11.2.2005

Dr. Uday C Ghoshal MD, DNB, DM, FACG, Rome Foundation Fellow

Professor, Department of Gastroenterology, SGPGI, Lucknow, India

PanelistsDr. M.L. Thakur, Dr. A. Chaudhary, Dr. S.A. Zargar, Dr. S.K.Sinha, Dr. Ashish

Kumar Jha, Dr. K. Mohandas, Dr. Sandeep Nijhawan

• Corrosive ingestion: A major public health issue1

• Age: Common in children (80%), accidental

• Adult: Commonly suicidal, often life-threatening

Type of ingestion2

• Western country: Most common substance is alkali

• India: Acids commoner (HCl & H2SO4, easy access)

Introduction

1.Bull World Health Organ 2009; 87: 950-954 2. Zargar SA et al, Gastroenterology 1989;97:702-707

Male, 30 y• H/O ingestion of toilet cleaning acid 6 hrs ago presented with

– Oropharygeal pain

– Increased salivation

– Dysphagia

– Odynophagia

• No history of

– Chest pain

– Epigastric pain

– Vomiting or hematemesis

• Examination

– Oral and pharyngeal mucosal burns

– Systemic examination: WNL

Case Scenario 1

Relationship between perioral & esophageal injury?

A. Such perioral injury is usually associated with severe esophageal injury

B. Such situation is related to less severe internal injury

C. There is no relationship between these two

D. Don;t know

Most commonly ingested caustic substances?

Lye: broad term used for strong alkali

Class Types Commercially available forms

Acids Sulfuric acid Batteries, industrial cleaning agents, metal plating

Oxalic acid Paint thinners, strippers, metal cleaners

Hydrochloric acid Solvents, metal cleaners, toilet and drain cleaners, antirust compounds

Alkali Sodium hydroxide Drain cleaners, home soap manufacturing

Potassium hydroxide Oven cleaners, washing powders

Sodium carbonate Soap manufacturing, fruit drying on farms

Ammonia Commercial ammonia Ammonium hydroxide

Household cleaners, household cleaners

Detergent, bleach Sodium hypochloriteSodium polyphosphate

Household bleach, cleaners, industrial detergents

Differences between alkalis and acids?

Zargar et al, Gastroenterology,1989;97:702-7

Marks IN et al, The natural history of corrosive gastritis: Am J Dig Dis 1963;8:509-24

Alkalis Acids

Ph >7 <7

Amount that can be ingested

Larger as these are tasteless and odorless

Lesser as odor is pungent and taste noxious

Depth of injury Deeper due to liquefactive necrosis and direct extension

Limited due to formation of a coagulum layer

Associated gastric injury More common Less common

Acids "lick oesophagus and bite the pyloric antrum", whereas the opposite situation results from alkaline ingestion

Zargar et alGastroenterology

1989

Broor et alGut1993

Broor et alGIE

1995

Poddar et alGIE

2001

Kochhar et alGIE

2002

Number 41 52 21 54 29

M:F 2:1 3:2 1:1 3:1 1:1

Acid 41 32 11 34 12

Alkali 0 14 10 20 17

Mean age(Years)

26 26.4 21.6 4.8± 3.4 29.3 ± 8.6

Indian studies

Caustic exposure

Necrosis

Ulceration

Fibrosis

Stricture

Carcinoma

Seconds

24-72 hours

14-21 days

Weeks-years

Decades

Perforation

Consequences of caustic injury over time?

Corrosive injury: clinical spectrum?

Zargar et al,Gastroenterology:1989;97,702-7

Clinical features Number of patients (n=41)

Oropharyngeal 30

Pain 30

Salivation 15

Laryngeal edema 2

Esophageal 27

Dysphagia 23

Odynophagia 14

Chest pain 7

Gastric 17

Epigastric pain 10

Vomiting 14

Retching 9

Hoarseness & stridor: Suggest laryngeal & epiglottic invovementDysphagia & odynophagia: Suggest esophageal involvementEpigastric pain & bleeding: Gastric involvement

Issues

• Acute management

• Gastric lavage and emesis

• Neutralization by acid or alkali

• Nasogastric tube placement

• Role of PPIs and H2 blockers

• Role of endoscopy

• Management algorithm

Case Scenario 1

UGI endoscopy following corrosive ingestion

A. Such perioral injury is usually associated with severe esophageal injury

B. Such situation is related to less severe internal injury

C.There is no relationship between these two

D.Don;t know

• Priority Airway, Breathing and Circulation (ABC)

• In unstable airway Intubation under fiberoptic laryngoscopy Tracheostomy may be required

• Gastric lavage Contraindicated

• Milk & water As antidotes or to dilute corrosive is not proven

• pH neutralization Not recommended (fear of exothermic reaction, which may increase the damage)

Corticosteroids: In patients with respiratory involvement, who should also receive broad spectrum antibiotics

Acute management?

• Routine use of NG tube: not recommended

• Best approach: NG tube placement should be individualized

Nasogastric tube

Advantage: Disadvantage:

Helpful to ensure patency of esophageal lumen

Itself leads to long stricture

Providing a lumen for dilatation of tight stricture

Nidus for infection

Worsening of gastroesophageal reflux

Delay in mucosal healing

Ramasamy K et al, J Clin Gastroenterol 2003; 37: 119-124

Kochhar R et al, Gastrointest Endosc 2009; 70: 874-880

• Efficacy of PPI and H2 blockers in minimizing esophageal injury by suppressing acid reflux: Not proven

• Cakal et al (Turkey)• Prospective cohort study• 13 patients (>18 years age)• May 2010 and June 2010

• Mucosal damage graded with Zargar grading• Given IV Omeprazole 80mg followed be 8mg/hr for 72 hours• Repeat UGIE after 72 hours and endoscopic healing was compared

Role of PPIs & H2 blockers?

Cakal B et al. Dis Esophagus 2013; 26: 22-26

Investigations in acute phase: CXR/AXR?

Investigations in acute phase: CT Scan?

Grade Features

Grade 1 No definite swelling of esophageal wall

Grade 2Edematous wall thickening without periesophageal soft tissue involvement

Grade 3

Edematous wall thickening with periesophageal soft tissue infiltration plus well-demarcated tissue interface

Grade 4

Edematous wall thickening with periesophageal soft tissue infiltration plus blurring of tissue interface or localized fluid collection around the esophagus or descending aorta

Contini S. World J Gastroenterol 2013 ; 19: 3918-30

A.Should be avoided as it does not have much

clinical utility

B.Should be done only during a period between 4

days and 7 days after ingestion

C.Should be done within 4 days

D.It only helps in prediction of prognosis but not

treatment

Endoscopy immediately following corrosive ingestion

• Cornerstone for diagnosis

• Usual recommendation1: within first 12-48 h

• Relatively safe and reliable up to 96 h2

(gentle insufflation and great caution are mandatory)

• Adequate sedation (general anaesthesia in children) is compulsory

• Endotracheal intubation: Strictly required for respiratory distress

• Contraindications: Perforation, severe supra-glottic or epiglottic burn

Endoscopy

1.Poley JW et al, Gastrointest Endosc 2004; 60: 372-3772. Previtera C et al, Pediatr Emerg Care 1990;6: 176-178

3. Tiryaki T et al, Pediatr Surg Int 2005; 21: 78-80

Endoscopic classification: Zargar’s classification

Zargar SA et al, Gastrointestinal Endosc 1991; 37: 165-169

Grade Features0 Normal

1 Superficial mucosal edema & erythema

2 Mucosal & submucosal ulceration

2 A Superficial ulceration, erosion, exudate

2 B Deep discrete or circumferential ulcer

3 Transmural ulceration with necrosis

3 A Focal necrosis

3 B Extensive necrosis

4 Perforation

Degree of injury

Number(total 81)

Complications Need for surgery

DeathsEarly Late

Grade 0 7 0 0 0 0

Grade 1 10 0 0 0 0

Grade 2a 19 0 0 0 0

Grade 2b 14 Minor bleed: 2 Stricture:10 0 0

Grade 3 31 Major bleed: 6Minor bleed: 3Perforation: 3Tracheo-esophageal fistula: 1

Stricture: 26

25-67% 4

Corrosive injury: grading and prognosis

Zargar SA et al, Gastrointestinal Endosc 1991; 37: 165-169

Management algorithm

25 Y male

• H/O ingestion of corrosive 4 months ago

• Dysphagia for solids X 1 month

• No history of vomiting or hematemesis

• Examination: WNL

• UGIE: Stricture at 25 cm, scope could not

be negotiated beyond

• Barium swallow: Shown

Case Scenario 2

Incidence of stricture:1,2

•Overall- 26%-55%•Grade 2B- 71%•Grade 3- 100%

•Time period- 80% strictures within 8 week2

(but can occur as early as 3 week to as late as after 1 year)

•Ingestion of powerful caustic substances (e.g. NaOH): Severe, long-standing strictures Dramatically altered esophageal motility

Corrosive stricture

1.Zargar SA et al, Gastrointestinal Endosc 1991; 37: 165-1692.Kay M et al, Curr Opin Pediatr 2009; 21: 651-654

• Timely evaluation & dilatation: central role in achieving better

outcome

• Dilatation should be avoided from 5-21 d (high risk of perforation)

• More number of sessions needed than non corrosive strictures

• Target: At regular intervals until a lumen size of 15 mm with

complete amelioration of dysphagia (adequate dilatation)

• Afterwards, dilation repeated whenever dysphagia recurs

• Perforation rate: 0.4-32%

Endoscopic dilatation for corrosive stricture: When & how?

Doğan Y et al, Clin Pediatr (Phila) 2006; 45: 435-438Panieri E et al, Pediatr Surg Int 1998; 13: 336-340

Dilators

• There are several different types: of dilators, including –Mercury-filled, rubber Maloney dilators–Wire-guided rigid Savary-Gilliard dilators–Balloon dilators that can either be through-the-sco

pe (TTS) or wire guided –Savary bougies: More reliable than balloon

dilators in consolidated and fibrotic strictures (such as old caustic stenosis or long, tortuous strictures)

Predictors of refractory corrosive stricture?

• Long stricture• Complex stricture • Delayed initiation of treatment• Dilation with balloon rather than with SG dilator• Thick esophageal wall on CT scan or EUS

Dilation: Early or late?

Costini S et al, Dig Liver Dis. 2009;41:263-268

Role of EUS & CT in prediction of outcome of corrosive esophageal injury

Chiu MH et al, Am J Gastroenterol 2004; 99: 851-854

How to augment result of endoscopic dilation?

• Nd-YAG LASER• Intra-lesional injection with various substances• Prosthesis placement• Endoscopic stricture incision

• Utility of corticosteroid: controversial

• Meta-analysis: No benefit for stricture prevention

• Systemic administration of steroids: ineffective(especially in grade 3

corrosive injury)

• Intra-lesional triamcinolone injections have been proposed to

prevent strictures, but optimal dose, frequency, and best application

techniques are still to be defined

• Triamcinolone: prevents cross-linking of collagen

Role of steroids in prevention & management of corrosive stricture

Systematic pooled analysis of 50 years of human data: 1956-2006.Clin Toxicol (Phila) 2007

Siersema PD et al, Gastrointest Endosc 2009; 70:1000-1012

Methods:

•N:71 (mean age 42.39 yrs; range, 13-78 yrs) with benign esophageal

strictures (corrosive 29, peptic 14, anastomotic 19, radiation-induced 9)

•All were managed: Endoscopic dilation (by using over-the-wire polyvinyl

dilators) & intra lesional triamcinolone injection

•At each session – 4 injections (4 quadrants) at proximal margin of stricture

and another 4 injections into strictured segment

• Intervals, & frequency of dilations and Periodic dilation index (number of dilations required/per month) were calculated before and after injections

Results: Mean number of sessions of injection: 1.4 (0.62)

Intra lesional triamcinolone augment the effects of dilation in benignesophageal strictures

Before injection After injection

Mean duration of treatment (month) 10.9 (range 1-120) 8.1(range 3-30)

Mean number of dilatation required 9.67(range 1-70) 3.8(range 1-16)

Periodic dilatation index 1.24(range 0.13-3.16) 0.5(range 0-2)

Periodic dilation index (dilation needed/mo) in relation to etiology of benign stricture

Kochhar R. Gastrointest Endosc 2002;56:829-34.

•Chemotherapeutic agent with DNA crosslinking activity

•Valuable in preventing strictures (either injected/ topically)

•Deleterious adverse effects (due to systemic absorption)

•Risk of secondary long term malignancy

•A recent systematic review: encouraging results in the long term

•Prospective studies are clearly mandatory to determine the most effective

concentration, duration and frequency of application

Mitomycin C for corrosive stricture

Berger M et al Eur J Pediatr Surg. 2012 Apr;22(2):109-16

•Introduction: • The topical application of Mitomycin C to the site of stricture: limited study

Systematic review in persistent esophageal stricture

Method and Results: •11 publications including 31 cases•Underlying cause of stricture: Caustic ingestion-19 (61.2%), esophageal surgery-7 (22.6%) and others-5 (16.2%)•Median age: 48 months (range 4 -276 months)

•In majority cases: Cotton soaked in solution applied endoscopically •Application: 1 to 12 times within intervals from 1 to 12 weeks

Mitomycin C in the therapy of recurrent esophageal strictures

Berger M et al Eur J Pediatr Surg. 2012 Apr;22(2):109-16

•Concentrations of Mitomycin C: Varied considerably (0.1-1 mg/Ml)•Mean follow-up- 22 months (range 6-60 months) Complete relief- 21 (67.7%) Partial relief- 6 (19.4%) No response- 4 •No adverse effects were reported

Conclusions:•The short-term results of topical Mitomycin C for refractory esophageal

stricture: Encouraging

•Prospective studies are mandatory to determine the optimal time points, dosage, and modalities of treatment before a recommendation

Mitomycin C in the therapy of recurrent esophageal strictures

Role of stents in corrosive stricture

• Design: Silicone rubber stent or Polyflex stents

• Helpful in preventing stricture formation, but efficacy < 50% with a

high migration rate (25%)

• Patient selection: challenging with concern of hyperplastic tissue • Home-made poly-tetra-fluoroethylene stents: 72% efficacy at 9-14

month, similar to home-made silicone stents

Corrosive stricture: prevention and management

Broto J et al, J Pediatr Gastroenterol Nutr 2003; 37: 203-206 Atabek C et al, J Pediatr Surg 2007; 42:636-640

• Success rate - 45% at 53 months• Migration rate - 10%• Significant hyperplastic tissue response

• Stent integrity & radial force maintained for 6-8 weeks (pH dependent)• Stent degradation occurs in 11-12 weeks (pH dependent)• No need for removal procedure

• Issues: Cost

Limited experience

Biodegradable stents (poly-L-lactide or polydioxanone)

Tokar JL et al , Gastrointest Endosc 2011; 74: 954-958 Repici A et al , Gastrointest Endosc 2010; 72: 927-934

Approved stents

Yim HB. Annals Palliative Medicine 2014; 3.

F, 30 y

• Consultation received from Surgical Gastroenterology for a patient with

dysphagia

• History of corrosive ingestion in an attempt for suicide 2 y ago

• Barium swallow then revealed long esophageal stricture with severe

gastric injury

• Underwent surgical management for the stricture with colon inter-

position

Case Scenario 3

Barium swallow and meal

A.Dilation with SG dilator is a safe option

B.TTS balloon is a safe option

C.Neither of these is safe

D.This is an absolute indication in which both

esophageal and gastric lesion should be

treated surgically

Endoscopic esophageal dilation in patients with co-existing cicatrizing gastric injury

F, 30 y

• Currently, recurrent dysphagia

• Esophagogastroduodenoscopy: Anastomotic stricture

• Examination: Poorly nourished, Pallor++

• Anemia- not responding to oral iron

• How to manage?

Case Scenario 3 (Contd.)

Work-upHb 7.4 Gm %MacrocyticNormal Iron profileMCV 112 FlS. Vitamin B12- 80 pg/ml

Follow-up

Late complication of corrosive ingestion: Esophageal cancer

• Incidence: 2-30% after 1-3 decades• Shortest time 1 y after ingestion• Some studies overestimated?• Both adenocarcinoma & squamous cell carcinoma• In strictured segement• Bypass surgery does not prevent• Endoscopic screening recommended

Conclusions

• Corrosive ingestion, particularly of acids, is common in India

• Early endoscopy is helpful in prognostication

• Acute management is important for outcome in severe injury

• Late outcome of esophageal stricture can be managed by endoscopic dilation

• There are novel methods to manage refractory stricture

• Surgical management play important role both in early and late stages