Corrosive Injury Of The Oesophagus

Question 1

What is the definition of corrosive injuries to the oesophagus?

Answer 1

Implies there has been tissue damage due to a chemical reaction on the oesophageal wall. Referred to as

• Caustic injury
• Caustic Burns
• Caustic ingestion

Question 2

What are few examples of these caustic agents

Answer 2

These agents are usually acidic or alkaline, available in various forms like crystals and liquids. They include:

• Car battery acid
• Pool acid
• Bleaches
• Detergents
• Pool cleaners
• Drain cleaners

Question 3

What is the immediate threat of ingesting one of these caustic agents?

Answer 3

Involvement of the airway passage

Question 4

Note that the oesophagus has 3 narrowings which are more prone to caustic injury .
What is the reason for this?

Answer 4

This is because there is a relative hold up of the liquid in these areas

Question 5

Severity of the injury is determined by 4 main determinants. What are they?

Answer 5

Amount of agent consumed
Type of agent consumed
Concentration of the agent consumed
Duration of contact

Question 6

What is the critical PH of an alkaline agent required to cause severe oesophageal injury?

Answer 6

PH of 11 and above

Question 7

What does the term “Lye” refer to?

Answer 7

This the general term used for alkaline cleaning products

Question 8

What are the dangers of ingesting solid lye products (crystals)?

Answer 8

• Tend to adhere to the mucosa
  
  • Cause deep burns where they adhere
  • Rarely cause injury beyond the oropharynx and proximal oesophagus

Question 9

What are the dangers of ingesting liquid lye products (crystals)?

Answer 9

• When swallowed, the liquid covers the entirety of the oesophagus.
  
  • Injury occurs easily within seconds or minutes

Question 10

What type of necrosis takes place in alkaline corrosive injury?

Answer 10

Liquefactive necrosis

Question 11

What are the 3 phases of alkaline corrosive injury:

Answer 11

1. Liquefactive necrosis
2. Reparative phase
3. Scar retraction

Question 12

Explain phase 1 of an alkaline corrosive injury:

Answer 12

Liquefactive necrosis:

• Happens between 1-5 days
• Diffuses into deeper lawyers

Question 13

Explain phase 2 of an alkaline corrosive injury:

Answer 13

Reparative phase:
- Begins from 5th day
- Development of granulation tissue
- Collagen deposition (peaks in week 2).
- Mucosal re-epithelialisation
> Fibroblast and collagen matrix results in severe oesophageal dysmotility

Question 14

Explain phase 3 of an alkaline corrosive injury:

Answer 14

Scar retraction

• Occurs in both longitudinal and circumferential direction
• Results in both oesophageal shortening and stricture formation.

Question 15

What type of necrosis takes place in acid injuries?

Answer 15

Coagulation necrosis

- The coagulum helps to limit penetration into deeper layers

Question 16

Why is the oesophagus often mildly damaged or spared in the case of acidic injury?

Answer 16

This may be due to the more neutral oesophageal environment leading into the stomach
Stomach is often involved -: Pulling of the acid in the stomach and pyloric spasm

Question 17

Zargar classification and its corresponding endoscopic description:
What does Grade 0 Zargar classification correlate with?

Answer 17

Normal mucosa

Question 18

Zargar classification and its corresponding endoscopic description:
What does Grade I Zargar classification correlate with?

Answer 18

Edema and erythema of the mucosa

Question 19

Zargar classification and its corresponding endoscopic description:
What does Grade IIa classification correlate with?

Answer 19

Hemorrhage
Erosions
Blisters
Superficial blisters

Question 20

Zargar classification and its corresponding endoscopic description:
What does Grade IIb classification correlate with?

Answer 20

Circumferential lesions

Question 21

Zargar classification and its corresponding endoscopic description:
What does Grade IIIa classification correlate with?

Answer 21

Focal deep gray or brownish-black ulcers

Question 22

Zargar classification and its corresponding endoscopic description:
What does Grade IIIb classification correlate with?

Answer 22

Extensive deep gray or brownish-black ulcers

Question 23

Zargar classification and its corresponding endoscopic description:
What does Grade IV classification correlate with?

Answer 23

Perforation

Question 24

Name 3 complications are associated with corrosive injuries:

Answer 24

1. Airway obstruction
   
   • Due to involvement with upper airway
   • Laryngeal oedema
   • Threatening airway obstruction.
2. Bleeding
   
   • Rarely a major issue
3. Perforation
   
   • Especially with trans mural injuries
   • Leads to mediastinitis

Question 25

What are the symptoms of corrosive injury?

Answer 25

1. Oropharyngeal pain 2. Odynophagia 3. Breathing difficulty 4. Dysphagia 5. Drooling and saliva

Question 26

During the examination of the patient, signs should you as a physician look out for? (3)

Answer 26

1. Respiratory signs :- Stridor, Bronchospasm 2. General conditions :- Shock 3. Abdominal signs :- Tenderness and Peritonitis

Question 27

What investigations should be done when a corrosive injury is suspected?

Answer 27

1. Blood/gas analysis - Often deranged in severe cases 2. Urea and electrolytes/ blood count 3. Chest x-rays - Look for signs of aspiration - May show mediastinal air if there is perforation 4. Endoscopic ultrasound. - Shows different levels of the oesophagus 5. CT scan - Can show depth of necrosis and trans-mural damage - Non-invasive and valuable I’m some patients

Question 28

Name 3 management steps for corrosive injury:

Answer 28

1. ABC Principles of resuscitation - Airway: pt may be incubated if there isn’t airway obstruction due to laryngeal oedema. 2. Supportive management - Pain management - Intravenous lines and fluids 3. Management of complications

Question 29

Name 3 management precautions that should be noted:

Answer 29

1. Avoid induced emesis:- further exposes oesophagus to damage by corrosive agents. 2. Avoid acid neutralization:- This causes an exothermic reacotion and further damage the oesophagus. 3. Give antibiotics if there is perforation.

Question 30

Battery button ingestion is common in children, it gets lodged in the upper oesophageal sphincter. How will the child present?

Answer 30

The child will present with 1. Drooling of saliva. 2. Feeding difficulties. It is very important to diagnose battery ingestion because the alkali in the battery leaks out of the device, causing corrosive injury to adjacent mucosa - Perforation may even occur

Question 31

What does a battery button look like on an x-ray?

Answer 31

Note that on an x-ray, it may be confused for a coin, physician should look out for halo sign on A-P view.c The battery has a rim on the periphery- halo

Question 32

How is an ingested button battery removed?

Answer 32

Endoscopic removal

Question 33

For patients that have ingested a button battery, what kind of nutritional support is offered?

Answer 33

Patients with severe injuries are fed with total parental nutrition until an alternative feeding route is established e.g. jejunostomy. Patients with mild insignificant injuries may be allowed to feed enterrally.

Question 34

2 of the complications associated with corrosive injury include oesophageal strictures and perforation. - Explain how these complications are managed:

Answer 34

Perforation: This requires emergency surgery after resuscitation and stabilization of the patient Oesophageal strictures: Carefully guided Dilatations should be repeated until the adequate lumen size is achieved.

Question 35

One of the complications of sustaining a corrosive injury, is the development of oesophageal strictures, how is this complication managed?

Answer 35

Carefully guided Dilatations should be repeated until the adequate lumen size is achieved. Should dilatations fail, the oesophagus is replaced with a section of the colon. - The native oesophagus has a higher risk of malignancy - It is thus removed to be replaced with a section of the colon