Management of Management of Corrosive Corrosive IngestionIngestion

Joint Hospital Grand RoundJoint Hospital Grand Round

United Christian HospitalUnited Christian Hospital

Dr WN FongDr WN Fong

BackgroundBackground

IntroductionIntroduction

Accidental - 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, psManagement is complicated ( young, ps

ychotic, suicidal and alcoholic)ychotic, 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 cleanser

s (sulfuric, HCl)s (sulfuric, HCl) Antirust (HOCl, oxaliAntirust (HOCl, oxali

c)c) Battery fluid (sulfuriBattery fluid (sulfuri

c)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 hypochlor

id 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 erythe

mama UlcerationUlceration HemorrhageHemorrhage Perforation (during fPerforation (during f

irst 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/ odynophagiaDysphagia/ odynophagia 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 steri

od/ 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 Findingsdings

II Superficial mucosal Superficial mucosal injuryinjury

Mucosal hyperemia Mucosal hyperemia & edema& edema

IIAIIA Partial thickness Partial thickness injury – injury – patchypatchy

Mucosal sloughingMucosal sloughing

Superficial 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 t

hin bariumhin barium Double contrast CT if evidence of duodenDouble contrast CT if evidence of duoden

um 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 in

gested 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 o

utcome 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 199Am J Emerg Med 1992;10:421-52;10:421-5

Stricture significantly reduced in those with advance injStricture significantly reduced in those with advance injury receiving steriodury 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/k30-40mg methyl prednisolone or dexamethasone 1mg/k

g/dayg/day 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 ingestion

Acute Caustic Ingestion

Severe InjuryUnknown agentSuicidal intent

Mild ExposureBleach

Detergent

No PerforationPerforation

Airway evaluationResuscitation

Plain films No SymptomsSymptoms

Mild injuryGrade I – 24hrs obsGrade II – 28hrs obs

Full thickness(grade IIb or III)

TPNAntibiotics Steriod

NPO orClear fluid

ImmediateResection

DischargeFollow up

Deterioration

Laparoscopy

Case SeriesCase Series

United Christian HospitalUnited Christian Hospital

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

PatiePatientnt

EndoscEndoscopicopic

gradegrade

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