esofagitis korosif final
TRANSCRIPT
Esofagitis korosif
Epidemiology
• Incidence: 5000-15000 / Yr in US• Etiology: – Infant and toddler: Accidental– Adolescent and Adult: Suicide attempts
Agents responsible for caustic ingestions
• Caustic agents or alkali (pH > 7)
• Corrosives or acids (pH < 7)
• Bleaches (pH = 7)
Commonly Ingested Caustic Agents
Ronald Amedee,2009
Alkali ingestion
• Liquefaction necrosis– early disintegration of the mucosa – deep penetration into tissues– Direct contact with cell membranes leads to
their disruption secondary to saponification and proteinate formation as the alkali reacts with membrane components
• More oral and upper esophageal involvement
Acid ingestion
• Coagulation necrosis– Causes a coagulum to form on the
mucosa– Eschar formation– Limiting deeper absorption
• Reaches the stomach– Acidic pH can heighten the injury
Acid Ingestion
• Esophageal damage is less– Protection by the slightly alkaline pH of
the esophagus– Resistance of squamous epithelium to
acids
• Antrum of the stomach is the most vulnerable region– Pooling and prolonged contact
Bleaches
• Neutral pH • Esophageal
irritants• No significant
morbidity & mortality
Disk Batteries
• Leakage of contents: NaOH, KOH, Hg–Mucosal damage: 1hr– Erosion: 2-4 hrs– Perforation: 8-12 hrs
• Direct caustic injury• Absorption of toxic substances• Pressure necrosis• Electrical discharge
Severity of injury
• Amount and type of agent ingested• Presence of other food in the
stomach• GI transit time• Presence of gastroesophageal reflux
• Acute Injury– Immediate changes to mucosa which
progress during the next 3 days
• Latent periode– Stricture formation may occur– The process may proceed as rapidly as 1
month or during a period of years
• Stricture Formation
Stages of esophageal burns
grade 1: superficial injurygrade 2: transmucosal injurygrade 3: transmural injury
Stages of esophageal burns
Stages of esophageal burns
• Mild Nonulcerative Esophagitis • Mild Ulcerative Esophagitis• Moderate to Severe Ulcerative
Esophagitis• Severe Ulcerative, Uncomplicated
esophagitis• Severe Ulcerative Esophagitis with
Complications
Sign and Symptoms of Caustic Ingestion
• Oral mucosal erythema, ulceration• Drooling• Tongue edema• Stridor• Hoarseness• Dysphagia• Odynophagia• Chest or back pain• Epigastric pain or tenderness• Vomiting• Hematemesis
• Laryngeal injury– Hoarseness, stridor, dyspnea
• Severe injury– Odynophagia, drooling, refusal of food
• Perforation– Chest pain, abdominal pain, rigidity
Diagnosis
• History• PE– Examination of lips, chin, hands, chest,
clothing– Examination at the oropharyng– Examination at the Larynx/Hypopharynx• Laryngeal mirror• Flexible nasopharyngoscope
• Obtain Container
Ancillary Procedure• Chest & Neck Radiography
– Foreign body ingestion (disc battery)• Esophagoscopy at 24-48 hours post-ingestion
– < 24 hours – underestimation of injury– > 48-72 hours with risk of iatrogenic
• Ba swallow– Not for acute management– 30-90% false (-) rates for moderate esophageal
involvement– Verify perforation – Evaluate progressive dysphagia due to stricture
formation
Remember
• Oral injuries (lip or buccal burns) cannot predict the presence or absence of more distal involvement
• 20% without oral burns have esophageal burns
• 70% with oral burns don’t have esophageal burns
Management 1
• Diluting agents such as water or milk to remove the agent from the esophagus
• Fluid intake should be no more than 15 mL/kg of weight
• No Gastric lavage • No induced vomiting with emetics (ipecac)
Management 2
• Steroid administration in the transmucosal (grade 2) injuries– Prednison 1 to 2 mg/kg/day (max 60
mg) This dosage is continued for a 21-day period on a tapered regimen
• Steroids are contraindicated in grade 3 injuries
• Protection from gastric acid– Sucralfate– Antacids, H2 Blocker, PPI
Management 3
• Antibiotics – Do not prevent from stricture formation– Signs or symptoms of a secondary
infection
• Lathyrogenic agents– Aminopropionitrile, Acetylcysteine, and
Penicillamine – Reduce collagen cross-bonding
Management 4
• Esophageal dilatation for stricture formation– Prograde– Retrograde– Balloon catheters
• Surgery– Esophageal
replacement• Colonic
interposition• Jejunal
interposition• Gastric pull-ups
Complications
• Stricture formation• Esophageal perforation• Tracheoesophageal fistula• Gastric perforation• Mediastinitis• Peritonitis• Pneumonia• Sepsis,• Hiatal hernia• Reflux esophagitis• Esophageal Ca