pthaigastro.org Caustic injury The 5 th Pediatric GI Days Pediatric GI & Liver Emergency : Current Practical Management
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1 The 5 th Pediatric GI Days Pediatric GI & Liver Emergency : Current Practical Management Caustic injury Phisek Yimyaem Pediatric Department, Khon Kaen Regional Hospital 18 July 2013
2 Outlines Introduction Type & mechanism Clinical manifestations Management & complications Severe corrosive ingestion in KKH Prevention Summary
3 Introduction Pediatric GI emergency Most often in first 3 years of life Most ingestions by children are accidental 75% of accidental ingestion: 2 nd containers Adolescents & young adult: related to attempted suicide ( more severe)
4 Corrosive ingestion : In KKH N = 5 ( M 2, F3 ) Mean age = 4 4 ingested acid ( HCl, 2 sulfuric acid, formic acid ) 1 ingesed weak base All from secondary container 4/5 EGD : abnormal 2 cases, normal 2 cases
5 Mechanisms of damage to UGI tract Strong alkaline: liquify tissue by dissolving & saponifying lipid producing liquefactive necrosis damages varies from minor erythema to deep ulceration or perforation Drain cleaner Oven cleaner Detergent Hair relaxer
6 .o r g Mechanisms of damage to UGI tract ro Strong acid: ig a st coagulate proteins inhibit deeper damage pt ha Toilet cleaner Lead acid battery producing coagulative necrosis Eschar formation
7 Mechanisms of damage to UGI tract Medication in pill : pill esophagitis Solid foreign bodies : perforation,pressure necrosis Pill esophagitis
8 Clinical manifestations Dysphagia Drooling Oropharygeal burn Retrosternal &Abdominal pain & vomiting Hematemesis Features suggesting upper airway injury (stridor, hoarseness, nasal flaring,retractions) ARDS
9 Clinical signs Drooling mucosal injury (Erythema,swelling, ulcer) Lack of visible damage in the mouth dose not preclude damage in lower in gut
10 Principle of management Stabilize ABCs, appropriate treatment of airway injury and hypotension Intubation may be necessary in respiratory distress External decontamination by copious irrigation with water min. History should focus on agent involved - amount, time of ingestion - intention ( severe) - child abuse (very small children & infants)
11 General management Do not induce emesis No gastric lavage or activated charcoal Neutralization should be avoid Dilution with water or milk may be useful ( intermediate ) NPO Intravenous fluid Chest X-ray Emergency endoscopy
12 Objective for Endoscopy Categorize the extend and grade of injury visible damage circumferential ulceration (grade 2b or greater) organs are involved Guided for treatment and indicated prognosis
13 When Endoscopy Endoscope if indicated warning sign Favor Early endoscopy > late endoscope Within 24 hours if possible Appropriate to identify the full extent of injury Should be avoid during 5 15 days post ingestion None of warning sign : watch and observe
14 Warning signs Drooling Dysphagia Abdominal pain & vomiting Visible mouth lesions Airway embarrassment Intentional ingestion
15 Zargar s classification of caustic injury Grade Visible appearance Clinical significance 0 Hx+ve, no symptom&visible damage Able to take fluids immediately 1 Edema, loss of normal vv pattern, hyperremia, no transmucosal injury 2a 2b 3a Transmucosal injury, friability, hemorrhage, blistering, exudate, scattered superficial ulceration 2a plus deep discrete ulceration and/or circumferential ulceration Scattered deep ulceration with necrosis of tissue Temporary dysphagia, able to swallow within 0-2 days, no long term sequalae Scarring, no stenosis, no long term sequalae Small risk of perforation,scarring may result in later stenosis Risk of perforation, high risk of later stenosis 3b Extensive necrotic tissue High risk of perforation and death, high risk of stenosis (1991)
16 Management of grade 2a or less Adequate nutrition (by mouth if possible) Repeat endoscopy at 2-3 wk (optional )
17 Management of grade 2 or higher ICU care Nutritional supplement : TPN Maintain acid reduction therapy (PPI twice daily) until completed healing Considered long term prophylaxis acid-suppressing Rx ATB; grade 2b or greater or fever Retained NG tube for feeding & stent
18 Corticosteroids : friend or foe? Still controversy in prevention of stricture May have use in the second or third degree injury Prednisolone 1-2 mg/kg/day to a maximum of 60 mg/day, tapered over a -3- week course Only a single controlled trial: Dexamethasone 1MKD may be benefit ( Bautista et al,eur Pediatr Surg 1996: ) High dose steroids for several weeks: increase complication
19 Corticosteroids (2) Systematic review, 6 studies in Europe ( 2=steroid,2= no steroid,2 compared with and without steroid) (steroid x 8 days) Pts with 2 nd and 3 rd degree burns (N=572) 305 pts ( 35.1%) with steroid VS 267 pts ( 33.3%) without steroid developed stricture Steroids do not prevent the development of strictures and may lead to the development of serious adverse effects (Peldova et al, Toxicol Rev,2005:125-9)
20 Complications Lip, mouth, oropharygeal burn Airway obstruction Esophageal & gastric perforation Mediastinitis Tracheoesophageal fistula Stricture formation Pyloric stenosis Late development of carcinoma
21 Follow up Grade 2 or greater : esophagogram (3 wk after ingestion) If present stricture, started dilatation Application of Mitomycin C or other agent (halofunginone) Other modality: laser or surgery Monitor other late complication Sliding hiatus hernia & GERD Motility disorder Pulmonary aspiration & chronic pulmonary disease Esophageal cancer
22 Severe corrosive ingestion : experience in KKH
23 In KKH : case 1 A 3 - yr old girl Accidentally ingested formic acid in secondary container Exfoliative skin and swelling of upper and lower lips Erythema of oral mucosa Stridor due to UAO
24 Case 1 : EGD esophagus stomach
25 Case 1 : hospital course Tracheostomy UGI study 1 mo after : no stricture
26 Case 1 : hospital course 3 mo after develops dysphagia and drooling : esophageal stricture Perform esophageal dilatation
27 In KKH : case 2 A 2 -yr - old boy Accidentally ingested toilet cleaner ( VIM,hydrochloric acid 13% w/w ) in secondary container V/ S : stable Erythema in oral cavity No stridor
28 EG junction pt ha ig a esophagus st ro.o r g Case 2 : EGD body antrum
29 Case 2 : hospital course 1 mo after : develops frequent vomiting UGI study : gastric outlet obstruction Perform gastro-jejunostomy
30 In KKH : case 3 4 yr-old boy Accidentally ingested of glass cleaners in secondary container ( Isopropyl alcohol,na lauryl ether sulfate,ethylene glycol N-Butyl ether ) Drooling,abdominal pain and vomiting 3 hours after,dysnea : on ETT No endoscopy
31 Case 3 : Chemical pneumonitis D1 Day 1 D3
32 Case 3 : pneumothorax D 4 D 4 Day 3
33 Prevention Banned sale of granular and concentrated household cleaners Child-safe containers with warning signs Sale of secondary containers should be banned Safe storage Warnings on disk battery or toys packages Fluid before pill medication and upright position
34 Prevention : secondary containers
35 pt ha ig a st ro.o r g Prevention : childproof cap
36 pt ha ig a st ro.o r g Prevention : warning sign
37 Do not induce emesis, lavage, neutralization, NPO, IV fluid Consider EGD within 12 hr after congestion Grade 0-1 Grade 2 Grade 3 Supportive Rx start oral feeding D/C with education Summary : Acute abdomen series if suspected perforation NG placement after EGD consider steroid &ATB& PPI & NPO1wk Esophageal stricture Esophageal dilatation NG placement after EGD consider steroid &ATB& PPI NPO1wk,start TPN Esophagogram 3 wk after ingestion No stricture D/C & F/U injury prevention & education
38
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