HSC Section 3 - Trauma, Critical Care and Sleep Medicine

A review of caustic ingestion injury

require immediate laparotomy, debridement of necrotic tissue and are likely to require jejunostomy feeding. 21 Those without features of perforation may proceed to develop organ necrosis and early identification of patients who have full-thickness injury of the oesophagus, stomach or duode- num is vital. Full-thickness injury to the stomach or duodenum is invariably accompanied by severe oesophageal injury and is an indication for resection of the oesophagus and the stomach. 44 The single most important factor contributing to mortality in corrosive injury is delay in the diagnosis and treatment of transmural oesophagogastric necrosis, 45 and an urgent surgical opinion is advised if this is suspected. Keypoints. • Decision to secure a definitive airway should be made on a case-by-case basis as part of a discussion between the otolaryngologist and anaesthetist. • Those with a suspected perforation require immediate laparotomy and debridement of necrotic tissue. • Those with perforations found at endoscopy (grade 4) will require surgical intervention as a matter of priority. 6. Follow-up and complications. The important complica- tion to consider with any caustic ingestion is perforation or organ necrosis as previously discussed within this article. It is also important to consider the late sequelae of caustic ingestion. Stricture formation is the most common late complica- tion of caustic ingestion with the incidence in those with a grade 2B and grade 3 oesophageal burns reported to be between 70% and 100%. 29,35 Formation is usually within 8 weeks but can occur as late as a year 29 and will often be seen along with oesophageal dysmotility. These strictures can often be managed with endoscopic dilatation under the gastroenterology team. Gastric outlet obstruction has a reported incidence of 5%. 46 Further late sequelae of corrosive gastric injury include intractable pain, gastric outlet obstruction, protein-losing gastroenteropathy and development of carcinoma. 47 It is felt by the authors that these patients with a high grade of injury should be followed up and managed by the gastroenterology team for monitoring of stricture formation and associated delayed complications.

otolaryngologist for initial assessment, observation of the airway and the commencement of medical therapy. A careful history and examination is required and life-threatening complications managed as a matter of priority, often in communication with our anaesthetic colleagues with a definitive airway secured if necessary. In those patients with a stable airway and no clinical or radiological sign of perfo- ration who remain symptomatic, medical therapy should be commenced and an urgent OGD, if not contraindicated within the first 24 h undertaken to grade the degree of injury and establish long-term prognosis. If perforation is sus- pected at presentation, a surgical opinion should be sought. For those adults who are asymptomatic following ingestion, an OGD may not be necessary; however, asymptomatic paediatric patients should be treated with more caution and a period of observation would be prudent. In those who are at high risk of developing late complications, follow-up with the gastroenterology team for regular review would be appropriate. It is worth mentioning that in those cases where the process of ingestion was in an act of deliberate self-harm, then referral for an in-patient psychiatric review prior to discharge is recommended. Using the information acquired from researching for this article, the authors have designed a guideline to aid with the management of those presenting with caustic ingestion injury (Fig. 1).

Conflicts of interest

None to declare.

Funding

None.

References

1 Goldman L.P. &Weigert J.M. (1984) Corrosive substance ingestion: a review. Am. J. Gastroenterol. 79 , 85 – 90 2 Turner A. & Robinson P. (2005) Respiratory and gastrointestinal complications of caustic ingestion in children. Emerg. Med. J. 22 , 359 – 361 3 Hospital episode statistics online [WWW document]. URL www.he sonline.nhs.uk [accessed on 21 December 2014] 4 Gumaste V.V. & Dave P.B. (1992) Ingestion of corrosive substances by adults. Am. J. Gastroenterol. 87 , 1 – 5 5 Riffat F. & Cheng A. (2009) Pediatric caustic ingestion: 50 consecutive cases and a review of the literature. Dis. Esophagus 22 , 89 – 94 6 ParkK.S. (2014) Evaluation andmanagement of caustic injuries from ingestion of acid or alkaline substances. Clin. Endosc. 47 , 301 – 307 7 Zargar S.A., Kochhar R., Nagi B. et al. (1992) Ingestion of strong corrosive alkalis: spectrum of injury to upper gastrointestinal tract and natural history. Am. J. Gastroenterol. 87 , 337 – 341

Conclusion

Caustic ingestion injury remains a potentially serious presenting complaint that will often involve the

© 2016 John Wiley & Sons Ltd Clinical Otolaryngology 42 , 701–708

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