11.2.2005 Dr. Uday C Ghoshal MD, DNB, DM, FACG, Rome Foundation Fellow Professor, Department of Gastroenterology, SGPGI, Lucknow, India Panelists Dr. M.L. Thakur, Dr. A. Chaudhary, Dr. S.A. Zargar, Dr. S.K.Sinha, Dr. Ashish Kumar Jha, Dr. K. Mohandas, Dr. Sandeep Nijhawan
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11.2.2005
Dr. Uday C Ghoshal MD, DNB, DM, FACG, Rome Foundation Fellow
Professor, Department of Gastroenterology, SGPGI, Lucknow, India
PanelistsDr. M.L. Thakur, Dr. A. Chaudhary, Dr. S.A. Zargar, Dr. S.K.Sinha, Dr. Ashish
Kumar Jha, Dr. K. Mohandas, Dr. Sandeep Nijhawan
• Corrosive ingestion: A major public health issue1
• Age: Common in children (80%), accidental
• Adult: Commonly suicidal, often life-threatening
Type of ingestion2
• Western country: Most common substance is alkali
A. Such perioral injury is usually associated with severe esophageal injury
B. Such situation is related to less severe internal injury
C.There is no relationship between these two
D.Don;t know
• Priority Airway, Breathing and Circulation (ABC)
• In unstable airway Intubation under fiberoptic laryngoscopy Tracheostomy may be required
• Gastric lavage Contraindicated
• Milk & water As antidotes or to dilute corrosive is not proven
• pH neutralization Not recommended (fear of exothermic reaction, which may increase the damage)
Corticosteroids: In patients with respiratory involvement, who should also receive broad spectrum antibiotics
Acute management?
• Routine use of NG tube: not recommended
• Best approach: NG tube placement should be individualized
Nasogastric tube
Advantage: Disadvantage:
Helpful to ensure patency of esophageal lumen
Itself leads to long stricture
Providing a lumen for dilatation of tight stricture
Nidus for infection
Worsening of gastroesophageal reflux
Delay in mucosal healing
Ramasamy K et al, J Clin Gastroenterol 2003; 37: 119-124
Kochhar R et al, Gastrointest Endosc 2009; 70: 874-880
• Efficacy of PPI and H2 blockers in minimizing esophageal injury by suppressing acid reflux: Not proven
• Cakal et al (Turkey)• Prospective cohort study• 13 patients (>18 years age)• May 2010 and June 2010
• Mucosal damage graded with Zargar grading• Given IV Omeprazole 80mg followed be 8mg/hr for 72 hours• Repeat UGIE after 72 hours and endoscopic healing was compared
Role of PPIs & H2 blockers?
Cakal B et al. Dis Esophagus 2013; 26: 22-26
Investigations in acute phase: CXR/AXR?
Investigations in acute phase: CT Scan?
Grade Features
Grade 1 No definite swelling of esophageal wall
Grade 2Edematous wall thickening without periesophageal soft tissue involvement
Grade 3
Edematous wall thickening with periesophageal soft tissue infiltration plus well-demarcated tissue interface
Grade 4
Edematous wall thickening with periesophageal soft tissue infiltration plus blurring of tissue interface or localized fluid collection around the esophagus or descending aorta
Contini S. World J Gastroenterol 2013 ; 19: 3918-30
A.Should be avoided as it does not have much
clinical utility
B.Should be done only during a period between 4
days and 7 days after ingestion
C.Should be done within 4 days
D.It only helps in prediction of prognosis but not
treatment
Endoscopy immediately following corrosive ingestion
• Cornerstone for diagnosis
• Usual recommendation1: within first 12-48 h
• Relatively safe and reliable up to 96 h2
(gentle insufflation and great caution are mandatory)
• Adequate sedation (general anaesthesia in children) is compulsory
• Endotracheal intubation: Strictly required for respiratory distress
• Contraindications: Perforation, severe supra-glottic or epiglottic burn
Endoscopy
1.Poley JW et al, Gastrointest Endosc 2004; 60: 372-3772. Previtera C et al, Pediatr Emerg Care 1990;6: 176-178
3. Tiryaki T et al, Pediatr Surg Int 2005; 21: 78-80
Endoscopic dilatation for corrosive stricture: When & how?
Doğan Y et al, Clin Pediatr (Phila) 2006; 45: 435-438Panieri E et al, Pediatr Surg Int 1998; 13: 336-340
Dilators
• There are several different types: of dilators, including –Mercury-filled, rubber Maloney dilators–Wire-guided rigid Savary-Gilliard dilators–Balloon dilators that can either be through-the-sco
pe (TTS) or wire guided –Savary bougies: More reliable than balloon
dilators in consolidated and fibrotic strictures (such as old caustic stenosis or long, tortuous strictures)
Predictors of refractory corrosive stricture?
• Long stricture• Complex stricture • Delayed initiation of treatment• Dilation with balloon rather than with SG dilator• Thick esophageal wall on CT scan or EUS
Dilation: Early or late?
Costini S et al, Dig Liver Dis. 2009;41:263-268
Role of EUS & CT in prediction of outcome of corrosive esophageal injury
Chiu MH et al, Am J Gastroenterol 2004; 99: 851-854
How to augment result of endoscopic dilation?
• Nd-YAG LASER• Intra-lesional injection with various substances• Prosthesis placement• Endoscopic stricture incision
• Utility of corticosteroid: controversial
• Meta-analysis: No benefit for stricture prevention
• Systemic administration of steroids: ineffective(especially in grade 3
corrosive injury)
• Intra-lesional triamcinolone injections have been proposed to
prevent strictures, but optimal dose, frequency, and best application
techniques are still to be defined
• Triamcinolone: prevents cross-linking of collagen
Role of steroids in prevention & management of corrosive stricture
Systematic pooled analysis of 50 years of human data: 1956-2006.Clin Toxicol (Phila) 2007
Siersema PD et al, Gastrointest Endosc 2009; 70:1000-1012
Methods:
•N:71 (mean age 42.39 yrs; range, 13-78 yrs) with benign esophageal
• Stent integrity & radial force maintained for 6-8 weeks (pH dependent)• Stent degradation occurs in 11-12 weeks (pH dependent)• No need for removal procedure
• Issues: Cost
Limited experience
Biodegradable stents (poly-L-lactide or polydioxanone)
Tokar JL et al , Gastrointest Endosc 2011; 74: 954-958 Repici A et al , Gastrointest Endosc 2010; 72: 927-934
Approved stents
Yim HB. Annals Palliative Medicine 2014; 3.
F, 30 y
• Consultation received from Surgical Gastroenterology for a patient with
dysphagia
• History of corrosive ingestion in an attempt for suicide 2 y ago
• Barium swallow then revealed long esophageal stricture with severe
gastric injury
• Underwent surgical management for the stricture with colon inter-
position
Case Scenario 3
Barium swallow and meal
A.Dilation with SG dilator is a safe option
B.TTS balloon is a safe option
C.Neither of these is safe
D.This is an absolute indication in which both
esophageal and gastric lesion should be
treated surgically
Endoscopic esophageal dilation in patients with co-existing cicatrizing gastric injury
Late complication of corrosive ingestion: Esophageal cancer
• Incidence: 2-30% after 1-3 decades• Shortest time 1 y after ingestion• Some studies overestimated?• Both adenocarcinoma & squamous cell carcinoma• In strictured segement• Bypass surgery does not prevent• Endoscopic screening recommended
Conclusions
• Corrosive ingestion, particularly of acids, is common in India
• Early endoscopy is helpful in prognostication
• Acute management is important for outcome in severe injury
• Late outcome of esophageal stricture can be managed by endoscopic dilation
• There are novel methods to manage refractory stricture
• Surgical management play important role both in early and late stages