2017-18 HSC Section 3 Green Book

Gastroenterology and nutrition

time of endoscopy. A grading system, developed by Zargar [9], classifies caustic injuries from grade 0 (no visible damage) to grade 3b (extensive necrotic tissue). The degree of esophageal injury closely correlates with morbidity and mortality. Grade 1 injury, seen in the majority of accidental caustic ingestions, consists of edema and erythema. These children can be fed normally and discharged. Those with grade 2a lesions (superficial and noncircumfer- ential ulcers) rarely progress to esophageal stenosis and usually have an uncomplicated course. Grade 2b injury (circumferential ulceration) is associated with an increased risk of stricture formation. These patients require careful observation as the diet is advanced and a barium contrast esophagram will need to be performed after 3 weeks to look for stricture formation. Grade 3a (scattered areas of necrosis) and grade 3b injuries result in a high degree of stricture formation. The DROOL Score, a promising new prognostic tool for predicting risk of developing an esophageal stricture without endos- copy [11], has recently been described and warrants further investigation. The score was derived by pro- spectively assessing children within 48 hours after a caustic substance ingestion using the following criteria: Drooling, Reluctance to eat, Oropharynx (presence of burns), Others (fever, hematemesis, abdominal tenderness, chest pain, dyspnea), and Leukocytosis. INITIAL TREATMENT Because of the absence of controlled studies, man- agement of caustic ingestion depends on observa- tional data and clinical experience. Protocols have been developed on the basis of perceived successful outcomes, but there are few randomized controlled trials that support the use of any of these treatments. It is universally recommended that induced emesis and gastric lavage should not be performed as this reduces the risk of further exposure of the esophagus to caustic injury [3 & ,12 & ]. In addition, neutralization with agents such as vinegar is not recommended because of the risk of exothermic reaction, which could cause further tissue injury [3 & ,12 & ]. Patients with drooling, dysphagia, or severe oral burns are given intravenous fluid support until endoscopic evaluation is performed [11,12 & ]. If a burn injury of grade 2b or greater is revealed, children are hospitalized. It has been recommended by some that a naso- gastric tube should be placed under direct endo- scopic vision or over a guide wire in those with grade 2b or greater injury without severe gastric involvement. The nasogastric tube can provide a route for feeding and may also act as a stent if a

KEY POINTS

absence of an oral burn is a poor indicator of an esophageal or gastric injury. Common symptoms following caustic ingestion include drooling, dyspha- gia, feeding refusal, chest pain, abdominal pain, and vomiting. Increased number of symptoms tends to correlate with a significant injury [7,8 & ], although absence or minimal symptoms do not exclude a serious burn [4,5,6 & ]. Airway symptoms are not com- mon, but dyspnea is usually a sign of a substantial injury. Severe symptoms following a caustic inges- tion can result from a perforation leading to media- stinitis or peritonitis. CLINICAL ASSESSMENT The most important step in assessing an esophageal burn is to accurately identify the location, extent, and severity of the injury. Studies have shown that clinical and radiological evaluations alone do not adequately predict the type and severity of injury [4,5,6 & ]. Endoscopic evaluation has become a main- stay in assessing burn injuries and is typically performed 12 48 h after ingestion based on retro- spective and a few prospective observational studies [8 & ]. It is thought that endoscopy prior to 12 h could miss evolving lesions and beyond 48 h may increase the risk of perforation; however, some reports indicate that endoscopy can be safely performed up to 96 h after ingestion [9]. It is recommended that endoscopy be discontinued at the first circum- ferential esophageal burn because of the risk of perforation [10]. A recent retrospective analysis of 206 children found that it was safe to advance the endoscope beyond the first severe burn to reveal additional esophageal and gastric injuries that would have been missed [5]. If a perforation is suspected, imaging studies (plain upright radio- graph of the chest and abdomen, water-soluble esophagram, or computed tomography with oral contrast) should be performed prior to considering endoscopy. Esophageal injury is evaluated at the Caustic ingestion continues to be a significant problem. Endoscopy is the primary method for evaluating severity of injury. Stricture is the main complication following caustic ingestion. Evidence-based treatment protocols to prevent strictures are still lacking. Caustic ingestion can lead to esophageal cancer.

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Volume 27 Number 5 October 2015

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