2017-18 HSC Section 3 Green Book

et al. [2] found only 53.6 % of their grade 3b patients developed strictures and Lu et al. [3] observed strictures in 26.7 % of the patients with grade 2b injury and 48.6 % of those with grade 3 injury. The discrepancies in the prediction of stricture forma- tion in these studies may be due to the variable time to the per- formance of EGD in these different studies. In the present study, nearly 40 % of patients with severe in- jury (grade ≥ 2b) did not develop strictures, highlighting the limitations of endoscopic evaluation. Our results show that a relook EGD on day 5 predicted the development of both eso- phageal and gastric cicatrization better than day 1 endoscopy. Day 5 EGD predicted the development of esophageal strictures with a positive LR of 5.65 compared with 2.66 for day 1 EGD ( ▶ Table 3 ). Similarly, day 5 EGD predicted antropyloric stenosis with a positive LR of 16 compared with 2.49 for day 1 EGD ( ▶ Table 4 ). These observations confirm the superiority of day 5 grading in predicting sequelae after caustic ingestion. Endoscopy within 12 – 24 hours is essential to grade initial injury and stratify patients with grade 3b injury who may be candidates for surgical intervention. Those with no signs of peritonism/peritonitis or mediastinitis can be scheduled for a relook endoscopy on day 5 to grade their injury again and offer prognostic information with regard to the subsequent likeli- hood of cicatrization. There is a limitation of endoscopy in defining the transmural extent of necrosis, although it has been suggested that grade 3 injuries at endoscopy correspond to transmural injury [16]. Re- cent studies have shown that computed tomography (CT) scan- ning may be superior to endoscopy in this regard [28 – 30, 36]. A systemic review concluded however that endoscopy was pre- ferable to CT in the assessment of risk in symptomatic patients following corrosive ingestion [27]. Attempts have also been made to use endosonography with a miniprobe to grade caus- tic-induced esophageal injury, but the limited data reported do not show any advantage of endosonography over endoscopy [37, 38]. Our study excluded patients who required immediate sur- gery after the day 1 endoscopy. Patients with manifest perfora- tion, signs of peritonitis, or massive GI bleeding need to under- go surgery immediately. Such patients cannot wait for a relook endoscopy. Data from our study were therefore limited in appli- cation to only those patients who were not candidates for early surgery and those who were fit enough for a relook endoscopy. Apart from this limitation, our study also suffers from the drawbacks of a retrospective study. Endoscopy was done by one of the two senior endoscopists (R.K., S.K.S.), but images were not stored in all patients, so could not be reviewed for in- terobserver variability. As in all the previous studies, we also graded the severity of gastric injury taking the stomach as a sin- gle unit. The proximal stomach has a large capacity and its cica- trization does not produce symptoms of GOO, whereas severe injury to the antropyloric area produces symptomatic stenosis. It would therefore be better in future studies to divide the stomach into proximal (fundus and body) and distal (antropylo- ric area) segments for the purpose of grading caustic-induced injury.

The strengths of this study are that it is based on a large da- taset that was prospectively obtained and that follow-up was available in all of the patients. In conclusion, a relook endoscopy is safe and is useful in es- tablishing the severity of mucosal injury to the upper GI tract. Day 5 endoscopy findings are better predictors of subsequent cicatrization than day 1 findings. As it was only the group of pa- tients with severe injury (grade ≥ 2b) who were downgraded to a degree that was clinically significant, we would recommend that a relook day 5 endoscopy be done only in such patients.

Competing interests

None

References

[1] Cabral C, Chirica M, de Chaisemartin C et al. Caustic injuries of the upper digestive tract: a population observational study. Surg Endosc 2012; 26: 214 – 221 [2] Cheng HT, Cheng CL, Lin CH et al. Caustic ingestion in adults: the role of endoscopic classification in predicting outcome. BMC Gastroen- terol 2008; 8: 31 [3] Lu LS, Tai WC, Hu ML et al. Predicting the progress of caustic injury to complicated gastric outlet obstruction and esophageal stricture, using modified endoscopic mucosal injury grading scale. BioMed Res Int 2014; 2014: 919870 [4] Park KS. Evaluation and management of caustic injuries from inges- tion of acid or alkaline substances. Clin Endosc 2014; 47: 301 – 307 [5] Poley JW, Steyerberg EW, Kuipers EJ et al. Ingestion of acid and alka- line agents: outcome and prognostic value of early upper endoscopy. Gastrointest Endosc 2004; 60: 372 – 377 [6] Ramasamy K, Gumaste VV. Corrosive ingestion in adults. J Clin Gas- troenterol 2003; 37: 119 – 124 [7] Rigo GP, Camellini L, Azzolini F et al. What is the utility of selected clinical and endoscopic parameters in predicting the risk of death after caustic ingestion? Endoscopy 2002; 34: 304 – 310 [8] Zargar SA, Kochhar R, Mehta S et al. The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns. Gastrointest Endosc 1991; 37: 165 – 169 [9] Keh SM, Onyekwelu N, McManus K et al. Corrosive injury to upper gastrointestinal tract: Still a major surgical dilemma. World J Gastro- enterol 2006; 12: 5223 – 5228 [10] Contini S, Scarpignato C. Caustic injury of the upper gastrointestinal tract: a comprehensive review. World J Gastroenterol 2013; 19: 3918 – 3930 [11] Zargar SA, Kochhar R, Nagi B et al. Ingestion of corrosive acids. Spec- trum of injury to upper gastrointestinal tract and natural history. Gastroenterology 1989; 97: 702 – 707 [12] Zargar SA, Kochhar R, Nagi B et al. Ingestion of strong corrosive alka- lis: spectrum of injury to upper gastrointestinal tract and natural his- tory. Am J Gastroenterol 1992; 87: 337 – 341 [13] Quingking CG, Dioquino C, Pascual J. Predictive factors of gastroin- testinal caustic injury according to clinical and endoscopic findings. Asia Pac J Med Toxicol 2013; 2: 19 – 22 [14] Gorman RL, Khin-Maung-Gyi MT, Klein-Schwartz W et al. Initial symptoms as predictors of esophageal injury in alkaline corrosive in- gestions. Am J Emerg Med 1992; 10: 189 – 194

Kochhar Rakesh et al. Relook endoscopy predicts … Endoscopy

218