Lesiones por cáusticos del tracto digestivo superior: características clínicas y endoscópicas / Caustics injuries in the upper gastrointestinal tract: clinical and endoscopic features

Describir las características clínicas y endoscópicas de las lesiones producidas por cáusticos en el tracto digestivo superior en pacientes del Hospital Nacional Daniel Alcides Carrión. Materiales y métodos: Se realizó un estudio descriptivo, se incluyó a pacientes con diagnóstico de ingesta de cáusticos admitidos en el servicio de Gastroenterología del HNDAC para la realización de una endoscopia digestiva alta durante el periodo de enero del 2009 a diciembre del 2012. Se documentó el tipo de sustancia cáustica ingerida, causa de ingesta, cantidad ingerida, modo de ingesta, síntomas o signos presentes, hallazgos endoscópicos según la clasificación de Zargar, presencia de complicaciones y tratamiento realizado. Se realizó el análisis descriptivo comparándolos según la sustancia cáustica ingerida: ácido o álcali. Resultados: Se obtuvieron 91 pacientes, la edad promedio fue de 30,6 +/- 16,3 años. Las sustancias caústicas ingeridas fueron: lejía (hipoclorito de sodio) en 71 (78%) pacientes, ácido muriático (ácido clorhídrico) en 18 (20%) pacientes, soda cáustica en 2 (2%) pacientes. La cantidad promedio ingerida fue de 136ml (entre 30-500 ml). Los síntomas y signos más frecuentes fueron: vómitos, dolor abdominal, náuseas y odinofagia. El 46% de los pacientes presentaron lesiones. El 100% de los pacientes que ingirieron ácido y el 33% de los que ingirieron álcali presentaron lesiones. Cinco (5%) pacientes presentaron lesiones orofaríngeas, 24 (26%) en esófago, 36 (40%) en estómago y 12 (13%) en duodeno. Se encontró 10 (11%) pacientes con lesiones de grado I, 16 (18%) pacientes con lesiones de grado II y 15 (16%) de pacientes con lesiones de grado III; 12 pacientes que consumieron ácido presentaron lesiones de grado III. Estenosis esofágica se encontró en 2 (2%) pacientes, estenosis gástrica en 7 (8%) pacientes y estenosis esofágica y gástrica en 3 (3%) pacientes. Dos pacientes requirieron dilataciones neumáticas y 10 tratamiento quirúrgico...

To describe the clinical and endoscopic features of caustics injuries in the upper gastrointestinal tract in patients of the National Hospital Daniel Alcides Carrión. Materials and methods: A descriptive study was conducted; the study populations were patients diagnosed with caustic ingestion who were admitted into the Gastroenterology service of the HNDAC to perform an upper endoscopy during the period of January 2009 to December 2012. We documented the type of caustic substance ingested, cause of intake, amount ingested, intake mode, signs or symptoms present, endoscopic findings as classified by Zargar, presence of complications and treatment performed. Analysis was performed comparing them based on the ingested caustic type: acid or alkali. Results: We obtained 91 patients; the average age was 30.6 +/- 16.3 years. Caustic substances ingested were: bleach (sodium hypochlorite) in 71 (78%) patients, muriatic acid (hydrochloric acid) in 18 (20%) patients, caustic soda in 2 (2%) patients. The average intake was 136ml (30-500 ml). The most frequent signs and symptoms were vomiting, abdominal pain, nausea and sore throat. The 46% of patients had injuries. 100% of patients who ingested acid and 33% who ingested alkali had lesions. Five (5%) patients had oropharyngeal lesions, 24 (26%) in the esophagus, 36 (40%) in the stomach and 12 (13%) in the duodenum. Grade I lesions were found in 10 (11%) patients, 16 (18%) patients with grade II lesions and 15 (16%) of patients with grade III, 12 patients who toke acid had lesions of grade III. Esophageal stricture was found in 2 (2%) patients, gastric stenosis in 7 (8%) patients and esophageal and gastric stenosis in 3 (3%) patients. Two patients required pneumatic dilation and 10 surgical treatments...

Successful management of oesophageal conduit necrosis by a single-stage reconstruction with the pedicled pectoralis major myocutaneous flap.

Conduit necrosis is a rare but potentially devastating complication of oesophageal surgery and the subsequent reversal of oesophageal discontinuity can be challenging. An option for both cervical-oesophageal reconstruction and neck wound closure has been limited and less successful. We report a patient with colon conduit necrosis and cervical-oesophageal discontinuity whose cervial oesophagus was successfully reconstructed with a single-stage pedicled pectoralis major myocutaneous flap and neck wound closure.

[Complex case with respiratory, endocrine and digestive manifestations--late complications after a colic replacement of the esophagus for lye ingestion]. / Caz complex cu tulburari respiratorii, endocrine si digestive--complicatii tardive post-esofagoplastie cu colon pentru ingestie de soda caustica.

Long term complications after colic replacement of the esophagus are well known and their managment is known as being difficult, due to multiple associated comorbidities; we present the case of a 26-year-old patient with multiple late complications after a coloesophagoplaty for lye ingestion during childhood. The patient finally died despite all the eforts of treatement during a prolonged hospitalisation. We will try to analyse the key moments on patient's evolution and discuss other possible options in this case.

Deaths related to chemical burns.

The authors present a series of 6 deaths due to the uncommon cause of chemical burns. Of the 6 deaths due to chemical burns, 4 deaths were due to ingestion of a chemical, 1 death was caused by chemical burns of the skin, and 1 death resulted from rectal insufflation of a chemical. Seven additional cases where chemical burns may have been a contributing factor to the death or an incidental finding are also presented. Four cases are related to an incident involving chemical exposure during an industrial explosion. Three cases involve motor fuel burns of the skin. Two cases concern a plane crash incident, and 1 case involved a vehicular collision. Cases are derived from the records of the Dallas County Medical Examiner's Office and those of the authors' consultation practices. Each of the cases is presented, followed by a discussion of the various mechanisms of chemical injury.

Esofagitis y gastritis cáustica / Esophagitis and caustic gastritis

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Thoracoscopic-assisted esophagectomy and laparoscopic gastric pull-up for lye injury.

BACKGROUND: Acquired esophageal strictures in children are often the result of ingestion of caustic agents. We describe 2 children with severe esophageal strictures following lye ingestion, who successfully underwent esophagectomy and gastric pull-up utilizing combined thoracoscopic and laparoscopic techniques. METHODS: This was a retrospective chart analysis of both patients. CASE 1: A 17-year-old female, who ingested a lye-containing substance, which lead to the need for gastrostomy and esophageal dilatations, developed an esophageal stricture. Thoracoscopic esophagectomy, laparoscopic gastric conduit creation, pyloroplasty, gastric pull-up, and esophagogastric anastomosis was performed one year later. She was tolerating a regular diet for almost 4 years following esophageal replacement when she developed a gastric ulcer with gastrobronchial fistula that required open repair via a right thoracotomy. She has since recovered and resumed her regular diet. CASE 2: A 13-month-old female who ingested a lye-based cleaner underwent tracheostomy and gastrostomy on the day of injury, and esophageal dilatations beginning 1 month later. Despite dilatations, she developed severe strictures for which at age 21 months she underwent thoracoscopic esophageal mobilization, laparoscopic creation of gastric conduit, pyloroplasty, and esophagogastric anastomosis. A right thoracotomy was necessary to negotiate the conduit safely up to the neck. She is tolerating feeds and has not developed any complications for nearly 3 years following esophageal replacement. CONCLUSIONS: Esophagectomy and gastric pull-up for esophageal lye injuries can be accomplished utilizing a combination of thoracoscopy and laparoscopy with excellent results. Long-term follow-up is necessary to manage potential complications in these patients.

Esophageal replacement using a reversed gastric tube for lye stricture in a child: report of a case.

A 5-year-old girl ingested lye, a detergent used in electric dishwashers. She was transferred to our hospital after balloon dilatation, performed for stenosis resulting from corrosive esophagitis, was complicated by esophageal perforation causing mediastinitis. Although the mediastinitis resolved with conservative treatment, the stenosis did not improve. Therefore, we performed esophageal replacement using a reversed gastric tube, which successfully relieved the obstruction, although she still had slight gastroesophageal reflux 6 months postoperatively.

Effects of caustic lye injury to the esophageal smooth muscle reactivity: in vitro study.

PURPOSE: We investigated late effects of caustic lye injury on esophageal smooth muscle reactivity in the rat model. MATERIALS AND METHODS: Male Sprague-Dawley rats were divided into two groups. Through a median laparatomy incision, abdominal esophageal segment was isolated. Orogastric and gastric (via gastrotomy) catheters were placed and tied over the isolated esophageal segment. Saline (0.9%) or 50% sodium hydroxide (1 ml) solution were instilled via orogastric catheter to the isolated segment in the control and caustic esophagus (CE group) groups, respectively. Then, the esophagus was rinsed with 0.9% saline via gastric catheter. The esophagus was removed and studied in organ chambers 28 days after the operation. RESULTS: Carbachol- and KCl-induced contractile responses of esophageal smooth muscle were significantly reduced in the CE group with decreased E(max) value compared with the control group. Relaxant responses to serotonin were significantly reduced in the CE group with decreased E(max) value compared with the control group. No significant differences were found in E(max) and pD(2) values for papaverine acting on esophageal strips from the two groups. CONCLUSION: The results provide evidence that, a surgically created caustic injury causes impaired smooth muscle reactivity that may contribute to esophageal motor dysfunction.

Colon-patch oesophagoplasty.

Colon-patch oesophagoplasty has been tried experimentally and used clinically to treat benign strictures of the oesophagus in children. However, reports are few. We advocate this operation and report on two cases where this technique was employed for caustic stricture using a vascularized colon patch avoiding the need for oesophageal substitution. This procedure has its immediate and late complications but after a long follow-up we are satisfied with our results. Patching is a useful alternative to substitution for limited benign strictures of oesophagus in children.

Pancreaticoduodenal necrosis due to caustic burns.

BACKGROUND AND METHODS: Fourteen patients with caustic necrosis of the digestive tract extending beyond the pylorus were included in a multicenter retrospective study to define a surgical strategy. Twelve patients underwent esophagogastrectomy. Two patients had total gastrectomy without esophagectomy. In addition, all patients underwent duodenal stripping (n = 7) or pancreaticoduodenectomy (n = 7). Immediate biliopancreatic reconnection was performed in ten patients. Four patients had biliary diversion and/or pancreatic duct ligation. RESULTS: Seven in-hospital deaths occurred after a mean delay of 27 days (range 16-45 days). There were two late deaths occurring 6 and 12 months postoperatively. Morbidity was noted in 86% of survivors. Acute or chronic airway tract injuries were incurred by 57% of patients. Among the five long-term survivors two were able to feed orally and had preserved voice function. One long-term survivor could resume oral feeding only, another was considered psychologically unfit for digestive reconstruction but had normal voice function and the last patient was deprived of oral feeding and phonation. CONCLUSIONS: Early radical debridement is capable of saving patients with gastrointestinal necrosis extending beyond the pylorus. Necrosis of the duodenum can be managed by pancreaticoduodenectomy or by duodenal stripping, with similar results. Immediate reconnection of the bile and pancreatic ducts to a small bowel Roux-en-Y loop appears preferable to biliary diversion and pancreatic duct ligation. Normal oral feeding and the preservation of voice function can sometimes be achieved but depends on late scarring of the airway-alimentary tract junction. Quality of life is often compromised by prolonged hospital stays, staged surgical procedures and the handicap of a feeding jejunostomy and tracheal tube.

The preventive effect of heparin on stricture formation after caustic esophageal burns.

BACKGROUND/PURPOSE: Preventing thrombus formation after caustic esophageal ingestion has been proposed to have beneficial effects. Therefore, an experimental study was carried out to investigate the effects of heparin on the esophagus after caustic burns. METHODS: Caustic esophageal burns were produced in rats by irrigation with 50% NaOH as described by Liu. Rats were divided into four groups as follows: group A, animals with esophageal burns, received placebo and underwent autopsy 48 hours after caustic injury; group B, animals with esophageal burns, received subcutaneous heparin treatment and underwent autopsy 48 hours after caustic injury; group C, animals with esophageal burns, received placebo and underwent autopsy 28 days after caustic injury; group D, animals with esophageal burns, received subcutaneous heparin treatment for 7 days and underwent autopsy 28 days after caustic injury. Histopathologic evaluation was performed in all groups, and collagen content of esophageal sections was analyzed by determination of hydroxyproline levels. RESULTS: Submucosal vascular thrombosis was encountered in all group A animals but the submucosal venules and arterioles were patent in most of group B animals. Esophageal strictures did not develop in any of group D animals, although varying degree of esophageal stenoses were encountered in all animals of group C. The circumferences of the burned segment have been narrowed to 3+/-1 mm in group C rats. There was obvious collagen deposition in submucosa, and epithelial regeneration was not complete in group C rats. Submucosa and epithelial integrity seemed normal in group D animals. Hydroxyproline contents in group D were significantly lower compared with group C (P < .05). CONCLUSIONS: Heparin has ameliorating effects on stricture formation after caustic esophageal burn. Those effects may occur through possible anticoagulant, antithrombotic, and endothelial protective effects, and modifying effects of heparin on wound healing.

Acute colitis caused by caustic products.

We report two cases of acute proctocolitis caused by rectal application of caustic products of domestic use. One 61-yr-old woman applied an ammonia solution enema; the other patient, a 63-yr-old woman, accidentally applied an enema containing lye. Both patients presented with intense anal pain, but the first patient also had abdominal pain with guarding, hematochezia, and leucocytosis. An acute proctocolitis was found at sigmoidoscopy in both patients. Only conservative and symptomatic measures were prescribed in both cases, and a clinical and endoscopic recovery was seen. In spite of persistent fibrosis in the lamina propria, no signs of stenosis were found.

Alpha/beta- and gamma/delta-T-cell-receptor-positive lymphocytes in healthy and inflamed human conjunctiva.

BACKGROUND: The possible existence and distribution patterns of alpha/beta- and gamma/delta-TCR+ cells, which are important constituents of immune surveillance and act via the CD3+ cell complex have not yet been elucidated in the healthy and inflamed conjunctiva. MATERIALS AND METHODS: Paraffin-embedded conjunctival specimens included 18 from 18 patients with ocular cicatricial pemphigoid (OCP), 20 from 20 healthy controls, 6 from 6 patients with lye burns, and 6 from 2 patients with Stevens-Johnson syndrome; all were worked up by histology and immunohistochemistry. RESULTS: alpha/beta-TCR+ cells were visualized in the conjunctival epithelium and stroma of healthy persons, OCP, lye burns and Stevens-Johnson syndrome. alpha/ beta-TCR+ cells and a small number of gamma/delta-TCR+ cells were observed in the corneal epithelium and stroma of patients who have failing corneal grafts. After ileal mucosa transplantation to the epibulbar conjunctiva, membrane staining changes to nuclear and cytoplasmic staining. Treatment with systemic cytotoxic drugs abolishes all alpha/beta-TCR+ and gamma/delta-TCR+ cells. CONCLUSIONS: alpha/beta-TCR+ cells can be found in the non-infected epithelium and stroma of the healthy and inflamed (OCP, lye burns, and Stevens-Johnson syndrome) conjunctiva, as well as in the corneal epithelium and stroma of failing corneal grafts, whereas gamma/delta-TCR+ cells are absent. A small number of gamma/delta-TCR+ cells are present in the corneal stroma and adjacent conjunctival epithelium of patients with chronic corneal graft rejection or after transplantation of gut tissue. Further investigations may establish the role, if any, of these T-cell subsets in immune surveillance of the non-infected outer eye and in corneal graft rejection.

Chronic esophagitis evolving to verrucous squamous cell carcinoma: possible role of exogenous chemical carcinogens.

BACKGROUND & AIMS: A patient exposed to aerosolized lye and ingested kerosene was followed up for 16 years with chronic esophagitis before developing verrucous esophageal squamous carcinoma. The aim of this study was to elucidate the pathogenesis of the carcinoma. METHODS: Multiple biopsy specimens were graded according to the severity of esophagitis and dysplasia. Molecular biological techniques and immunocytological assay were used to look for human papillomavirus infection, p53 mutations, loss of heterozygosity for TP53 and chromosome 8 markers, and ras mutations. RESULTS: Morphological features of the chronic esophagitis in this patient were similar to the precancerous lesions from high-risk areas for esophageal squamous cancer and the precancerous lesions induced in rats by N-methyl-N-nitrosoaniline. Gastroesophageal acid reflux and human papillomavirus infection were ruled out. No loss of heterozygosity of p53 or for chromosome 8 markers was found. Mutations of the ras oncogene were not identified. By immunocytological assay overexpression of p53 was identified only in the invasive portion of the carcinoma. CONCLUSIONS: In this patient, verrucous squamous carcinoma evolved from chronic esophagitis, squamous papillary hyperplasia, and dysplasia. Although exogenous carcinogens may have been important, they probably did not act by causing loss of heterozygosity or ras mutations. p53 overexpression occurred late.

Reconsidering the diagnosis and treatment of patients following ingestion of liquid lye.

Concentrated lye rapidly produces liquefaction necrosis, which can completely dissolve organs of the upper gastrointestinal tract, damaging adjacent structures including, in rare instances, even the transverse colon. Patients so afflicted will survive only if the injury is promptly detected and treated by radical surgical extirpation of all necrotic tissue. Symptoms are unreliable, and definitive diagnosis requires endoscopic evaluation. For years endoscopists were warned to stop at the first site of injury to avoid perforation of the damaged esophagus, but fiberoptic instruments now allow panendoscopy to be safely performed in almost all cases. Endoscopy alone, however, cannot detect extraluminal injury. If there is visual evidence of injury to the duodenum, computed tomography should be routine to search for injury to adjacent structures. Even in the absence of duodenal injury, computed tomography may prove valuable in assessing and managing patients with extensive damage to the esophagus or stomach. In cases of mediastinal or intraabdominal visceral necrosis, steroid therapy, by depressing the patient's ability to mount an inflammatory response, might worsen the injury and lead to life-threatening sepsis. The use of corticosteroids to treat patients following ingestion of caustic substances should therefore be abandoned as both ineffective and potentially dangerous.