2017-18 HSC Section 3 Green Book

Reprinted by permission of Endoscopy. 2017; 49(7):643-650.

Original article

Relook endoscopy predicts the development of esophageal and antropyloric stenosis better than immediate endoscopy in patients with caustic ingestion

Authors Rakesh Kochhar 1 , Munish Ashat 2 , Yalaka Rami Reddy 1 , Narender Dhaka 1 , Manish Manrai 1 , Saroj K. Sinha 1 , Usha Dutta 1 , Thakur D. Yadav 3 , Vikas Gupta 3

in grade 3b injury, stricture formation occurs in incremental proportion beyond grade 2b injury [3, 4, 7 – 12]. It has been suggested that patients with grade ≤ 2a injury have infrequent complications and can be discharged the same day on oral feeds, while those with grade ≥ 2b injury are at an increased risk of immediate or late complications and need to be kept un- der observation for complications or followed up for sequelae [1, 2, 13]. The need for endoscopy in all patients with caustic ingestion has been questioned, especially in children, as it was suggested that, in the absence of symptoms, severe injury is unlikely [14]. Some endoscopists have therefore compared endoscopy with ences in endoscopic grading on EGDs performed on day 5 and day 1 and to assess the impact of relook endoscopy findings on the development of esophageal and/or antropy- loric cicatrization. Patients and methods Consecutive patients admitted within 24 hours of caustic ingestion between 2009 and 2014 underwent EGD and had their mucosal changes grad- ed. Injuries of grade ≤ 2a were classified as mild and ≥ 2b were classified as severe. Patients were followed up for the development of cicatrization and managed per protocol. Sensitivity, specificity, positive predictive value (PPV), neg- ative predictive value (NPV), and likelihood ratios (LRs) were calculated to compare day 1 and day 5 EGD findings. Results A total of 62 patients (35 men; mean age 33 ± 15) underwent both day 1 and day 5 EGDs. Antropyloric steno- sis developed in 16 patients, esophageal strictures in nine, and four had both esophageal and antropyloric strictures. Compared with day 1 EGD, endoscopic grading of severe in- jury on day 5 had higher specificity (83 % vs. 65 %), higher PPV (60 % vs. 41 %), and higher positive LR (5.65 vs. 2.66) for predicting the development of esophageal stricture. Similarly, day 5 endoscopic grading had higher specificity (95 % vs. 61 %), higher PPV (88 % vs. 54 %), and higher posi- tive LR (16 vs. 2.5) for predicting the development of antro- pyloric stenosis. Conclusion Endoscopic assessment on day 5 is a better predictor of esophageal and gastric cicatrization than day 1 EGD, which significantly overestimates the grade of in- jury.

Institutions 1 Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India 2 Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois, USA 3 Department of Gastroenterology and General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

submitted 9.10.2016 accepted after revision 6.2.2017

Bibliography DOI https://doi.org/10.1055/s-0043-104857 Published online: 2017 | Endoscopy © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X

Introduction Endoscopy has been the cornerstone for evaluation of injury to the upper gastrointestinal (GI) tract following caustic ingestion. Initial endoscopic grading of mucosal injuries has been shown to be the key determinant in the outcome of such patients [1 – 9]. The most widely used classification of endoscopic grading of GI mucosal injury was devised by our clinical research group after modification of the old existing classification system [8]. There is a close correlation between endoscopic grading and the development of local and/or systemic complications, as well as mortality [8, 10 – 12]. While mortality is seen primarily Corresponding author Rakesh Kochhar, MD, Department of Gastroenterology, F-Block, Nehru Hospital , Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh-160012, India dr_kochhar@hotmail.com ABSTRACT Background and aims Early ( < 24 hours) esophagogas- troduodenoscopy (EGD) is used to prognosticate mucosal injury after caustic ingestion. We aimed to compare differ-

Kochhar Rakesh et al. Relook endoscopy predicts … Endoscopy

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