2017-18 HSC Section 3 Green Book

Therapy of caustic ingestion: new treatment considerations Shub

stricture occurs [5,7,12 & ,13]. However, concerns about the risk of complications, such as infection, acid reflux, and long stricture formation, have caused others to recommend against this procedure [3 & ]. No randomized controlled studies have been conducted to assess the efficacy and safety of naso- gastric tube placement. As children recover and esophageal edema diminishes, oral feedings can be initiated. If oral or enteral feeds are not tolerated, then total paren- teral nutrition (TPN) will be required. In those with severe gastric burns, TPN is recommended until the injury heals [5]. The use of corticosteroids to prevent stricture formation is controversial. Theoretically, corticoste- roids prevent strictures by reducing inflammation and fibrous tissue formation. In an animal model, corticosteroid and antibiotic therapy given early after a grade 3 burn injury resulted in decreased incidence of stricture formation compared with controls [14]. However, in a meta-analysis of 328 patients with grade 2 injuries, there was no statisti- cal difference in stricture formation between those who received corticosteroids and those who did not [15]. Another meta-analysis involving 10 studies and 572 patients revealed similar findings [16]. In contrast, a recent randomized controlled prospec- tive study involving 83 children with grade 2b esophageal burns suggested that a 3-day course of high-dose methylprednisolone (1 g/1.73m 2 ) reduced the occurrence of esophageal strictures [17 & ]. There were no significant side-effects encoun- tered in the treatment group. A limitation of this study was that it did not evaluate the effectiveness of corticosteroid therapy in the prevention of strictures in the highest risk patients (grade 3 burn injury). Prospective randomized controlled multicenter trials, assessing dose, length of therapy, and safety profile, are needed before this treatment approach can be generally advocated. Antibiotics have been commonly used to treat caustic ingestion [5,7,11,13,17 & ,18 & ,19,20], despite lack of evidence to support this. They are, however, recommended when respiratory infections or per- foration is suspected [12 & ]. Theoretically, antibiotics are indicated in the treatment of grade 3 esophageal injuries based on known risk for the development of microabscess formation in the esophageal wall [12 & ]. Prophylactic antibiotic treatment during esopha- geal dilatation may be warranted because cerebral abscesses have been described as a complication of repeated dilatations [21]. Antibiotics have also been recommended in patients who are receiving cortico- steroid therapy to prevent stricture formation [3 & ], although there are no good studies to support this. In general, because the efficacy of antibiotic

treatment for caustic ingestion has not been proven in patients without infection, their routine use cannot be recommended [3 & ]. The use of proton pump inhibitors (PPIs) or histamine H 2 -receptor antagonists has been a com- mon practice in the management of caustic inges- tion [5,7,8 & ,11,12 & ,13,17 & ,18 & ,19]. The rationale is that antacids decrease acid and pepsin exposure to the injured tissue and promote mucosal healing. However, there have been no controlled trials in children that have confirmed the efficacy of this treatment. Furthermore, no studies have deter- mined the optimal dose or length of treatment for these medications. A prospective study in 13 adult patients with caustic esophageal injury suggested that there was benefit from the use of high-dose PPI therapy [22]. This study has limited application because of the small sample size and the lack of a control group. Larger prospective controlled trials are needed to provide evidenced-based recommen- dations. LONG-TERM MANAGEMENT Esophageal stricture formation is one of the most serious complications that may develop after a caus- tic ingestion. Children with grade 2b and grade 3 injuries must be closely monitored for signs of dys- phagia as an indication of stricture formation. The risk for stricture formation in grade 2b injury has been reported to be 32% in one large series [5]. The rate of stricturing may be as high as 75% in children with grade 3 injury [7]. Long esophageal strictures may occur in up to 40% of those who have grade 3 injuries following alkaline ingestions [7,23]. Stric- tures can develop as early as 3 weeks after ingestion and 80% of strictures will develop within 8 weeks [2]. Gastric outlet obstruction is a less frequent but serious complication of caustic ingestion and usually occurs following ingestion of concentrated liquid acids [24]. Diagnostic testing to evaluate for the develop- ment of strictures is usually performed about 2 3 weeks after the injury. A barium esophagram can outline a stricture and determine the extent of formation [25]. Endoscopy can identify the degree of mucosal healing, the location of a stricture, and can be used to initiate esophageal dilatation. Current recommendation for the initial manage- ment of esophageal strictures in childrenwith caustic ingestion is endoluminal dilatation [13,26]. Histori- cally, approaches have included antegrade dilatation with Savary Gilliard or Jackson dilators and retro- grade dilatation using a Tucker dilator passed over a string or guide wire. Recently, most centers are using balloondilators passed endoscopically or over a guide

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