Management of Corrosive Ingestion

1. Management of Corrosive Ingestion Joint Hospital Grand Round United Christian Hospital Dr WN Fong

2. Background

3. Introduction Accidental - 80% children Intentional - adolescents and adults • Extensive damage to aerodigestive tract  Perforation  Death • Alkaline > Acid • Management is complicated ( young, psychotic, suicidal and alcoholic)

4. Alkaline corrosives – pH ≧12 Granular, paste and liquid Drain and over cleanser Washing detergents Cosmetic and soaps Button batteries Acid corrosive – pH <2 Toilet bowl cleansers (sulfuric, HCl) Antirust (HOCl, oxalic) Battery fluid (sulfuric) Swimming pool and slate cleanser (HCl) Corrosive Agent

5. Corrosive Agent • Mild Alkaline – pH 10.8 to 11.4 • Sodium carbonate • Ammonium hydroxide • Bleaches ( sodium and calcium hypochlorid and hydrogen peroxide)

6. Pathogenesis and Pathology • Degree of injury • Agent • Concentration • Quantity • Physical state • Duration of exposure

7. Alkali Liquefaction necrosis (potent solvent x lipoprotein lining) Thrombosis of adjacent vessels Heat production Acid Coagulation necrosis Eschar formation

8. Anatomical • Cricopharyngeal area • Aortic arch • Tracheal bifurcation • Lower esophageal sphincter • Antrum (fasting) / body (after meal)

9. Short Term Mild mucosal erythema Ulceration Hemorrhage Perforation (during first 2 weeks) Long Term Stricture formation Gastric outlet obstruction Shortening of esophagus altered LES Change in esophagus motility  GERD which accelerate stricture formation CA esophagus Consequence

10. Oropharyngeal pain Dysphagia with drooling saliva Hoarsiness and stridor Dysphagia/ odynophagia Retrosternal chest pain, radiate to back Hematemesis Cervical emphysema mediastinitis Epigastric pain Retching Emesis of tissue, blood or coff ee ground material peritonitis Tachypnea, Shock Metabolic acidosis coagulopathy Clinical Features

11. Management • Acute Phase • Airway • Fluid resuscitation • Assess the severity of injury • Emergency surgery • Controversies : neutralization, use of steriod/ antibiotics

12. Evaluation of Injury Endoscopy Radiography

13. Endoscopy • Laryngoscopy • Potential airway obstruction • OGD • Gold standard • Within 12-24 hrs • Should be avoid from D5 – D15 (risk of perforation) • Classification (I, IIa, IIb and III)

14. Classification of corrosive injury

15. Radiography • Plain X-ray • CXR • AXR • Contrast radiography ie water-soluble or thin barium • Double contrast CT if evidence of duodenum abnormality

16. Role of Surgery • Acute Phase – emergency measure • Evidence of perforation • Shock, acidosis, coagulopathy and who ingested large amount of corrosive • 3rd degree burn on endoscopy • Early surgical intervention may improve outcome in grade 3 injury. Gastrointest Endosc. 91;37:165-169

17. Controversy

18. Neutralization • Absolute Contraindicate • Gastric lavage • Induce vomiting • Relative Contraindicate • Milk and water • Activated charcoal • Exothermic reaction and • obscure subsequent endoscopy

19. Steriod • Animal study – decrease stricture formation • Human study – inconclusive • Review of 13 publications –Howell Am J Emerg Med 1992;10:421-5 • Stricture significantly reduced in those with advance injury receiving steriod • RCT –Anderson KDN Eng J Med 1990;323:637-640 • steriod do not prevent stricture • Recommend dose • 30-40mg methyl prednisolone or dexamethasone 1mg/kg/day • Duration : > 3 weeks

20. Antibiotics • No clear data support its use • No RCT in human avaliable • Consensus : • Antibiotics should be given in patient treated with steriod • Otherwise antibiotics is not advocated

21. Acid Suppression • Esophageal shortening • altered LES • Esophageal dysmotility  GERD – accelerate stricture formation

22. Flowchart – Managment of caustic ingestion Deterioration  Laparoscopy

23. Case Series United Christian Hospital July 03’ – June 04’

26. Bring Home Message • Airway • Early endoscopy is indicated • Surgery ?? • Magnitude of surgery ?? • Early surgical intervention may decrease mortality

27. Thank You