Esofagitis korosif

Epidemiology

• Incidence: 5000-15000 / Yr in US• Etiology: – Infant and toddler: Accidental– Adolescent and Adult: Suicide attempts

Agents responsible for caustic ingestions

• Caustic agents or alkali (pH > 7)

• Corrosives or acids (pH < 7)

• Bleaches (pH = 7)

Commonly Ingested Caustic Agents

Ronald Amedee,2009

Alkali ingestion

• Liquefaction necrosis– early disintegration of the mucosa – deep penetration into tissues– Direct contact with cell membranes leads to

their disruption secondary to saponification and proteinate formation as the alkali reacts with membrane components

• More oral and upper esophageal involvement

Acid ingestion

• Coagulation necrosis– Causes a coagulum to form on the

mucosa– Eschar formation– Limiting deeper absorption

• Reaches the stomach– Acidic pH can heighten the injury

Acid Ingestion

• Esophageal damage is less– Protection by the slightly alkaline pH of

the esophagus– Resistance of squamous epithelium to

acids

• Antrum of the stomach is the most vulnerable region– Pooling and prolonged contact

Bleaches

• Neutral pH • Esophageal

irritants• No significant

morbidity & mortality

Disk Batteries

• Leakage of contents: NaOH, KOH, Hg–Mucosal damage: 1hr– Erosion: 2-4 hrs– Perforation: 8-12 hrs

• Direct caustic injury• Absorption of toxic substances• Pressure necrosis• Electrical discharge

Severity of injury

• Amount and type of agent ingested• Presence of other food in the

stomach• GI transit time• Presence of gastroesophageal reflux

• Acute Injury– Immediate changes to mucosa which

progress during the next 3 days

• Latent periode– Stricture formation may occur– The process may proceed as rapidly as 1

month or during a period of years

• Stricture Formation

Stages of esophageal burns

grade 1: superficial injurygrade 2: transmucosal injurygrade 3: transmural injury

Stages of esophageal burns

Stages of esophageal burns

• Mild Nonulcerative Esophagitis • Mild Ulcerative Esophagitis• Moderate to Severe Ulcerative

Esophagitis• Severe Ulcerative, Uncomplicated

esophagitis• Severe Ulcerative Esophagitis with

Complications

Sign and Symptoms of Caustic Ingestion

• Oral mucosal erythema, ulceration• Drooling• Tongue edema• Stridor• Hoarseness• Dysphagia• Odynophagia• Chest or back pain• Epigastric pain or tenderness• Vomiting• Hematemesis

• Laryngeal injury– Hoarseness, stridor, dyspnea

• Severe injury– Odynophagia, drooling, refusal of food

• Perforation– Chest pain, abdominal pain, rigidity

Diagnosis

• History• PE– Examination of lips, chin, hands, chest,

clothing– Examination at the oropharyng– Examination at the Larynx/Hypopharynx• Laryngeal mirror• Flexible nasopharyngoscope

• Obtain Container

Ancillary Procedure• Chest & Neck Radiography

– Foreign body ingestion (disc battery)• Esophagoscopy at 24-48 hours post-ingestion

– < 24 hours – underestimation of injury– > 48-72 hours with risk of iatrogenic

• Ba swallow– Not for acute management– 30-90% false (-) rates for moderate esophageal

involvement– Verify perforation – Evaluate progressive dysphagia due to stricture

formation

Remember

• Oral injuries (lip or buccal burns) cannot predict the presence or absence of more distal involvement

• 20% without oral burns have esophageal burns

• 70% with oral burns don’t have esophageal burns

Management 1

• Diluting agents such as water or milk to remove the agent from the esophagus

• Fluid intake should be no more than 15 mL/kg of weight

• No Gastric lavage • No induced vomiting with emetics (ipecac)

Management 2

• Steroid administration in the transmucosal (grade 2) injuries– Prednison 1 to 2 mg/kg/day (max 60

mg) This dosage is continued for a 21-day period on a tapered regimen

• Steroids are contraindicated in grade 3 injuries

• Protection from gastric acid– Sucralfate– Antacids, H2 Blocker, PPI

Management 3

• Antibiotics – Do not prevent from stricture formation– Signs or symptoms of a secondary

infection

• Lathyrogenic agents– Aminopropionitrile, Acetylcysteine, and

Penicillamine – Reduce collagen cross-bonding

Management 4

• Esophageal dilatation for stricture formation– Prograde– Retrograde– Balloon catheters

• Surgery– Esophageal

replacement• Colonic

interposition• Jejunal

interposition• Gastric pull-ups

Complications

• Stricture formation• Esophageal perforation• Tracheoesophageal fistula• Gastric perforation• Mediastinitis• Peritonitis• Pneumonia• Sepsis,• Hiatal hernia• Reflux esophagitis• Esophageal Ca