Think before you drink

1. Think before you drink Joint Hospital Surgical Grand Round Dr. WH She Queen Mary Hospital

2. 52/M • Bipolar and delusional disorder • Drank unknown amount of self made cocktail • Strong acidic solution, pH < 2 • Coca Cola • Complained of dysponea and epigastric pain • Physical examination • Tachycardia • Tenderness and guarding over epigastrium

3. Resuscitated and intubated • Blood results • Metabolic acidosis (pH 7.2, HCO3 -13 mmol/L, base excess -14 mmol/L) • Acute renal failure (201 umol/L) • Raised AST level (252 U/L) • Chest X-ray – no abnormality detected

4. Upper endoscopy • Gangrenous appearance of the esophageal and gastric mucosa, distally to duodenum

8. Laparotomy • Findings • Full thickness gangrene of stomach with fundal perforation • Esophagus • Mucosal gangrene, spare muscle and adventitia • Duodenum • 1st part gangrenous changes • Some involvement of 2nd part • Patches fat necrosis at pancreatic tail • Proximal jejunum normal

12. Procedures • Total gastrectomy, distal exclusion of esophagus, feeding jejunostomy and tracheostomy • Post operative period • Remained critical and septic

15. Further laparotomies • Findings • Pancreatic necrosis • Perforated esophageal and duodenal stumps • Procedures • Pancreatic necrosectomy • Esophageal drain and controlled duodenostomy

19. Caustic ingestion • Accidental • Usually in children • Intentional • Usually adults • Higher concentration • Larger amount • More severe Gumaste VV et al. Am J Gastroenterol 1992 Schaffer SB et al. J La State Med Soc 2000 Satar S et al. Am J Ther 2004 Mckenzie LB et al. Pediatrics 2010

20. pH < 3 or > 11 • Extent of injury • Type of agent • Concentration • Quantity • Physical form • Duration of contact

21. Acid • Lick the esophagus and bite the pyloric antrum • Coagulation necrosis • Eschar formation, prevent deeper tissue penetration Estrera A et al. Ann Thorac Surg 1986 Gumaste VV et al. Am J Gastroenterol 1992 Ertekin C et al. Hepatogastroenterology 2004

22. Acid • Pool in stomach • Pyloric spasm • Gastric perforation and stricture • Example • Hydrochloric acid, sulphuric acid • Toilet bowl cleaners or swimming pool cleaners Schaffer SB et al. J La state Med Soc 2000 Kochhar R. et al. J Gastroenterol Hepatol 2004 Tohda G et al. Surg Endosc 2008

23. Alkaline • Highly viscous, longer duration of contact • More uniformly severe mucosal injury to esophagus • Liquid form • More distal injuries • Solid form • Adhere to mucosa of mouth, upper airway and esophagus • Spare stomach Schaffer SB et al. J La State Med Soc 2000

24. Alkaline • Liquefactive necrosis • Denaturation of proteins and collagen • Sponification of fats • Dehydration of tissues • Thrombosis of blood vessels • Example • Drain cleaners • Hair relaxers • Detergents • Disk batteries Schaffer Sb et al. J La State Med Soc 2000 Ertekin C et al. Hepatogastroenterology 2004

25. Acute problems • Laryngeal spasm, edema • Perforation • Upper gastrointestinal bleeding • Acute pancreatitis • Death • Tracheoesophageal fistula • Aorto-enteric fistula

26. Chronic problems • Esophageal stricture • Gastric outlet obstruction • Esophageal carcinoma

27. Management • Resuscitation • Endoscopy • Conservative management • Operative management

28. Zwischenberger JB et al. Am J Respir Crit Care Med 2001

29. Endoscopy • Classification by Zargar Zargar SA et al. Gastroenterology 1989 Zargar SA et al.Gastrointest Endosc 1991 Zargar SA et al. Am J Gastroenterol 1992

30. Grade 1

31. Grade 2a

32. Grade 2b

33. Grade 3

34. Endoscopy • Timing of upper endoscopy • No consensus yet • Early endoscopy • First 24 hours • Assess the severity and extent of injury • Risk of perforation Ramasamy K et al. J Clin Gastroenterol 2003 Tohda G Et al. Surg Endosc 2008 Cheng HT et al. BMC Gastroenterol 2008 Celik B et al. Dis Esophagus 2009

35. Endoscopy • Unable to assess the depth of lesion • Despite concomitant use of endoscopic ultrasound Kirsh MM et al. Ann Thorac Surg 1976 Chiu HM et al. Gastrointest Endosc 2004

36. Three phases of tissue injury from alkaline ingestion

37. Conservative management • Clinically stable without peritonitis • Usually for Zargar’s grade I and II • Grade III injury in the absence of clinical and biological signs of severity • Low mortality rate Zerbib P et al. Ann Surg 2011

38. Operative management • Clinically unstable or signs of perforation • Aim • Resect the necrotic tissues • Prevent extension of the injury to the adjacent organs • Delayed presentation or operation • Massive ingestion of strong corrosive agents Cattan P et al. Ann Surg 2000

39. Esophago-gastrectomy, cervical esophagostomy and feeding jejunostomy • High mortality rate • Pancreatoduodenectomy • Extensive duodenal necrosis • Reconstruction • Stable, and survive from complications Sarfati E et al. Br J Surg 1987 Cattan P et al. Ann Surg 2000

40. Use of nasogastric tube • Controversial • For • Decrease incidence of stricture formation and allowed nutritional support Ramasamy K et al. J Clin Gastroenterol 2003 Atabek C et al. J Pediatr Surg 2007

41. Use of nasogastric tube • Against • Long term indwelling N/G insertion would cause long strictures of the esophagus Gumaste VV et al. Am J Gastroenterol 1992 Ramasamy K et al. J Clin Gastroenterol 2003

42. Use of steroid • Debatable • For • Decrease strictures • Dosage matters Howell JM et al. Am J Emerg Med 1992 Mamede RC et al. Dis Esophagus 2002 Pelclova D et al. Toxicol Rev 2005

43. Use of steroid • Against • Risk of the use of steroids • Randomized trial • No difference • Small sample size • Meta-analyses • No difference • 19% (steroid treated group) vs 40% rate of stricture Anderson KD et al. N Engl J Med 1990 Pelclova D et al. Toxicol Rev 2005 Ramasamy K et al. J Clin Gastroenterol 2003

44. Outcome • Depends on • Amount of caustic substances ingested • Severity of injury • Clinical status

45. Our patient • Unknown amount of caustic substances ingestion • Clinically unstable • Metabolic acidosis • Acute renal failure • Endoscopic Zargar’s grade IIIb

46. Upper airway injury • Esophageal necrosis • Gastric perforation • Duodenal involvement

47. Poor biochemical predicting factors • pH < 7.2 • Base deficit > 16 mmol/L • Two fold increase of serum AST Chou SH et al. World J Surg 2010

48. Conclusions • Difficult to manage • High morbidities and mortality • Early recognition of the type, amount and duration of caustic ingestion • Decision on appropriate investigations and treatments

49. Acknowledgement • Prof. S Law • Dr. D Tong