Accuracy of contrast swallow study in assessment of caustic esophageal stricture length in children: Agreement study.

BACKGROUND: Caustic esophageal stricture length assessment is essential for planning endoscopic management and predicting its prognosis. We aimed to assess the accuracy of contrast swallow study (CSS) in measuring stricture length in comparison to endoscopy (definitive investigation for actual length measurement). METHOD: Medical records of caustic esophageal strictures between 2010 and 2020 were retrospectively reviewed. Reliability study was done to compare between radiological and endoscopic measurement of stricture length. RESULT: 124 CSSs for 91 patients were analyzed. Six studies showed no stricture, single stricture was reported in 101 studies, double strictures were reported in 16 studies, triple strictures were reported in one study (136 radiological stricture). Endoscopy revealed 133 true strictures. Number of the strictures was consistent between CSS and endoscopy in 112 studies (90.3%) and different in 12 studies (9.7%). Eight endoscopies revealed strictures not reported in CSS (5.5% false negative strictures), while 10 CSSs reported 11 strictures that were not detected during the endoscopy (7.6% false positive strictures). Reliability analysis revealed interclass correlation coefficient = 0.6 (95% CI 0.5 to 0.7) indicating moderate reliability. CONCLUSION: CSS is not accurate in assessing caustic esophageal stricture length. Combination of CSS and endoscopic investigation is better for proper evaluation of these patients. Level III of evidence.

Case report of tracheobronchial injuries after acid ingestion: CT findings with serial follow-up: Airway complication after acid ingestion.

RATIONALE: Tracheobronchial injury from acid ingestion is a less reported clinical presentation than injury of the gastrointestinal tract, but it can occur due to direct exposure from acid aspiration and cause fatal complications. PATIENT CONCERNS: A 43-year-old man presented to the emergency department after ingesting nitric acid complaining of chest pain and dyspnea. DIAGNOSES: The initial chest computed tomography (CT) images revealed an acute lung injury related to acid aspiration. The follow-up chest CT showed acute and late tracheobronchial injures. INTERVENTIONS: Bronchoscopy showed deep caustic airway injuries consisting of hemorrhage, sloughing of the mucosa, and ulceration of the trachea and left-side bronchial tree. OUTCOMES: Progressive narrowing of the left main bronchus with total collapse of the left lung occurred as a late complication of acid ingestion. LESSONS: Tracheobronchial injury should be considered in cases of aspiration pneumonia after acid ingestion; chest CT can be used to detect and assess acute and late complications of tracheobronchial injuries.

Serial anterior segment optical coherence tomography post autologous simple limbal epithelial transplantation.

A 24-year-old young man presented to us with total limbal stem cell deficiency (LSCD) in the right eye 1 year post ocular chemical burn. The patient subsequently underwent limbal biopsy in the healthy contralateral eye and autologous simple limbal epithelial transplantation in the right eye. The patient was followed up with sequential imaging of the cornea with high-resolution anterior segment optical coherence tomography (HR-ASOCT) for 3 years. The serial HR-ASOCT imaging in the operated eye showed regeneration of the epithelium from the limbal transplant over the human amniotic membrane (hAM) with integration of the transplant within the cornea with subepithelial retention of the hAM. Over the long-term follow-up, thinning of the hAM and thickening of the epithelium was noted. At 3 years, the cornea maintained an intact epithelium with no signs of recurrence of LSCD.

Corrosive injury of the upper gastrointestinal tract: the evolving role of a radiologist.

Corrosive injury is a devastating injury which carries significant morbidity. The upper gastrointestinal tract is predominantly affected with severity ranging from mild inflammation to full thickness necrosis which may result in perforation and death. Among the complications, stricture formation is most common, causing dysphagia and malnutrition. Endoscopy has a pivotal role in the diagnosis and management, with a few shortcomings. Imaging has an important role to play. Besides radiography, there is an increasing role of CT scan in the emergency setting with good accuracy in identifying patients who are likely to benefit from surgery. Further, CT scan has a role in the diagnosis of complications. Oral contrast studies help in assessing the severity and extent of stricture formation and associated fistulous complications in the subacute and chronic phase. The scope of intervention radiology for this condition is increasing. Fluoroscopy-guided balloon dilatation, drainage of collections or mucoceles, endovascular embolization of point bleeders, placement of feeding jejunostomy and image-guided biopsy are among the procedures that are being performed. Through this review we aim to stress the role the radiologist plays in the diagnosis and follow-up of these patients and in performing radiological interventions. Besides this, we have also highlighted few salient points to help understand the pathophysiology and management of such injuries which is paramount to ensure a good long-term outcome.

"Virtual Biopsies" of Normal Skin and Thermal and Chemical Burn Wounds.

The search for noninvasive methods to image and measure the mechanical properties of skin has been a frequent subject of research for many years. Although suction testing, elastography, and other testing can be noninvasive, these tests fail to yield comparable results to destructive tests such as uniaxial tensile testing. Accordingly, researchers have developed a technique to combine optical coherence tomography with vibrational analysis (vibrational optical coherence tomography) to image and analyze the biomechanical properties of tissues noninvasively and nondestructively. The result of this analysis is a "virtual biopsy" of skin, along with a physical analysis of the major components of the epidermis and dermis.In this study, the authors compare virtual biopsies of thermal and chemical burns to that of normal skin. They conclude that the enhanced optical coherence tomography images and measurements of the resonant frequency after thermal or chemical burns exhibit large differences when compared with the morphology and moduli of normal skin. Using vibrational optical coherence tomography, it is possible to follow changes in the morphology and physical properties of the epidermis and dermis associated with skin diseases and therapeutic treatments in situ.

Evaluation of severe caustic gastritis by computed tomography and its impact on management.

INTRODUCTION: Serious caustic burns of the stomach that present with no clinico-biological severity criteria (CBSC) can be treated conservatively. However, even if there are no CBSC at admission, 20% of patients still require delayed emergency surgery for peritonitis due to gastric perforation thus showing the limitations of this strategy in the diagnosis of irreversible gastric necrosis lesions. The aim of this study was to identify reliable computed tomography (CT) signs of irreversible gastric necrosis in patients with stage 3 endoscopic lesions. PATIENTS AND METHODS: In a prospective study from March 2014 to January 2017, thoraco-abdomino-pelvic CT scan was performed in 30 consecutive patients with stage 3 endoscopic gastric lesions. The CT results were concealed from the clinicians and compared to CBSC results. RESULTS: Twenty patients were treated conservatively and ten patients were operated on. Seventy percent of the patients underwent urgent delayed surgery for symptoms that developed late but before alterations in the CBSC. The CT scan showed a perfusion defect (PD) of gastric mucosal enhancement in all patients operated on for gastrointestinal distress, and could have provided an early diagnosis of irreversible gastric necrosis. CONCLUSION: CT was a more effective diagnostic tool for the diagnosis of irreversible gastric necrosis following caustic ingestion than a strategy based on digestive endoscopy and the use of CBSC. CT could eventually replace gastrointestinal endoscopy in the emergency evaluation of gastroesophageal caustic burns.

The ocular surface after simple limbal epithelial transplant (SLET): A high-resolution OCT study of the early postoperative period.

Simple limbal epithelial transplantation (SLET) is an emerging technique for treating unilateral limbal stem cell deficiency. We report the high-resolution, anterior segment optical coherence tomography (OCT) features of the first 2 weeks of a patient undergoing SLET for an old acid injury of the right eye, repeatedly from postoperative day 1 through day 14. Three out of 11 explants with the subjacent human amniotic membrane (hAM) and the overlaid bandage contact lens were imaged. The hAM was intact and of the same thickness throughout the study period; the sub-hAM space increased from day 3 to 9 and disappeared by day 10; the explants started thinning from day 3 with the fibrin around them starting to decrease from day 2 and completely disappeared by day 4. Epithelialization occurred between day 8 and 14 and proceeded more rapidly towards the limbus than centrally. There was no change of the corneal stromal thickness or reflectivity. This case report uses high-definition, spectral-domain OCT to document the events on the ocular surface after a successful SLET surgery and opens up an avenue to study epithelialization in a convenient and noninvasive manner.

Emergency Computed Tomography Predicts Caustic Esophageal Stricture Formation.

BACKGROUND: Endoscopy is the best predictor of stricture formation after caustic ingestion. OBJECTIVE: Our aim was to compare the accuracy of emergency computed tomography (CT) and endoscopy in predicting risks of esophageal stricture. METHODS: We describe a CT classification of esophageal caustic injuries: Grade I show normal esophagus; Grade IIa display internal enhancement of the esophageal mucosa and enhancement of the outer wall conferring a "target" aspect; Grade IIb present as a fine rim of external esophageal wall enhancement. In 152 patients (56 males, median age 45) who underwent esophageal preservation after caustic ingestion we compared the accuracy of the CT and endoscopic (Zargar) classifications in predicting esophageal stricture. RESULTS: On endoscopy esophageal injuries were classified as grade 1 (n = 50; 33%), grade 2a (n = 11; 7%), grade 2b (n = 19; 13%), grade 3a (n = 14; 9%), and grade 3b (n = 58; 38%). On CT, 47 (31%) patients had grade I, 47 (31%) had grade IIa and 58 (38%) had grade IIb esophageal injuries. Fifty-six (37%) patients developed esophageal strictures. The risk of esophageal stricture formation was 0%, 17%, and 83%, for grade I, IIa, and IIb CT injuries and 0, 0, 28, 50, and 76% for endoscopic grade 1, 2a, 2b, and 3a and 3b injuries, respectively. ROC curve analysis at 120 days after ingestion showed that CT outperformed endoscopy in predicting stricture formation (AUC: 85.1 [95% CI, 74.9-95.3] vs 77.8 [95% CI, 66.5-89.0], P = 0.047) and did just as well as a combined CT-endoscopy algorithm (AUC: 85.8 [95% CI, 76.5-95.0] vs 85.1 [95% CI, 74.9-95.3], P = 0.73). CONCLUSION: Emergency CT outperforms endoscopy in predicting esophageal stricture formation after caustic ingestion. Emergency endoscopy evaluation after caustic ingestion is not indispensable.

Button battery and magnet ingestions in the pediatric patient.

PURPOSE OF REVIEW: Pediatric foreign body ingestion is a common occurrence that presents a challenge both to pediatric gastroenterologists and primary care providers. Increasing prevalence of smaller, more technologically advanced toys in the household has resulted in an increased exposure to higher voltage batteries and powerful magnets that carry a high incidence of morbidity and mortality. This review highlights the latest findings regarding the patients at risk for button battery and magnet ingestions, the symptoms of presentation, and complications of these objects in contributing to long-standing gastrointestinal injury. RECENT FINDINGS: Button batteries may lead to esophageal injury within a few hours. Batteries retained in the esophagus are larger in diameter on average and size is associated with esophageal impaction as well as higher grade esophageal injury. Magnet ingestions, when multiple or with another metallic object, are often initially asymptomatic but may have acute worsening, and therefore warrant close monitoring. SUMMARY: Button battery and magnet ingestions have increased in incidence over the past two decades. Recent literature demonstrates that higher voltage, larger lithium button batteries, and prevalence of high-powered magnets can lead to significant morbidity. High suspicion, early referral, and removal may lead to improved outcomes.

SURGICAL TREATMENT OF BENING ESOPHAGEAL STRICTURES AFTER CORROSIVE INJURIES.

The research is based on the results of the examination and treatment of 156 patients who received treatment for extended benign esophageal strictures after corrosive injuries in the department of diseases of the esophagus and the gastrointestinal tract of the State Institution "V. T. Zaitsev Institute of General and Urgent Surgery of NAMS of Ukraine" for the period from 2000 to 2016. Surgical treatment by the developed in our hospital technique performed in the patients of the main group and the classical methods of surgery were used in the patients of comparison group. The developed in our clinic method of one-step transhital esophagogastroplasty with formation of a single anastomosis on the neck in patients with extended benign esophageal strictures after corrosive injuries in the state of compensation and subcompensation can be considered as a method of choice. Adequate preoperative verification of the type of extended damage by the cicatricial process of the upper part of digestive tract and the impossibility of eating in a natural way in the acute postburn period, as well as significant nutritive disorders in patients, provide the basis for two-step surgical treatment. This approach involves formation of gastrostomy at the first step for the restoration of trophological status of the patient and esophagoplasty at the second step. The two-step surgical treatment of patients with extended benign esophageal strictures after corrosive injuries with the formation of contact gastrostomy at first step and the implementation of esophagogastroplasty on the second step promotes improvement of treatment outcomes and life quality of the operated patients.

Correlation of 99mTc sucralfate scan and endoscopic grading in caustic oesophageal injury.

PURPOSE: To determine a correlation between the 99mTc sucralfate scan and the endoscopy findings in children with caustic oesophageal injury. METHODS: This is an observational analytic study of children who had both 99mTc sucralfate scan and endoscopy after caustic substance ingestion at our institution in a period between January 2009 and September 2016. The oesophageal injury was classified into low grade and high grade according to the degree of adhesion on 99mTc sucralfate scan and modification of Zargar endoscopic grading. RESULTS: Out of a total of 197 children, 40 children were identified who had both investigations done on average 26 h post-injury. Low-grade adhesion on 99mTc sucralfate scan was found in 27 children (68%), and all had low-grade Zargar's oesophageal injuries. None of these subsequently developed residual pathology. Thirteen had high-grade adhesion and five of these had high-grade injury on endoscopy. Three (23%) developed oesophageal strictures. Correlation of 99mTc sucralfate and endoscopic findings reached statistical significance with a p value of 0.0014. No morbidity was associated with either the scan or endoscopy. CONCLUSIONS: We concluded that low-grade sucralfate scan finding has the potential to successfully eliminate the need for invasive endoscopy under general anaesthesia and thereby reducing procedure-related morbidity, hospitalization and associated costs. However, mandatory endoscopy is required in children with high-grade adhesion seen on 99mTc sucralfate scan. This requires confirmation using a larger prospective study.

Risk factors for symptomatic esophageal stricture after caustic ingestion-a retrospective cohort study.

Esophageal stricture is a major secondary complication of ingesting caustic agents. We examined our experiences with caustic injuries with a view to finding clinical and biological risk factors of esophageal strictures secondary to caustic ingestion. Records were retrieved for 58 adults admitted consecutively to our intensive care unit for caustic ingestion. Fifty cases were managed conservatively and therefore retained for analyses. Patients were grouped according to whether they developed strictures or not during the follow-up period. Mucosal damage was assessed by emergency endoscopy. Eleven patients (22%) developed a stricture. At referral, dysphagia, epigastric pain, and hematemesis were associated with secondary stricture (respectively P = 0.047, P = 0.008, P = 0.02). A high Zargar endoscopic grade (above IIa; P = 0.02), the ingestion of strong acids or alkalis (P = 0.006), hyperleukocytosis (P = 0.02), and a low prothrombin ratio (P = 0.002) were associated with a higher risk of developing a stricture. The median delay of stricture diagnosis was 12 (8;16) days after ingestion, with extreme values from 4 to 26 days. Initial symptoms such as dysphagia or hematemesis, early endoscopy showing >IIa grade esophagitis, and certain laboratory results should draw the physician's attention to a high risk of esophageal stricture.

Transplanted adipose-derived stem cells can be short-lived yet accelerate healing of acid-burn skin wounds: a multimodal imaging study.

The incidence of accidental and intentional acid skin burns is rising. Current treatment strategies are mostly inadequate, leaving victims disfigured and without treatment options. Here, we have shown that transplantation of adipose-derived stem cells (ASCs) accelerates the process of acid burn wound-healing. Pre-conditioning of ASCs using ascorbic acid (AA) or hypoxic conditions provided additional benefit. While the wounds were ultimately healed in all mice, histological analysis revealed that, in non-transplanted animals, the number of hair follicles was reduced. Bioluminescent imaging (BLI) of transplanted ASCs revealed a gradual loss of transplanted cells, with a similar rate of cell death for each treatment group. The signal of fluorinated cells detected by a clinically applicable 19F MRI method correlated with the BLI findings, which points to 19F MRI as a reliable method with which to track ASCs after transplantation to skin wounds. No difference in therapeutic effect or cell survival was observed between labeled and non-labeled cells. We conclude that, despite being short-lived, transplanted ASCs can accelerate wound-healing and reduce hair loss in acid-burn skin injury. The fluorine nanoemulsion is a clinically applicable cell label capable of reporting on the survival of transplanted cells.

Corrosive-Induced Carcinoma of Esophagus: Esophagographic and CT Findings.

OBJECTIVE: The purpose of this study was to evaluate the esophagographic and CT findings of corrosive esophageal cancer. MATERIALS AND METHODS: The records of all patients who presented with corrosive esophageal strictures at one institution between June 1989 and April 2015 were retrospectively identified. The search yielded the records of 15 patients with histopathologically proven esophageal cancer. Esophagograms (13 patients) and chest CT images (14 patients) were interpreted independently by two reviewers. Esophagographic findings included the location of tumor, morphologic type, presence and length of mucosal irregularity, presence of asymmetric involvement, and presence of rigidity. CT findings included presence and type of esophageal wall thickening, pattern of enhancement, presence of periesophageal infiltration, and presence of hilar or mediastinal lymphadenopathy. RESULTS: Esophagography showed that the tumor was involved with the stenotic portion in 10 of the 13 patients (76.9%). The most common morphologic feature was a polypoid mass, in 10 patients. In 12 patients (92.3%), mucosal irregularities were observed; the mean affected length was 4.92 cm. Asymmetric involvement and rigidity were observed in nine patients (69.2%). On CT scans, eccentric wall thickening was observed in 10 of the 14 patients (71.4%), homogeneous enhancement in nine (64.2%), and periesophageal infiltration in 11 (78.5%). CONCLUSION: Esophagography commonly shows corrosive esophageal cancer as a polypoid mass with long-segment mucosal irregularities at the stenotic portion, asymmetric involvement, and rigidity. CT shows eccentric esophageal wall thickening with homogeneous enhancement and periesophageal infiltration, which are suggestive of the development of malignancy in patients with corrosive esophageal strictures.

Caustic esophageal injury by impaction of cell batteries.

The ingestion of cell batteries can cause serious complications (fistula, perforation or stenosis) at the esophageal level. The damage starts soon after ingestion (approximately 2 hours) and is directly related to the amount of time the battery is lodged in said location, the amount of electrical charge remaining in the battery, and the size of the battery itself. Injury is produced by the combination of electrochemical and chemical mechanisms and pressure necrosis. The ingestion of multiple cells and a size > = 20 mm are related with more severe and clinically significant outcomes. A female patient, 39 years old, with a history of previous suicide attempts, was admitted to the Emergency Room with chest pain and dysphagia after voluntary ingestion of 2 cell batteries. Two cell batteries are easily detected in a routine chest X-ray, presenting a characteristic double-ring shadow, or peripheral halo. Urgent oral endoscopy was performed 10 hours after ingestion, showing a greenish-gray lumpy magma-like consistency due to leakage of battery contents. The 2 batteries were sequentially removed with alligator-jaw forceps. After flushing and aspiration of the chemical material, a broad and circumferential injury with denudation of the mucosa and two deep ulcerations with necrosis were observed where the batteries had been. The batteries' seals were eroded, releasing chemical contents. Despite the severity of the injuries, the patient progressed favorably and there was no esophageal perforation. Esophageal impaction of cell batteries should always be considered an endoscopic urgency.

Computed Tomography Evaluation of Esophagogastric Necrosis After Caustic Ingestion.

BACKGROUND: Endoscopy is the standard of care for emergency patient evaluation after caustic ingestion. However, the inaccuracy of endoscopy in determining the depth of intramural necrosis may lead to inappropriate decision-making with devastating consequences. Our aim was to evaluate the use of computed tomography (CT) for the emergency diagnostic workup of patients with caustic injuries. METHODS: In a prospective study, we used a combined endoscopy-CT decision-making algorithm. The primary outcome was pathology-confirmed digestive necrosis. The respective utility of CT and endoscopy in the decision-making process were compared. Transmural endoscopic necrosis was defined as grade 3b injuries; signs of transmural CT necrosis included absence of postcontrast gastric/ esophageal-wall enhancement, esophageal-wall blurring, and periesophageal-fat blurring. RESULTS: We included 120 patients (59 men, median age 44 years). Emergency surgery was performed in 24 patients (20%) and digestive resection was completed in 16. Three patients (3%) died and 28 patients (23%) experienced complications. Pathology revealed transmural necrosis in 9/11 esophagectomy and 16/16 gastrectomy specimens. Severe oropharyngeal injuries (P = 0.015), increased levels of blood lactate (P = 0.007), alanine aminotransferase (P = 0.027), bilirubin (P = 0.005), and low platelet counts (P > 0.0001) were predictive of digestive necrosis. Decision-making relying on CT alone or on a combined CT-endoscopy algorithm was similar and would have spared 19 unnecessary esophagectomies and 16 explorative laparotomies compared with an endoscopy-alone algorithm. Endoscopy did never rectify a wrong CT decision. CONCLUSIONS: Emergency decision-making after caustic injuries can rely on CT alone.