Flashcards in Chemical esophageal injuries Deck (29):
Is an alkaline chemical or an acidic chemical more likely to cause a severe esophageal injury?
Alkaline. Chemicals with pH >11, such as liquid lye or button batteries. The high viscosity leads to slow transit time and prolonged exposure with rapid deep tissue penetration. This leads to liquefactive necrosis.
Why does acid ingestion result in less severe injury?
Because coagulation necrosis creates eschar that limits progression of injury
Should stomach contents be diluted after ingestion of caustic material?
No, this can cause emesis and result in further damage and reexposure to same caustic elements, leading to progression of injury.
After ingestion of a caustic agent, should measures be made to neutralize the corrosive agent? Should an NG tube be passed on arrival?
No. This can lead to an exothermic reaction, that may further injure the surrounding tissue. An NG tube should not be placed blindly and are contraindicated.
What are the indications for endoscopy after caustic material ingestion?
Stridor, symptomatic children (vomiting/drooling), oropharyngeal burns and all intended suicidal ingestions
When should an endoscopy be performed for the evaluation of caustic esophageal injuries and why?
Within the first 12 to 24 hours. iatrogenic perforations often occur in a delayed fashion on the 2nd or 3rd day after injury; when burn weakens with friable granulation tissue.
What is the appearance of a grade I caustic injury on endoscopy?
Mucosal edema and hyperemia (represents superficial mucosal burn)
What is the appearance of a grade IIa caustic injury on endoscopy?
Patchy ulcerations, exudate and slough (represents transmucosal injury)
What is the appearance of a grade IIb caustic injury on endoscopy?
Circumferential injury (represents transmucosal injury)
What is the appearance of a grade III caustic injury on endoscopy?
Deep ulceration, black or gray discoloration, full thickness necrosis, thrombosed submucosal vessels(represents transmural injury and peri-esophageal or peri-gastric extension)
Which grade injury is likely to develop stricture?
Grade IIb (>70%) and all Grade III progress to stricture formation.
Why should endoscopy be limited to only assess site of maximal injury?
To minimize risk of perforation and provide evaluation for directed therapy
Aside from early endoscopy, what comprises the work up of caustic ingestion?
Contrast swallow with gastrograffin (water soluble), followed by thin barium.
What is the management of mild esophageal injury (grade I and IIa)?
Observation, diet advancement over 24 to 48 hours, and a follow up contrast study at 3 weeks to r/o stricture formation.
What is the management of grade IIb and III injuries?
Observation at a minimum of 48 hours to one week, with parenteral nutrition. Gastrostomy tubes may be placed for severe injuries for enteral conduit and for retrograde dilatations. Antibitotics to cover oropharyngeal flora for 3 weeks, H2 blockers
Why are patients placed on H2 blockers for treatment of caustic ingestion with grade II-III injuries?
To decrease acid reflux secondary to esophageal dysmotility and theorectically decrease stricture rates.
When does a delayed perforation occur post ingestion of caustic agents resulting in esophageal injury?
How is severe esophageal injury (full thickness/perforation) treated?
Esophagectomy, cervical esophagostomy, feeding gastrostomy and jejunostomy, or esophagectomy with transhiatal gastric transposition
What is the mortality in delayed resection in setting of third degree burns and perforation?
Complication of caustic ingestion of battery, usually with the first week after injury?
What are the options for esophageal replacement?
Colonic interpostion graft, gastric tube or free jejunal grafts
Which esophageal replacement technique is the most widely used?
Colonic interposition graft
What are the advantages and disadvantages of colonic interposition graft?
Reliable blood supply and similar anatomic reservoir but may develop redundancy and stasis as late complications
What are the major disadvantages of a gastric esophageal reconstruction?
May be of inadequate length, and pyloroplasty may lead to dumping symptoms.
Why should grade IIb and III injuries after caustic ingestion have long term annual follow up?
The development of strictures and the high incidence of cicatrical cancer.
What is the timing of dilatation for esophageal strictures s/p caustic ingestion and why?
>4 weeks because dilations earlier have significant risk of iatrogenic perforations.
How are intractable and persistent strictures managed?
Surgical intervention. Intractable strictures may require bypass, resection or esophagoplasty. Persistent strictures will require esophagectomy
What type of cancer is associated with strictures due to caustic ingestion?
Squamous cell carcinoma