- type
- amount
- time from ingestion
- determine severity
- co-ingestion of other drugs
- Signs and symptoms
Pathophysiology: mechanism of injury
- alkali-induced injury
- acid-induced injury
- Alkali-induced injury: liquefactive necrosis
progression of alkali-induced injury?
most common location of injury?
- Acid-induced injury: coagulation necrosis
location of injury?
classification of burn
- signs of esoghrageal perforation?: pneumomediastinum, mediastinal widening, SQ emphysema in neck, pleural effusion, hydropneumothorax, subdiaphragmatic air
- GI perforation?
จะส่งตรวจเพิ่มเติมอะไรบ้าง?
- indication: symptomas + ingestion of substance with high risk of esophageal injury
symptoms? : oral burns
ให้ส่งตรวจ CBC, serum lactate, serum elestrolytes, liver function tests
- imaging
CXR when respiratory symptoms
1. R/O other causes (FB ingestion, pneumonia)
2. complication: esophageal or gastric perforation
CT grading
- Early upper endoscopy (do not require surgery)
timing?
early (3-48 hr) and preferably during first24 hr after ingestion
hemodynamic stable
if > 48 hr: inaccurate and caution because increased risk of esophageal perforation
contraindication?
GI perforation
Endoscopy grading: Zargar classification
for?
evaluation extent of esohageal and gastric damage and guide management
Severity grading
- low-grade injury: endoscopy grade 1, 2A or CT grade 1
- high-grade injury: endoscopy grade 2B, 3 or CT grade 2,3
Management?
- Asymptomatic without significant ingestion
- Symptomatic or significant ingestion
- Surgery
Symptomatic or significant ingestion: hospitalization for supportive care
- what is significant ingestion?
high-concentration acid or alkali or high volume (> 200 ml) of low-concentration acid or alkali
- supportive care?
1. respiratory support (maintain airway + supplemental oxygen), fluid resuscitation, pain control
if respiratory distress or severe oropharyngeal or glottic edema and/or necrosis -> laryngoscopy for evaluate need for intubation (protect airway) and prior to upper endoscopy
2. admit ICU for managing acute, life-threatening complications of injury (mediastinitis, peritonitis, respiratory distress, shock)
3. fasting until initial evaluation
4. Avoid NG: retching and vomiting, which can compound existing injuries and possibly lead to perforation of the esophagus or stomach.
5. Gastric acid suppression with intravenous proton pump inhibitors is used to prevent stress ulcers of the stomach
6. ATB: when suspected perforation
broad-spectrum ATB
7. No role for emetics, neutralizing agents, or corticosteroids
Surgery
- Emergency surgery for transmural necrosis or perforation
when?
Clinical signs of perforation (eg, mediastinitis, peritonitis) and CT evidence of transmural necrosis
operation?
1. laparotomy
2. endoscopic vacuum therapy with extraluminal and intraluminal sponges q 3 days
3. esophagogastrectomy: pt left eith cervical esophagostomy (spit fistula), a defunctionalized duodenum, and a feeding jejunostomy
4. total gestrectomy
management depend on severity grading
- Low-grade injury
1. supportive care with pain control
2. initiate with liquid diet then advanced to regular diet in 24-48 hr
3. lomg-term endoscopic surveillance for esophageal cancer
- High-grade injury
1. inpatient monitoring for sign of perforation 1 wk
if concerning clinical signs and/or symptoms -> re-imaging with CT
2. Oral liquid after first 48 hr if patient is able to swallow saliva
if tolerate oral liquid -> early enteral feeding initiate through nasojejunal tube or jejunostomy
if not tolerate enteral nutrition -> total parenteral nutrition
suspected in abnormal lab
- leukocytosis
- high serum c-reactive protein concentration
- sever acidosis: low pH, high blood lactate concentration
- renal failure
- deranged liver function test
- thrombocytopenia
CT scan can reliably identify transmural necrosis
- Bleeding: 2-4 wk after ingestion
- fistulization: after massive ingestion of strong corrosive ingestion
tracheoesophageal fistula
aortoentericl fistula
GI bleeding
- strictures: most common
develop within 2 mo
management in esophageal strictures?
- endoscopic
- surgical reconstruction
gastric stricture
- esophageal squamous cell carcinoma
How screening?
Grade 2B, 3A: stricture?
- UGI study 3 wk then F/U q 1 mo for 1 yr