CORROSIVE INGESTION INJURIES. Dr L Fourie Moderator Prof. Mokoena

Transcription

1 CORROSIVE INGESTION INJURIES Dr L Fourie Moderator Prof. Mokoena

2 OVERVIEW Definition Pathophysiology Acute phase management and classification. Management and prevention of late sequelae Conclusion

3 DEFINITION A caustic or corrosive substance can be defined as something that eats away or destroys tissues. Typically acids or alkali. Sometimes used to describe oxidising agents and dessicants.

4 HOUSEHOLD AGENTS Acid Alkali Battery acid (Sulphuric acid) Drain cleaners(naoh 4-54%) Antirust compounds(hydrochloric acid) Toilet cleaners (hydrochloric/sulphuric acid) Swimming pool cleaners Washing powders /Detergents Hair straighteners (Lye) Bleaches Denture cleaning tablets

5 PATHOPHYSIOLOGY ACIDS Pungent and very bitter usually only a small amount is ingested. Cause coagulative necrosis. The coagulum offers some protection to underlying tissues. More severe damage to the stomach due to pyloric spasm and accumulation in the antrum. This typically causes strictures in the pre-pyloric area where the acid pools. When a large amount has been ingested the entire stomach and even small bowel can be involved.

6 PATHOPHYSIOLOGY ALKALI Strong alkali are tasteless and odourless, they can be ingested in large quantities. Higher viscosity than acids and longer passage time through the oesophagus. Oesophageal injury is greater with alkali than acids. They dissolve lipoproteiens on the mucosal surface resulting in rapid penetration into muscular layers. Prolonged exposure causes liquefaction necrosis as well as a severe inflammatory reaction that results in vascular thrombosis and necrosis.

7 Acute phase Presentation and management

8 SYMPTOMS AND SIGNS Larynx and Pharynx Stridor Hoarseness Laryngitis Oesophagus Dysphagia Odynophagia Stomach Epigastic pain Heamatemesis Perforation Hypotension Fever Chest pain Peritonitis

9 COMPLICATIONS Early: Oedema Ulceration Bleeding Perforation Metabolic acidosis Shock Sepsis Airway obstruction Death

10 MANAGEMENT Acute phase Airway evaluation and protection Dyspnoea Hoarseness Stridor Fluid resuscitation PPI / H2 blockers? IV antibiotics

11 MANAGEMENT Contra indicated: Induced emesis Gastric lavage Activated charcoal Neutralizing agents CONTROVERSIAL Chemical reaction produces heat Effectiveness not proven Must be taken within 1 hr

12 INVESTIGATIONS AXR and CXR Air under the diaphragm Pneumothorax Pleural effusion Endoscopy Laryngoscopy Contrast studies-exclude distal obstruction

13 IMPORTANCE OF EVALUATING THE UPPER AERODIGESTIVE TRACT Incomplete laryngeal protection with aspiration. Pharyngeal muscle dysfunction. Naspharyngeal regurgitation Tongue fixation Hypopharyngeal stenosis Injuries to upper oesophagus and pharynx- effect surgical reconstrution

14 ENDOSCOPY Must be done within 24-48h Dangerous between day 5-15 (tissue softening increases the risk of perforation) Third degree burn to hypopharynx is a contraindication Small diameter flexible endoscope Advanced under direct visualiztation Minimal air insufflation

15 DEGREE OF BURN ENDOSCOPIC EVALUATION First Degree Mucosal hyperaemia Oedema Second Degree Exudates Ulcerations Pseudomembranes Third degree Mucosal sloughing Deep Ulceration Massive Haemorrhage Charring Perforation

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17 INDICATIONS FOR EMERGENCY SURGERY Signs of perforation Peritonoitis Extravisceral air Mediastinitis Retrosternal chest pain Fever Tachycardia Shock

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19 Patients with complex/multiple perforations and widespread necrosis, may require extensive debridement, oesophagectomy or even oesophagogastrectomy. With more devastating injuries burns can be found in bowel distal to the stomach. Adjacent organs like transverse colon, liver,biliary tree, pancreas and spleen. These injuries have a very high mortality.

20 PREDICTORS OF OPERATIVE OUTCOME. PATIENTS REQUIRE OESOPHAGOGASTRECTOMY IN THE ACUTE STAGE. WORLD J SURG (2010), 3, Ph < 7.2 Base deficit > 16 Age: over 65 Twofold level of AST Factors predicting the hospital mortality of patients with corrosive gastrointestinal injuries.

21 FEEDING STRATEGIES Oral Appropriate in 1st degree burns. Gastric Feeding Cannot be used if stomach is involved. Risk of reflux into oesophagus. Risk of vomiting Post Treitz feeding tube Advantageous if it can be safely and correctly placed. Feeding jejunostomy Ideal Feed while protecting the injured upper gastro intestinal tract. Parenteral nutrition Associated complications including mucosal atrophy.

22 LATE SEQUELAE OF CORROSIVE INGESTION 1) Oesophageal stricture 2) Gastric stricture 3) Oesophageal cancer 4) Tracheo-Oesophageal fistula

23 1)PREVENTION OF OESOPHAGEAL STRICTURES Steroids Do corticosteroids prevent oesophageal stricture after corrosive ingestion(pelcove D, Navratil, toxicology Rev 2005; ) Ten studies, 572 patients Conclusion: NOT beneficial for 2 nd or 3 rd degree burns and do not prevent stricture. May lead to serious adverse effects.

24 PREVENTION OF OESOPHAGAL STRICTURES TPN- NPO allows re-epithelialisation, no randomised study. Intraluminal stent- Controversial (Gastroint. Endosc, 2004) PPI and H2 blockers- protect injured mucosa from gastric acid.

25 MANAGEMENT OF BENIGN STRICTURE Balloon or Bougie dilatation No data to support the superiority of one over the other. Rule of three Strictures caused by caustic ingestion are often complex ( > 2cm long, tortuous or diameter precludes the passage of a endoscope). Complex stricture is more difficult to treat and tend to recur. Refractory strictures : recur in 2-4days or require more then 7-10 dilatations

26 1)MANAGEMENT OF OESOPHAGEAL STRICTURE Stents (intraluminal self expandable plastic stents) - An option in refractory stricture. Not first line management for benign strictures Goal is to hold the stricture open for a prolonged time allowing tissue to remodel before removing the stent Complications Growth of granulation tissue into the lumen of the stent. Migration Perforation

27 MANAGEMENT OF BENIGN OESOPHAGEAL STRICTURE Intraluminal steroid therapy. Kocar et al Kochhar and m Akharia n Dilatation index before steroids Dilatation index after steroids 0.53 Altinas E

28 SURGERY Distal Oesophagectomy and primary anastomosis Oesophagectomy + oesophagostomy with feeding jejunostomy,followed by colonic interposition graft. Jejunal free graft with microvascular anastomosis Gastric transposition- more suitable for malignant disease. Sleeve resection of short strictures are usually not successful

29 GASTRIC STRICTURES Patients typically present with features of gastric outlet obstruction. These signs can be masked by a concomitant oesophageal stricture. Contrast studies are good means of evaluating strictures and planning operative intervention. Feeding jejenostomy can be used to improve the patient s nutritional status and ensure the success of surgery.

30 MANAGEMENT OF GASTRIC STRICTURES CHRONIC CORROSIVE INJURIES OF THE STOMACH. N ANANTHAKRISHAN WORLD J SURG2010;3;

31 TIMING

32 CARCINOMA A strong association exists between caustic injury and squamous cell carcinoma of the oesophagus. 1-7% of patients with squamous ca has a history of caustic ingestion fold increased risk Many authors recommend endoscopic surveillance beginning 20 years after caustic injury.

33 CONCLUSION The degree of damage caused by corrosive substance is determined by the type of substance, concentration, amount ingested and intent. In the acute phase resuscitation and early endoscopy and layngoscopy is fundamental. Patients with signs of perforation need emergency surgery. Oesophageal and gastric burns may result in strictures. Steroids do not prevent strictures but intra-luminal steroids can be used to decrease the amount of dilatations. Surgical management of strictures must be well timed to allow also for psychological and nutritional rehabilitation.

34 REFERENCES 1. Corrosive Ingestion in Adults Kovil Ramsamy, MD, and Vivek V. Gumaste, MD, MRCP(I), FACG J Clin Gastroenterol 2003;37(2): Factors Predicting the Hospital Mortality of Patients with Corrosive Gastrointestinal Injuries Receiving Esophagogastrectomy in the Acute Stage Shah-Hwa Chou Yu-Tang Chang Hsien-Pin Li Meei-Feng Huang Chia-Hua Lee Ka-Wo Lee World J Surg (2010) 34: Steroids for the Treatment of Corrosive Esophageal Injury: A Statistical Analysis of Past Studies. Howell JM, Dalsey WC, Hartsell FW, Butzin CA. Am J Emerg Med 1992;10(5): Clinical evaluation and management of caustic injury in the upper gastrointestinal tract in 95 adult patients in an urban medical Center. Tohda G, Sugawa C, Gayer C, Chino A, McGuire TW, Lucas CE. Surg Endosc (2008) 22: A standadized protocol for the acute management corrosive ingestion in children. Baskin D, Urganci N, Abbasoğlu L, Alkim C, Yalçin M, Karadağ C, Sever N. Pediatric Surg.Int (2004)20: Chronic corrosive injuries of the stomach. Ananthakrishan N. World J Surg2010;3; Caustic ingestion injuries of the upper aerodigestive tract Scott JC, Jones B Laryngoscope 1992 jan,102(1): Sabiston Text Book of Surgery 2. Mastery of Surgery 3. Greenfield Textbook of Sur.gery