroids

The use of corticosteroids in the treatment of esophageal strictures is controversial; at the time of writing, studies have failed to find any benefit of steroid administration in terms of stricture prevention.


Thus, systemic steroids are currently reserved for patients with symptoms involving the airway.

When should doctors suspect child neglect?

Neglect is the persistent failure to meet a child's basic and essential needs.


Children require adequate food, water, shelter, protection and health care; inability to provide any of these can be considered to be child neglect.


While over-reporting child abuse and/or neglect has been identified as a problem, healthcare workers are advised to alert the authorities whenever they suspect a child is being abused or neglected.

Late Complications of Corrosive Ingestion

Esophageal strictures are the commonest, and most dreaded, late sequel of corrosive ingestion; they are more common in patients who have ingested powerful caustic substances (such as sodium hydroxide).


In most patients, these develop around 8 weeks following ingestion, but can occur as early as 3 weeks afterwards, or as late as 1 year after.


Other important late sequelae of corrosive gastrointestinal tract injury include intractable pain, gastric outlet obstruction, late achlorhydria, protein-losing gastroenteropathy, mucosal metaplasia, and development of carcinoma.

Treatment of Esophageal Strictures

In patients who have ingested corrosives, timely detection, evaluation, and dilatation of esophageal strictures plays a key role in achieving a good outcome.


Note that delayed management is usually associated with marked esophageal wall fibrosis and collagen deposition, making dilatation more complex.


Dilatation can be carried out with a balloon or bougies; neither method shows a clear advantage over the other.

Indications for Emergency Tracheostomy in Corrosive Ingestion

Caustic ingestion may result in severe respiratory complications such as laryngeal injury and upper airway edema, potentially necessitating tracheostomy; this is usually coupled with extensive esophageal damage.


The rate of lower airway and pulmonary involvement is usually low, probably due to the protective pharyngeal-glottic mechanism.


Note that laryngeal injuries can be diagnosed via flexible fiberoptic or rigid laryngoscopy.

Intraluminal Stenting

Specially designed silicone rubber stents have been found to be helpful in preventing stricture formation; unfortunately, the efficacy is less than 50%, with a high migration rate.


The development of hyperplastic tissue is a potential complication.


Note also that certain biodegradable stents (poly-L-lactide or polydioxanone) are currently under evaluation for use in patients with benign strictures.

Nasogastric tubes in individuals with a stricture

Enteral nutrition via a nasogastric tube has been shown to be as effective as jejunostomy feeding, for maintenance of nutrition in patients who have ingested corrosives.


However, this does not justify their indiscriminate use, especially if the patient is capable of tolerating normal enteral feeds.


In addition, while a nasogastric tube may be helpful in ensuring patency of the esophageal lumen, the tube itself can contribute to the development of long strictures; thus routine use in this regard is not recommended.


In addition, any esophageal catheterization may be a nidus for infection, while nasogastric tube placement may worsen gastroesophageal reflux, with a consequent delay in mucosal healing.

References

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  3. MOWRY JAMES B., SPYKER DANIEL A., CANTILENA LOUIS R., BAILEY J. ELISE, FORD MARSHA. 2012 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 30th Annual Report. Clinical Toxicology [online] 2013 December, 51(10):949-1229 [viewed 29 September 2014] Available from: doi:10.3109/15563650.2013.863906
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  8. PELCLOVá D, NAVRáTIL T. Do corticosteroids prevent oesophageal stricture after corrosive ingestion? Toxicol Rev [online] 2005, 24(2):125-9 [viewed 30 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16180932
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