Corrosive ingestion  
จะซักประวัติอะไรบ้าง

- type

- amount

- time from ingestion

- determine severity

- co-ingestion of other drugs

 

Signs and symptoms?

- 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?

Pathologic classification?

classification of burn

จะตรวจร่างกายอะไรบ้าง

- 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

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

Asymptomatic without significant ingestion: D/C
 

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

transmural necrosis?

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

complication?

- 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?

Follow up?

Grade 2B, 3A: stricture?

- UGI study 3 wk then F/U q 1 mo for 1 yr