Dr. Arun Aggarwal Gastroenterologist: Pediatric GI- Surgery conference

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Pediatric GI- Surgery conference

• Dr. Arun Aggarwal Gastroenterologist

By Dr. Arun Aggarwal Gastroenterologist
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Caustic esophageal injury in children

• Seen most often in young children between 1-3
  years of age
• boys accounting for 50 to 62 of cases
• Most ingestions by children are accidental and
  the amounts ingested tend to be small.
• The opposite is the case in adults, in whom
  ingestion often is deliberate and related to
  attempted suicide

By Dr. Arun Aggarwal Gastroenterologist
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• The most common causes of caustic esophageal
  burns are alkaline household cleaning products,
  such as oven and drain cleaners, strong lyes that
  contain sodium and potassium hydroxides, and
  laundry detergents and cleaning agents
  with sodium phosphate, sodium carbonate, and
  ammonia.
• Esophageal burns are rare with household bleaches
  (sodium hypochlorite) because these have a
  relatively neutral pH.
• Some caustic ingestions are caused by acid
  household products including toilet bowel
  cleaners, battery fluids, and muriatic
  (hydrochloric) acid used in swimming pools.
• Esophageal injury from acids may be attenuated
  compared with alkalis, and perforation of the
  esophagus is less common

By Dr. Arun Aggarwal Gastroenterologist
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Mechanisms of injury alkali versus acids

• Alkalis cause liquefaction necrosis. This type
  of injury leads to early disintegration of the
  mucosa, allowing deep penetration and even
  perforation.
•  Acids or corrosives cause coagulation necrosis.
  
• However, esophageal injury from acids may be
  attenuated compared with alkalis because the
  coagulum that forms on the mucosal surface may
  limit deeper penetration of the caustic
  substance.
• Degree and extent of damage depends on type of
  substance, morphologic form of agent, quantity,
  and intent.

By Dr. Arun Aggarwal Gastroenterologist
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Timing of tissue damage and repair
Injury Time
Acute injury Day 0
Inflammation, vascular thrombosis 1 to 7 days
Granulation tissue (vulnerable to perforation) 10 to 21 days
Fibrosis/stricture 3 weeks
By Dr. Arun Aggarwal Gastroenterologist
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CLINICAL MANIFESTATIONS 

• Early signs and/or symptoms may not correlate
  with the severity and extent of tissue injury. 
• The most common symptom is dysphagia.
• Esophageal studies during the acute phase of
  injury have shown loss of motility with delayed
  transit.
• Patients may also present with drooling,
  retrosternal or abdominal pain, hematemesis, and
  features suggesting upper airway injury such as
  stridor, hoarseness, nasal flaring, and
  retractions.

By Dr. Arun Aggarwal Gastroenterologist
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• 1030 patients with esophageal burns have no
  oropharyngeal damage.
• 70 patients with oropharyngeal burns do not have
  significant damage to esophagus.
• Injuries of oropharynx are not a reliable index
  of damage to esophagus.
• 1. Gumaste VV, Dave PB. Ingestion of corrosive
  substances by adults. Am J Gastroenterol.
  19928715. 2. Haller JA, Andrews HG, White JJ,
  et al. Pathophysiology and management of acute
  corrosive burns of the esophagus results of
  treatment in 285 children. J Pediatr Surg.
  19716578584.

By Dr. Arun Aggarwal Gastroenterologist
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• larynx or epiglottis hoarseness and stridor
• Esophagus dysphagia and odynophagia
• stomach epigastric pain and hematemesis (or
  aortoenteric fistula)
• Absence of pain not preclude significant GI
  damage.

By Dr. Arun Aggarwal Gastroenterologist
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DIAGNOSTIC EVALUATION
By Dr. Arun Aggarwal Gastroenterologist
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• The objectives of early endoscopy are to
  establish the presence or absence of esophageal
  and/or gastric lesions and to determine the
  severity of involvement.
• Endoscopy is contraindicated in patients who are
  hemodynamically unstable, have evidence of
  perforation or severe respiratory distress, or
  exhibit severe oropharyngeal or glottic edema and
  necrosis.
• Radiologic examination is valuable and essential
  for follow-up to detect the presence of
  strictures. However, barium studies are not
  reliable in detecting acute injury or in
  predicting stricture formation.

By Dr. Arun Aggarwal Gastroenterologist
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Grading of esophageal burns from caustic injury
Injury Findings
Grade 0 Normal mucosa
Grade 1 (superficial) Superficial hyperemia and edema
Grade 2A (transmucosal) Hemorrhage, exudates, linear erosions, blisters, shallow ulcers involving the mucosa and submucosa
Grade 2B Circumferential burn present
Grade 3 A Deep ulceration, eschar formation with necrosis, full-thickness injury with and without perforation, lt1/3 of esophagus
Grade 3 B gt 1/3 of esophagus
By Dr. Arun Aggarwal Gastroenterologist
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• First-degree burns are those with injury limited
  to edema and erythema.
• Second-degree burns are characterized by linear
  ulceration and necrotic tissue with whitish
  plaques. Grade 2A are localized or partial and
  Grade 2B are circumferential.
• Third-degree burns include circumferential injury
  with sloughing of the mucosa.
• Some authors use third-degree burns to define
  patients with perforation.
• Linear burns rarely lead to stenosis, whereas
  circumferential burns frequently heal with
  stricture formation

By Dr. Arun Aggarwal Gastroenterologist
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TREATMENT

• The initial treatment observation, with an
  emphasis on preventing vomiting, choking, and
  aspiration.
• The induction of vomiting is contraindicated
  because vomiting may lead to additional
  esophageal injury.
• use of neutralizing not recommended.
• use of diluting agents not recommended
  ingestion of diluting agent can induce vomiting,
  potentially leading to further complications.

By Dr. Arun Aggarwal Gastroenterologist
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• gastric lavage (x)
• induced emesis (x)
• milk and water (?) diluting agents,
  effectiveness not proven
• radiologic studies
• endoscopy
• oral intake
• prevention of strictures

By Dr. Arun Aggarwal Gastroenterologist
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Nasogastric tube

• In patients in whom extensive circumferential
  burns (Grade 2B or 3) are seen during upper
  endoscopy, NG tube should be placed under direct
  visualization during the endoscopic procedure.
• NG tube should not be inserted blindly because
  perforation or additional injury can occur while
  passing the tube.
• NG tube can provide a route for nutritional
  support during the healing phase, and help
  maintain a lumen during stricture formation.
• It also can serve as a guide for esophageal
  dilatation.

By Dr. Arun Aggarwal Gastroenterologist
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Endoscopy

• assess oropharynx, larynx, esophagus, stomach,
  and duodenum
• laryngoscopy airway obstruction ? early
  intubation or tracheostomy
• No GI injury ? observation, discharged, evidence
  of GI injury ?managed appropriately

By Dr. Arun Aggarwal Gastroenterologist
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Endoscopic grading
First degree (superficial) nonulcerative esophagitis, mild erythema, edema of mucosa
Second degree (transmucosal) whitish exudate, erythema, underlying ulceration that may extend into the muscularis
Third degree (transmural) dusky or blackened transmural tissue, deep ulcerations (may extend into periesophageal tissue, lumen may be obliterated)
By Dr. Arun Aggarwal Gastroenterologist
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• performed between 24-48 hrs after injury,
  allowing time to manifest most information
• wound softening after 23 days and lasts up to 2
  weeks (avoid endoscopy between days 5-15,
  increase danger of perforation)
• endoscope should be advanced until a
  circumferential 2rd degree burn or 3rd degree
  burn is seen, attempts to past ? increase risk of
  perforation

By Dr. Arun Aggarwal Gastroenterologist
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Corticosteroids 

• Does not help protect against the development of
  esophageal strictures, and may be harmful
  (increased vulnerability to infection and GI
  bleeding).
• Corticosteroids also should not be used for acid
  ingestion because esophageal strictures are less
  likely and there is a greater risk of masking the
  clinical features of gastric necrosis and
  perforation.
• 1. Hawkins D B, Demeter M J, Barnett TE. Caustic
  ingestion controversies in management a review
  of 214 cases. Laryngoscope 1980 90 98109.
• 2. Oakes D D. Reconsidering the diagnosis and
  treatment of patients following ingestion of
  liquid lye. J Clin Gastroenterol 1995 21 8586.

By Dr. Arun Aggarwal Gastroenterologist
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Oral Intake

• graded 1? permit oral intake and discharged
  within days
• grades 2 or 3 ? nutritional support by parenteral
  or NG tube (blind passage increases risk of
  iatrogenic esophageal perforation)
• Grade 2 NPO 3-5 days
• Grade 3 NPO gtone week

By Dr. Arun Aggarwal Gastroenterologist
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LATE COMPLICATIONS
By Dr. Arun Aggarwal Gastroenterologist
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Stricture formation

• Stricture formation is the primary complication
  of caustic injury, occurring in 2 to 38 of all
  ingestions and in 3 to 57 of ingestions with
  documented esophageal burns.
• Most third-degree (circumferential) burns lead to
  esophageal strictures regardless of treatment.
• Once a stricture is confirmed radiologically,
  esophageal dilatation usually is required to
  maintain or reestablish normal swallowing.
• All patients with significant burns and the
  potential for stricture formation should be
  evaluated with barium contrast studies two to
  three weeks post ingestion.
• Contrast studies are not reliable in detecting
  acute injury or in predicting stricture
  formation.

By Dr. Arun Aggarwal Gastroenterologist
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Treatment of Strictures

• (Endoscopic) dilatation / bougination
• Surgery
• emergent surgery perforation or shock, acidosis,
  coagulation disorder with ingested large amount
  of caustic agent ? improve outcome
• reconstruction colon interposition

By Dr. Arun Aggarwal Gastroenterologist
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• A variety of dilators can be used, including
  mercury-filled bougies, Maloney antegrade
  dilators or Tucker dilators used in retrograde
  dilatation, and dilators passed over a string or
  guide wire.
• Because caustic strictures appear to perforate
  easily, retrograde dilatation has been considered
  the safest method, although this method requires
  a gastrostomy and a string for guidance.
• Balloon dilators under endoscopic control are
  also commonly used in children.
• Perforation should be less likely with these
  instruments because only radially directed force
  is exerted, and the longitudinal shearing force
  with ante grade and retrograde dilators is
  avoided.

By Dr. Arun Aggarwal Gastroenterologist
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• Although esophageal dilatation may be beneficial
  initially, repeated dilatations usually are
  needed.
• Only 33 to 48 of patients with caustic
  strictures have long-term success with repeated
  dilatations.
• The remaining patients, who often have long
  strictures, have increasing difficulty in
  swallowing because of progressive obstruction.
• Many of these patients have extensive strictures
  that ultimately require esophagectomy with colon
  interposition within two years following the
  ingestion. 

By Dr. Arun Aggarwal Gastroenterologist
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• Left panel shows an esophageal stricture six
  weeks after lye ingestion. A gastrostomy with
  retrograde string placement was performed with
  multiple dilatations by string bougie. The
  patient was able to eat normally for two to three
  weeks after each dilatation, but required monthly
  dilatation. Right panel shows the stricture after
  two years and multiple dilatations.

By Dr. Arun Aggarwal Gastroenterologist
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• Mitomycin C, an inhibitor of fibroblast
  proliferation, has been used in children who have
  required repeated dilatations.
• Although there are no controlled trials, the
  application of mitomycin C to the surface of the
  stenotic esophagus right after dilatation has
  been reported to decrease the need for further
  dilatation.
• A retrospective case series from eight
  institutions in Europe, Australia and the United
  States described 16 patients with esophageal
  strictures, 10 of which were caused by caustic
  ingestion. Each was treated with topical
  mitomycin C following esophageal dilatation. The
  treatment was successful in eliminating or
  reducing the need for repeated dilatations in 82
  of the patients.
• Rosseneu S, Afzal N, Yerushalmi B, et al. Topical
  application of mitomycin-C in oesophageal
  strictures. J Pediatr Gastroenterol Nutr 2007
  44336.

By Dr. Arun Aggarwal Gastroenterologist
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Prevention of Strictures

• Intraluminal stent (silicone rubber) may be
  helpful in selected esophageal injuries patients
  (grade 2 or 3).
• long term outcome unclear
• 1. Berkovits RN, Bos CE, Wijburg FA, et al.
  Caustic injury of the esophagus. J Laryngol Otol.
  199611010411045.
• 2. De Peppo F, Zaccara A, DallOglio L, et al.
  Stenting for caustic strictures. J Pediatr Surg.
  1998335457.

By Dr. Arun Aggarwal Gastroenterologist
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Pyloric stenosis

•  Pyloric stenosis can occur with both acids and
  alkalis and often is associated with esophageal
  injury and strictures.
• With severe injury to the stomach, gastric outlet
  obstruction may occur as early as three weeks or
  as late as 10 weeks.

By Dr. Arun Aggarwal Gastroenterologist