2017-18 HSC Section 3 Green Book

Original article

mucosal injuries [1, 15, 20]. These studies have however not given any details of the findings of the second endoscopy or the impact of these. We therefore planned the present study: (i) to evaluate differences in endoscopic grading on day 5 com- pared with day 1; and (ii) to compare the predictive abilities of day 1 and day 5 endoscopy for the subsequent development of esophageal and/or antropyloric stenosis. Patients and methods In this retrospective observational single-center cohort study, consecutive patients presenting to us within 24 hours of caustic ingestion between 2009 and 2014 were studied. The study was approved by our Institute Ethics Committee. Patients were interrogated about the nature, volume, and type of caustic material ingested, and the intention of the in- gestion, whether suicidal or accidental. After a detailed evalua- tion of the patient had been completed, resuscitation measures were instituted with appropriate intravenous fluids and oxygen supplementation. We have previously shown that patients with both the acute and chronic phases of caustic ingestion have hypo/achlorhydria because of damage to the antral mucosa [21 – 23]. Accordingly, proton pump inhibitors (PPIs) were not given in either the acute or chronic phases of caustic ingestion. Those with clinical signs and/or imaging findings of perforation or peritonitis were transferred to the surgical floor. Those who were hemodynamically stable were taken for an endoscopy after informed consent had been obtained. All endoscopies were done with the patient under conscious sedation using midazolam by one of two experienced endos- copists (R.K., S.K.S.) on the day of hospitalization using a stand- ard gastroscope (GIF Q160 or GIF Q 180; Olympus Corp., Tokyo, Japan). The endoscope was not advanced further if findings suggestive of perforation or impending perforation were iden- tified. Endoscopic findings were graded on a 6-point scale as: grade 0, normal mucosa; grade 1, edema or hyperemia; grade 2a, friability, erosions, exudates, whitish membranes, or he- morrhages; grade 2b, features of grade 2a injury plus deep, dis- crete, or circumferential ulcers; grade 3a, multiple ulcers and areas of necrosis (small scattered); and grade 3b, extensive ne- crosis [8]. Patients were prescribed antibiotics if there was any evi- dence of infection; no steroids or PPIs were given [24, 25]. Pa- tients with grade 3b burns were monitored in an intensive care setting and a surgical opinion was obtained. Those with fea- tures suggestive of perforation or peritonitis underwent surgi- cal intervention. Patients with mild injury (grade ≤ 2a) were started on oral feeds and discharged the same day; they were scheduled for repeat esophagogastroduodenoscopy (EGD) on day 5. Those patients who were stable on day 5 and had not under- gone surgery underwent a relook endoscopy that was per- formed by the same endoscopists with the same precautions that were followed on day 1. Mucosal injuries were again grad- ed, and based upon the findings of the relook EGD, patients were again divided into mild or severe injury.

▶ Fig. 1 Esophageal findings: a on day 1 endoscopy showing black discoloration of the mucosa with patches of ulceration (arrow) in between, graded as 3a; b on day 5 endoscopy showing linear ul- ceration (arrow) and clearly visible mucosal/submucosal hemor- rhages (arrowheads), interpreted as grade 2a.

clinical symptoms and signs, laboratory parameters, or a com- bination of these to generate scoring systems [7, 13, 15 – 18]. However, endoscopic grading has been found to be the single most important predictor [5] and is recommended as the key investigation modality wherever possible by the British Society of Gastroenterology [19]. There are some limitations of early (< 24 hours) endoscopic evaluation in predicting the outcome of patients with caustic ingestion. The endoscopy findings may be difficult to interpret in patients with active bleeding or in the presence of food or blood clots [7]. A compounding factor in the interpretation of endoscopic findings is the presence of mucosal and submuco- sal edema and hemorrhages, which can lead to the overestima- tion of mucosal injuries. There have been suggestions in the literature that a second endoscopy after 2 – 15 days may be helpful in better assessing

Kochhar Rakesh et al. Relook endoscopy predicts … Endoscopy

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