Management of Esophageal Caustic Injury
Management of Esophageal Caustic Injury
Management of Esophageal Caustic Injury
EDITORIAL
Mark Anthony A De Lusong, Aeden Bernice G Timbol, Danny on the gastrointestinal system maintain its place as an
Joseph S Tuazon, Section of Gastroenterology, Department important public health issue in spite of the multiple
of Medicine, Philippine General Hospital, University of the efforts to educate the public and contain its growing
Philippines, Manila 01004, Philippines number. This is due to the ready availability of caustic
agents and the loose regulatory control on its production.
Author contributions: All authors gathered the available
literature; Tuazon DJS made the initial draft; Timbol ABG
Substances with extremes of pH are very corrosive and
added the tables, figures, and algorithm and made revisions on can create severe injury in the upper gastrointestinal
the article; De Lusong MAA made critical revisions and final tract. The severity of injury depends on several aspects:
approval of the version to be published. Concentration of the substance, amount ingested, length
of time of tissue contact, and pH of the agent. Solid
Conflict-of-interest statement: All authors have no conflict materials easily adhere to the mouth and pharynx, causing
of interest to declare. All authors have seen and approved the greatest damage to these regions while liquids pass
manuscript submitted. The article has not received prior publication through the mouth and pharynx more quickly consequently
and is not under consideration for publication elsewhere. producing its maximum damage in the esophagus and
stomach. Esophagogastroduodenoscopy is therefore a
Open-Access: This article is an open-access article which was
highly recommended diagnostic tool in the evaluation of
selected by an in-house editor and fully peer-reviewed by external
reviewers. It is distributed in accordance with the Creative caustic injury. It is considered the cornerstone not only in
Commons Attribution Non Commercial (CC BY-NC 4.0) license, the diagnosis but also in the prognostication and guide
which permits others to distribute, remix, adapt, build upon this to management of caustic ingestions. The degree of
work non-commercially, and license their derivative works on esophageal injury at endoscopy is a predictor of systemic
different terms, provided the original work is properly cited and complication and death with a 9-fold increase in morbidity
the use is non-commercial. See: http://creativecommons.org/ and mortality for every increased injury grade. Because of
licenses/by-nc/4.0/ this high rate of complication, prompt evaluation cannot
be overemphasized in order to halt development and
Manuscript source: Invited manuscript prevent progression of complications.
Correspondence to: Mark Anthony A De Lusong, MD, Section
Key words: Caustic ingestion; Esophageal caustic; Caustic
of Gastroenterology, Department of Medicine, Philippine General
Hospital, University of the Philippines, Taft Avenue, Manila 01004, injury; Corrosive ingestion; Esophageal injury
Philippines. delusongmd@gmail.com
Telephone: +639-02-5548400-2075 © The Author(s) 2017. Published by Baishideng Publishing
Fax: +639-02-5672983 Group Inc. All rights reserved.
Received: October 15, 2016 Core tip: Caustic ingestion maintains its place as an
Peer-review started: October 19, 2016 important public health issue in spite of the multiple
First decision: November 14, 2016 efforts to educate the public. This is due to the ready
Revised: February 25, 2017 availability of caustic agents and the loose regulatory
Accepted: March 12, 2017
control on its production. Substances with extremes of
Article in press: March 14, 2017
pH are very corrosive and can create severe injury in
Published online: May 6, 2017
the upper gastrointestinal tract. Locations most seriously
affected are in the esophagus and stomach and may
lead to chronic complications like stricture formation,
gastric outlet obstruction, and malignant transformation.
Abstract Prompt evaluation is therefore emphasized in order
Ingestion of caustic substances and its long-term effect to halt development and prevent progression of these
[4]
complications. liquid form and events commonly occurred at home .
Indian data, on the other hand, showed that majority of
ingestions in their country were due to acids since these
De Lusong MAA, Timbol ABG, Tuazon DJS. Management were cheaper and more readily available .
[3,4]
It is for this reason that authorities advocate avoiding because of the liquefactive necrosis caused by alkali
th th
endoscopy between the 5 and the 15 day after caustic agents, which causes a deeper penetration of injury
[3,6] rd
ingestion . By the 3 week, scar retraction occurs compared to the less severe and often limited mucosal
and may continue for a few more months until stricture injury of acidic substances. Periodic endoscopic evaluation
formation occurs. The lower esophageal sphincter is therefore suggested starting 20 years after the caustic
pressure becomes also impaired in the process causing ingestion with an interval of 1 to 3 years.
an increased frequency and severity of acid reflux
that further aggravates existing mucosal injury and
[7]
accelerates the stricture formation . DIAGNOSIS AND STAGING
The severity of injury depends on several aspects: Laboratory tests
concentration of the substance, amount ingested, length Laboratories were not found to directly correlate with
of time of tissue contact, and pH of the agent. Solid the severity or the outcome of the injury. One study
materials easily adhere to the mouth and pharynx, showed that age, an elevated white blood cell count
causing greatest damage to these regions. Liquids, on (> 20000 cells/mm), and the presence of gastric deep
the other hand, pass through the mouth and pharynx ulcer or gastric necrosis are independent predictors of
[9]
more quickly consequently producing its maximum death . Basically, laboratory work-ups play a more
[7,8]
damage in the esophagus and stomach . important role in guiding patient management than in
[7,8]
predicting morbidity or mortality .
A B C
D E F
Figure 1 Endoscopic pictures of Zargar classification 0 to ⅢB. A: Zargar Grade 0: Normal mucosa; B: Zargar Grade Ⅰ: Edema and erythema of the mucosa; C:
Zargar Grade ⅡA: Hemorrhage, erosions, blisters, superficial ulcers; D: Zargar Grade ⅡB: Circumferential bleeding, ulcers. Exudates; E: Zargar Grade ⅢB: Focal
necrosis, deep gray or brownish black ulcers; F: Zargar Grade ⅢB: Extensive necrosis, deep gray or brownish black ulcers.
mucosal healing and to prevent stress ulcers. Efficacy maintains that patients treated with steroids should also
[16]
of these agents for caustic ingestion has not yet been be treated with antibiotics .
proven, although a small study done in 2013 has shown
Steroids
[7,16,19]
endoscopic healing after omeprazole infusion .
Sucralfate is now a common adjunct in the manage Initial studies on corticosteroid administration to prevent
ment of acute ulcers. It achieves its therapeutic effect by stricture formation in caustic ingestion were mainly on
maintaining mucosal vascular integrity and blood flow. In children and results were conflicting. Methylprednisolone
the setting of caustic ingestion, sucralfate is said to hasten 2
at a dose of 1 g/1.73 m per day for 3 d showed benefit
mucosal healing by providing a physical barrier between [25]
in reducing stricture development . Likewise, dexame
the harmful effects of the corrosive substance and the thasone (1 mg/kg per day) was shown to be better than
[20-22]
gastroesophageal mucosa . Several small randomized prednisolone (2 mg/kg per day) in preventing stricture
controlled studies have assessed the efficacy of sucralfate formation (38.9% vs 66.7%) and severe stricture
in corrosive esophagitis. Results from these studies showed development (27.8% vs 55.6%) .
[26]
that sucralfate may decrease the frequency of stricture However, another study showed that prednisolone
formation with advanced corrosive esophagitis. However, at a dose of 2 mg/kg intravenous did not provide
further research with a larger sample size is required to any benefit in preventing stricture development . A
[27]
[20,23]
support its recommended use in this setting . systematic pooled analysis of caustic ingestion supported
this finding as it failed to show additional benefit with
Antibiotics the use of steroid in patients with grade II esophageal
[28]
To date, evidence is still conflicting with regard the use burns . Based on the above evidence, it seems prudent
of antibiotics. A study in 1992 analyzed the utility of to avoid systemic corticosteroids in caustic ingestion until
antibiotic together with systemic steroid administration in further research confirms its efficacy.
caustic ingestion. It was concluded that antibiotics with
steroids may be useful in preventing strictures in patients Triamcinolone and mitomycin-C
[24]
with extensive burns . But since it was not possible Intralesional steroid such as triamcinolone (40-100 mg/
to separate the effect of the antibiotic from that of the session) has long been known to augment the dilatation
possible effect of the steroid in this study, it may be difficult of caustic-induced esophageal strictures although
[29,30]
to support the use of antibiotic in preventing stricture results from most studies are still conflicting .
formation with such limited data. Hence, the consensus Recently, mitomycin C has been shown to decrease
Time of ingestion
Type of substance (concentration)
Volume of ingested material
History and physical examination
Presence of co-ingestion
Signs and symptoms of burn, tissue damage (dysphagia, odynophagia, bleeding, etc .),
respiratory and cardiovascular instability
Specific measures
Figure 2 Management algorithm for caustic substance ingestion. CT: Computed tomography; GI: Gastroenterology; ICU: Intensive care unit.
[35]
the rate of caustic stricture formation in animals due achieved compared to triamcinolone .
[31]
to its antifibroblastic properties . It has been used as
[32-34]
an adjunct after dilatation of caustic strictures in
humans (including those with long strictures) by applying ENDOSCOPY
[34,35]
mitomycin-C topically at a dose of 0.4 mg/mL . In Endoscopy is important not only in the diagnosis of
a study of 16 patients treated with endoscopic topical corrosive ingestion but also in determining subsequent
application of mitomycin-C, a decrease in the number management. In general, patients with normal looking
of dilatations and apparent relief of dysphagia were mucosa or those with very mild injury may be dischar
ged. For those with Zargar grade Ⅰ or ⅡA, in-hospital biodegradable (BD) stent - each with its own advantage
observation is advised and gradual progression of diet and disadvantage.
from liquids is done in the next 24 to 48 h. Patients SEMS are often discouraged in benign esophageal
with at least grade ⅡB are monitored more closely. An stenosis due to its high rate of necrosis and ulceration,
endoscopically-guided nasoenteric feeding tube may be tissue hyperplasia, new stricture or fistula formation,
placed with caution, bypassing the areas of necrosis, and the tendency for the metal portion to embed within
to facilitate feeding while initiating trial of per orem the esophageal wall. Plastic stents are said to have
feeding. For grade Ⅲ injuries, the patient’s response to lesser tissue hyperplasia but with higher rate of stent
treatment and feeding is usually observed for at least a migration and lower tendency to sustain significant
[14]
week . Prophylactic esophageal stenting in the acute radial force. Both of these stents require repeated endo
[36]
setting is generally not recommended due to a high scopic intervention for stent retrieval. Recently, BD have
perforation rate. been introduced in the hopes of avoiding the above
complications and the need for re-intervention for stent
[42]
extraction .
LATE COMPLICATIONS AND A study in 2012 compared these 3 stents in patients
MANAGEMENT with refractory benign esophageal stenoses. In this
study, long-term resolution of dysphagia was highest in
Esophageal stricture is one of the most common se
the metal stents group (40%) compared to BD stents
quelae of caustic injury. Up to 70% of patients with grade
(30%) and plastic stents (10%). Tissue migration was
ⅡB and more than 90% of patients with grade Ⅲ injury
[37] highest in the plastic stent group and lowest in the
are likely to develop esophageal stricture . [43]
BD stent group . To date, there is still no ideal stent
Peak development of strictures commonly starts
th recommended for universal use among patients with
on the 8 week post-ingestion, although it has been
[7,37,38] benign esophageal strictures, the choice for each patient
reported to occur as early as 3 wk . The timing of [44]
should be individualized .
management is crucial in achieving long-term functional
effects.
Surgery
Corrective surgery for esophageal strictures from caustic
Endoscopic dilatation
injury is done only in severe cases where endoscopic
The primary non-surgical treatment of caustic esophageal
therapy fails or is deemed harmful. Surgical options
stricture is endoscopic dilatation. This can be achieved
with Bougies or balloon dilators. For tight and fibrotic include partial or total esophagectomy with gastric
[38]
strictures, bougies dilators are often more reliable than pull up or, preferably colonic interposition . Gastric
[37]
balloon dilators . A prospective study published in 2015 pull-up in general, is quicker and requires only one
assessed a rigorous weekly schedule of bougie dilatation anastomosis. However, the long-term functional outcome
(Savary-Gilliard) along with intralesional triamcinolone in may decrease with development of complications such
patients with refractory esophageal corrosive strictures. as recurrence of stricture, bothersome reflux, and
[7,16,45-52]
It was noted that this intervention was safe and effective subsequent metaplasia over the anastomotic site .
in improving dysphagia, achieving clinically significant On the other hand, colon interposition is a more complex
dilatation, reducing dilatation frequency, maintaining procedure requiring 3 anastomoses, albeit with a more
luminal patency of ≥ 14 mm
[14,39]
. stable long-term functional outcome. It is often asso
Using balloon dilators, a lower dilatation force should ciated with a lower incidence of stricture formation than
[40]
be used initially to avoid perforation . This may need gastric pull-up hence its preferential use in the setting
[16]
to be repeated and advanced slowly to achieve effective of a relatively spared and healthy stomach . Mortality
and safe dilatation. The interval between dilatations rates of late reconstructive surgery depend on local
[16]
varies from 1-3 wk among different studies but usually surgical expertise.
an interval of 3-4 wk is recommended.
For either technique, the goal is to achieve relief of
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