Delayed gastric emptying in patients with caustic ingestion. Indications for emergency surgery rely more often on clinical grounds than on radiological findings; in the presence of doubtful clinical features a decision to perform laparotomy is likely more advantageous for patients than a conservative attitude especially in patients who ingested large amounts of corrosive substances[60]. Browne J., Thompson J. Caustic ingestion. In contrast, a meta-analysis of 362 children showed a 40% rate of stricture in the no-steroid group versus a 19% rate of stricture in the steroid-treated group.14, The landmark randomized trial by Anderson et al2 found no difference in the incidence of stricture formation with the use of steroids, though the number of patients in the study was relatively low. Patients with clinical or radiological evidence of perforation require immediate laparotomy, usually followed by esophagectomy, cervical esophagostomy, frequently concomitant gastrectomy and even more extensive resections, and jejunostomy feeding[58-60]. TM . about navigating our updated article layout. Prevention of stricture with intraluminal stenting through laparotomy after corrosive esophageal burns. Click here to have WISER help you identify an unknown chemical Late reconstructive surgery is often unavailable in developing countries. A definitive study on the value of steroids is lacking but, if used, most resources suggest the concurrent use of antibiotics.2,4,7 Dosing is controversial and recommendations vary widely.1,8 Side effects of steroids, especially vulnerability to infection, should be considered.2. Breathing it can cause severe irritation of the upper respiratory tract with coughing, burns and difficulty breathing. Although severe esophageal injuries have been reported in 12.0%[47] and 19.3%[48] of asymptomatic children, significant lesions at endoscopy are not usually observed when symptoms are absent after unintentional ingestion of less aggressive substances[24,49], thus making routine post-ingestion endoscopy questionable in this group of patients. Demirbilek S, Aydin G, Ycesan S, Vural H, Bitiren M. Polyunsaturated phosphatidylcholine lowers collagen deposition in a rat model of corrosive esophageal burn. 0000009673 00000 n Hair Loss Treatment. Stridor and drooling were considered 100% specific for significant esophageal injury[22,23], but no single symptom or symptom cluster can predict the degree of esophageal damage[20,24,25]. The patient underwent intubation at the outside emergency department because of respiratory distress and was transferred to our facility. However, secondary extension of caustic burns is unpredictable and re-exploration is indicated when in doubt. Gupta NM, Gupta R. Transhiatal esophageal resection for corrosive injury. Corrosive ingestion and the surgeon. It is also known as lye Sodium hydroxide has a variety of domestic, commercial, and industrial uses. The conventional acceptance that acids preferentially damage the stomach, due to the protective esophageal eschar, has recently been questioned, with observation of extensive esophageal damage and perforations after acid ingestion[12]. Friedman investigated risk factors for alkali ingestion in children. . Mortality and morbidity for caustic ingestion is most severe for extensive injuries. The innermost is the mucosa, consisting of squamous epithelium, lamina propria, and muscularis mucosa. Mattos G. M., Lopes D. D., Mamede R. C., Ricz H., Mello-Filho F. V., Neto J. The specific pathophysiologic mechanisms are becoming better understood and may have a role in the future management and prevention of long-term consequences, such as esophageal strictures. Until now, none of the above approaches, albeit appealing, has been tested in humans. In the past, there was a tendency to wait at least 24 hours to allow time for the injury to mature.5 Most authors4,7 are recommending earlier endoscopy and suggesting a wait of only 12 hours and a total wait of no more than 24 hours after ingestion for early assessment and treatment. The patient received flexible endoscopy within the 24 hours following injury. Sodium hydroxide is a pH balancer used in a wide range of beauty and skin care items, like cleansers, soaps, makeup, and creams or lotions. Kochhar R, Poornachandra KS, Puri P, Dutta U, Sinha SK, Sethy PK, Wig JD, Nagi B, Singh K. Comparative evaluation of nasoenteral feeding and jejunostomy feeding in acute corrosive injury: a retrospective analysis. This topic will review the clinical . Caustics and Batteries. Please remove adblock to help us create the best medical content found on the Internet. A high white blood cell count (> 20000 cells/mm3), elevated serum C-reactive protein, age and the presence of an esophageal ulcer have been considered predictors of mortality in adults[32]; an arterial pH less than 7.22 or a base excess lower than -12 have been considered indication of severe esophageal injury and of emergency surgery[33]. Milk and activated charcoal are contraindicated because may obscure subsequent endoscopy. The conservative management of severe caustic gastric injuries. Doan Y, Erkan T, Cokura FC, Kutlu T. Caustic gastroesophageal lesions in childhood: an analysis of 473 cases. Chronic Effects [4,6] Chronic exposure to sodium hydroxide is toxic to multiple body systems. Breathing difficulty (from inhaling sodium hydroxide) Lung inflammation Sneezing Throat swelling (which may also cause breathing difficulty) ESOPHAGUS, INTESTINES, AND STOMACH Blood in the stool Burns of the esophagus (food pipe) and stomach Diarrhea Severe abdominal pain Vomiting, possibly bloody EYES, EARS, NOSE, AND THROAT Drooling This helps dissolve most of the unwanted material in the wood, leaving relatively pure cellulose, which forms the basis of paper. In severe cases involving strong caustic substances, a person may develop very . Lakhdar-Idrissi M, Khabbache K, Hida M. Esophageal endoscopic dilations. Ingestion of sodium hydroxide can cause spontaneous vomiting, chest and abdominal pain, and difficulty swallowing with drooling. Methods: PubMed was searched from January 1950 to June 2018 using the terms "Hypochlorite", "Sodium . In developing countries, experienced pediatric surgical centers are not widely available and this should be considered before abandoning the conservative approach of dilatation. Perforation may occur during this period if ulceration exceeds the muscle plane. . 0000044094 00000 n The native esophagus can be left or removed. The patient received a nasogastric tube over a guide wire and was given multiple broad spectrum antibiotics without steroids. CAUSTIC SODA, CAUSTIC SODA; SODIUM HYDROXIDE; SODIUM HYDROXIDE, SODIUM HYDRATE, SODIUM HYDROXIDE, SODIUM HYDROXIDE (NA(OH)), and . Isbister GK, Page CB. The preservation of the native esophagus is still debated. The system shown in Table 2 correlates findings seen on endoscopy. HHS Vulnerability Disclosure, Help Expired - Lifetime Application number US177542A Inventor Everett C Hughes 1, 9, 10 Recent meta-analyses have revealed conflicting results. McAuley CE, Steed DL, Webster MW. Reported discrepancies between endoscopic findings and the extent of necrosis found at surgery suggest the need for better criteria to improve patient selection for emergency surgery. 1 Household stress (such as marital conflict, mental or physical illness or loss of a family member) was identified as the leading risk factor. First-aid measures after ingestion : Rinse mouth with water. Ferry G. D. Caustic esophageal injury in children. Reactive oxygen species generation with subsequent lipid peroxidation may contribute either to the initial esophageal injury, or to the subsequent stricture formation. The problem is largely unreported in these settings and its true prevalence simply cannot be extrapolated from the scarce papers or personal experience. It is commonly known as lye or potash. Moreover, cost and minimal experience in caustic strictures make the use of biodegradable devices questionable, especially in developing countries. Eighty percent of patients with grade 3 burns develop stricture, while only one third of those with grade 2 burns will eventually develop stenosis.7, Injury to the esophagus is rapid, as described above, for both acids and alkalis, but this acute tissue disintegration and deep tissue penetration may continue for hours.1 Injury progresses within the first week after ingestion, with inflammation and vascular thrombosis. De Peppo F, Zaccara A, DallOglio L, Federici di Abriola G, Ponticelli A, Marchetti P, Lucchetti MC, Rivosecchi M. Stenting for caustic strictures: esophageal replacement replaced. If it contacts tissues, it can cause severe damage, such as burning or ulcers, on contact. Spectrum of injury to upper gastrointestinal tract and natural history. What is sodium hydroxide food grade? Progress in Chemical Toxicology,3, 99. Sodium hydroxide is easy to handle, inexpensive, and very effective for the neutralization of strong or weak acids. Richmond, V. (2000). Outcome following surgical management of corrosive strictures of the esophagus. Late reconstructive surgery after emergency esophagectomy: When the stomach has been removed or shows chronic injuries, the use of a gastric tube for esophageal reconstruction is obviously precluded. After caustic ingestion, patients may present with a combination of many symptoms or none at all depending on the nature of the agent, the specifics of the ingestion (quantity, intent, timing), and what tissues were affected. 0000002687 00000 n After extubation the patient had persistent difficulty with secretions. Song HY, Han YM, Kim HN, Kim CS, Choi KC. Sodium hydroxide is a very strong chemical that is also known as lye and caustic soda. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Orocecal transit time is prolonged mainly in patients with lower third esophageal involvement of the burn[65], probably related to autovagotomy due to vagal entrapment in the cicatrization process involving the lower third of the esophagus. Maximal esophageal wall thickness, observed at CT scan, was associated with a higher number of sessions required for adequate dilatation[92], and recurrent strictures were significantly more frequent after delayed dilatation (Figure (Figure44)[93-95]. sharing sensitive information, make sure youre on a federal 0000009694 00000 n It is used in soaps and detergents, textiles, dyes, pulp and paper products, explosives, and petroleum products, Caustic Soda Poisoning is the accidental or intentional intake of any product containing the compound, The condition is diagnosed based upon the clinical history, combination of signs and symptoms, and additional tests (that may include, in some cases, radiological studies and laboratory tests), In case of an emergency, call 911 (or your local emergency number) for assistance, In case of poisoning, call National Poison Control Center at 800-222-1222 (or your local poison control center) and follow instructions, Provide them with information such as dosage, type, strength and time of ingestion of medication, age, weight and general health status of affected individual. The absence of pain does not preclude significant gastrointestinal damage. The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns. Potassium hydroxide is a caustic chemical. Additionally, the degree of esophageal injury at endoscopy is an accurate predictor of systemic complications and death, with each increased injury grade correlated with a 9-fold increase in morbidity and mortality[14]. Immediate medical attention and special treatment, if necessary . Furthermore, significantly lower glutathione concentrations, a known endogenous free-radical scavenger, were found in the same tissues compared with controls, further supporting the presence of reactive oxygen species and free-radical damage[17]. Previtera C, Giusti F, Guglielmi M. Predictive value of visible lesions (cheeks, lips, oropharynx) in suspected caustic ingestion: may endoscopy reasonably be omitted in completely negative pediatric patients? Acquired oesophageal strictures in children: emphasis on the use of string-guided dilatations. Indeed, radiological intramural and well-contained transmural esophageal ruptures were observed in 30% of balloon dilatation procedures[106]. This article discusses poisoning from touching, breathing in (inhaling), or swallowing sodium hydroxide. Saponification of fats, denaturation of proteins, and blood vessel thrombosis will occur during the injury process.1,4,5,11 This injury occurs quickly, with a 30% solution of sodium hydroxide being able to produce full thickness Intraluminal stent: Specially designed silicone rubber[78] or, more recently, polyflex stents[79] have been found helpful in preventing stricture formation but the efficacy is less than 50%, with a high migration rate (25%). Temiz A, Oguzkurt P, Ezer SS, Ince E, Hicsonmez A. Predictability of outcome of caustic ingestion by esophagogastroduodenoscopy in children. Steroids: Systemic administration of steroids seems ineffective in preventing strictures[55,56], especially in patients with 3rd degree esophageal burns. Technetium-labeled sucralfate swallow has high sensitivity and specificity but limited ability to show extent of injury. Sarfati E, Gossot D, Assens P, Celerier M. Management of caustic ingestion in adults. P = 0.0008. In addition, balloon inflation may cause either extrinsic mechanical compression of the trachea or obstruction at the endotracheal tube tip[107]. Concentrated vapors lead to serious damage to the eyes and respiratory system. The reported incidence ranges from 2% to 30%, with an interval from 1 to 3 decades after ingestion[53]. 2 NH Locations: Landcare Stone Madbury, NH Stratham Hill Stone Stratham, NH Shipping Nationwide Gupta SK, Croffie JM, Fitzgerald JF. Mitomycin C: Mitomycin C, a chemotherapeutic agent with DNA crosslinking activity, when injected or applied topically to the esophageal mucosa, may be valuable in preventing strictures, but this drug has deleterious adverse effects, especially if systemic absorption occurs across the intact mucosa[74]. Severe injuries of the stomach at endoscopy require careful monitoring with a low threshold for laparotomy. Household bleaches (3 to 6% sodium hypochlorite) usually cause esophageal irritation, but rarely cause strictures or serious injury such as perforation. Esophagogastroduodenoscopy is considered crucial and usually recommended in the first 12-48 h after caustic ingestion, though it is safe and reliable up to 96 h after the injury[13,42]; gentle insufflation and great caution are mandatory during the procedure. Is endoscopy always necessary? Late reconstructive surgery, mainly using colon transposition, offers the best results in referral centers, either in children or adults, but such a difficult surgical procedure is often unavailable in developing countries. Zareba, G., Gelein, R., Morrow, P. E., & Utell, M. J. This article discusses poisoning from touching, breathing in (inhaling), or swallowing sodium hydroxide. Pelclov D, Navrtil T. Do corticosteroids prevent oesophageal stricture after corrosive ingestion? The https:// ensures that you are connecting to the Acute surgery is quite exceptional in the pediatric population and most authors recommend exhausting all resources to try to preserve the childs native esophagus[25]. Sodium hydroxide is very corrosive. Nasogastric tube: Though a nasogastric tube may be helpful to ensure patency of the esophageal lumen, the tube itself can contribute to the development of long strictures and routine use is not uniformly recommended[22]. Kiviranta NK. Treatment consists of respiratory and cardiovascular support. Khan BA, Kochhar R, Nagi B, Raja K, Singh K. Gall bladder emptying in patients with corrosive-induced esophageal strictures. Sodium hydroxide is known as industrial soap because of its degreasing characteristics. FELDSTEIN, M. (2013). Updates on the evaluation and management of caustic exposures. Symptoms may take anywhere from 2-12 hours to develop. Endoscopic dilatation: Timely evaluation and dilatation of the stricture play a central role in achieving a good outcome[91]. This is for information only and not for use in the treatment or management of an actual poison exposure. Likewise, compared with alkali, ingestion of a strong acid may be associated with a higher incidence of systemic complications, such as renal failure, liver dysfunction, disseminated intravascular coagulation and hemolysis[13]. DallOglio L, De Angelis P. Commentary on Esophageal endoscopic dilations. Medical or endoscopic prevention of stricture is debatable, yet esophageal stents, absorbable or not, show promising data. . Kochhar R, Sriram PV, Ray JD, Kumar S, Nagi B, Singh K. Intralesional steroid injections for corrosive induced pyloric stenosis. Bibliographies of retrieved studies were reviewed and general medical and major gastroenterology journals manually searched over the previous 5 years. Potassium hydroxide poisoning. This article discusses poisoning from touching, breathing in (inhaling), or swallowing sodium hydroxide. Accordingly, alkali ingestion may lead to more serious injury and complications, but this distinction is probably not clinically relevant in the setting of strong acid or base ingestion, both being able to penetrate tissues rapidly, potentially leading to full-thickness damage of the esophageal/gastric wall. Definition Sodium hydroxide is a very strong chemical that is also known as lye and caustic soda. Before A cut-off value for unsuccessful dilatation treatment may be difficult to define, especially in developing countries, where alternative surgical options are not widely available. The dissolution/dissociation in water is strongly exothermic, so a vigorous reaction occurs when sodium hydroxide is added to water. Considering that 10%-30% of caustic ingestions globally do not show any upper gastrointestinal injury[22,51], the indication for early endoscopy should be made on a case-by-case basis, with consideration of symptoms, otorhinolaryngeal injuries, and the amount and nature of the ingested substance. Finally, a recent case will be presented that highlights the difficulty this problem poses to a medical team. Malondialdehyde, an end-product of lipid peroxidation, was found at significantly higher levels than normal in esophageal tissue exposed to sodium hydroxide, signifying the presence of reactive oxygen species at 24 h post exposure. It has 3 primary layers. Chirica M, Vuarnesson H, Zohar S, Faron M, Halimi B, Munoz Bongrand N, Cattan P, Sarfati E. Similar outcomes after primary and secondary esophagocoloplasty for caustic injuries. Sodium Hydroxide Safety Data Sheet according to Federal Register / Vol. Endoscopic classification[8] is important for prognosis and management (Table (Table3).3). Ramasamy K., Gumaste V. V. Corrosive ingestion in adults. 0000006712 00000 n If you have an exposure, y ou may also consult . Prevention of stricture is still a debatable issue, yet esophageal stents may offer promising outcomes. Sodium hydroxide, This is for information only and not for use in the treatment or management of an actual poison exposure. Gerzic ZB, Knezevic JB, Milicevic MN, Jovanovic BK. Tube feedings were started and the patient remained afebrile. Hot Zone : Rescuers should be trained and appropriately attired . When lip and oropharyngeal injuries are the main clinical findings, esophageal or gastric injuries are generally no greater than grade 1[46]. Caustic ingestion, Corrosive stricture, Developing countries, Surgical management, Endoscopic management. However, timely and early surgery may be the only hope for patients with severe injuries, and a rather aggressive attitude should be considered in such patients. Experimentally, biodegradable stents were not able to prevent strictures in pigs after circumferential submucosal resection[85]. Mukherjee K, Cash MP, Burkey BB, Yarbrough WG, Netterville JL, Melvin WV. The new PMC design is here! Partial gastric resection is preferred by many[133,134] for the long-term risk of malignant transformation, though the need for gastric resection as prophylaxis against future malignancy has been overstated in the literature[29]. Olives are often soaked in sodium hydroxide for softening; Pretzels and German lye rolls are glazed with a sodium hydroxide solution before baking to make them crisp. It is made of solid white crystals that absorb water from the air. Bleeding following corrosive ingestion is usually self-limiting: though massive hemorrhage from the stomach or duodenum has been reported a short time after corrosive ingestion[30], severe bleeding typically occurs at 2 wk after ingestion[29]. ingestion causes liquefactive necrosis with diffusion into deeper layers of the injured mucosa. The 5%-8% perforation rate after balloon dilatation[104] may be as high as 32% in caustic strictures[105]. A meta-analysis of studies between 1991 and 2004, and an additional analysis of the literature over a longer period from 1956 to 2006 did not find any benefit of steroid administration in terms of stricture prevention. Kamijo Y, Kondo I, Kokuto M, Kataoka Y, Soma K. Miniprobe ultrasonography for determining prognosis in corrosive esophagitis. Arvalo-Silva C., Eliashar R., Wohlgelernter J., Elidan J., Gross M. Ingestion of caustic substances: a 15-year experience. Agarwal S, Sikora SS, Kumar A, Saxena R, Kapoor VK. This case highlights the unpredictability of these injuries. 0000004358 00000 n government site. Doctors will first assess vital signs, looking at breathing, heart rate, body temperature, and blood pressure. Zargar SA, Kochhar R, Nagi B, Mehta S, Mehta SK. Learn more Conservative management of severe gastric injuries at laparotomy, with partial or total conservation of the stomach, has been recently advocated by some in the absence of clinical and biological signs of severity[62]. Wang RW, Zhou JH, Jiang YG, Fan SZ, Gong TQ, Zhao YP, Tan QY, Lin YD. 0000010762 00000 n The patient's past medical and surgical history were unremarkable. 0000079653 00000 n National Capital Poison Center (USA)3201 New Mexico Ave, Suite 310 Washington, DC 20016Administrative Line: (202) 362-3867Emergency Line: 1 (800) 222-1222Fax: (202) 362-8377 Email:pc@poison.orgWebsite:http://www.poison.org, American Association of Poison Control Centers (USA)515 King St., Suite 510, Alexandria, VA 22314Phone: (703) 894-1858Email:info@aapcc.orgWebsite:http://www.aapcc.org, https://medlineplus.gov/ency/article/002487.htm(accessed on 09/24/2017), https://www.atsdr.cdc.gov/MMG/MMG.asp?id=246&tid=45(accessed on 09/24/2017), http://www.merckmanuals.com/home/injuries-and-poisoning/poisoning/caustic-substances-poisoning(accessed on 09/24/2017), https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm253338.htm(accessed on 09/24/2017). For skin exposure, treatment may include: Surgical removal of burned skin (debridement) Transfer to a hospital that specializes in burn care; Washing of the skin (irrigation), possibly every few hours for several days Patients may have obvious burns to the lips, mouth, and oropharyx. Federal government websites often end in .gov or .mil. Excessive salivation Smacking of the lips Tongue flicking Difficulty swallowing Vomiting (with or without blood) Abdominal pain Blood in the stool (melena) Difficulty breathing Lethargy Ulceration of the mouth, esophagus, or stomach (oral ingestion) Combined antegrade and retrograde dilation: a new endoscopic technique in the management of complex esophageal obstruction. Our service was consulted to evaluate the patient's upper airway to assess if the patient could be extubated on posttrauma day 4 (Figure 1). Surgery for non-responding esophageal strictures: When esophageal dilatation is not possible or fails to provide an adequate esophageal caliber in the long-term, esophageal replacement by retrosternal stomach or, preferably, right colonic interposition should be considered. Sodium hydroxide is a very strong chemical. Fibroblasts appear at the injury site around day 4, and around day 5, an esophageal mold is formed, consisting of dead cells and secretions. It is present as a stabilising agent in bleach. Berger M, Ure B, Lacher M. Mitomycin C in the therapy of recurrent esophageal strictures: hype or hope? Weaker alkalis that are powdered or granular, such as dishwater detergents, tend to injure the upper airway and can cause laryngeal edema and airway compromise.1,8,13. Esophageal stricture may be seen as early as 3 weeks after ingestion.2,15 It occurs in 10% to 20% of caustic injuries, most commonly at the level of the cricoid cartilage, the region of the aortic arch, and below the left main stem bronchus, as well as the esophageal hiatus, all of which are anatomic regions of narrowing in the esophagus.1,11 Stricture can lead to severe dysphagia, with approximately 80% of strictures causing obstructive symptoms 2 months after their formation.8 Of children ingesting alkalis, 30% will develop esophageal burns; of these, 50% will develop strictures.5 Severe and recalcitrant strictures may require esophageal replacement with colon or jejunum interpositional grafts, while less severe strictures are managed with dilation.1,2,5,11,15 Balloon dilation is the procedure of choice for management of most strictures in children.4 The literature suggests a baseline barium esophagram 3 to 4 weeks after ingestion to establish baseline for future stricture formation.1 Complications of stricture include nutritional compromise, hospitalization, chronic anemia, and repeated dilations.1. A CT scan may offer a promising role in assessing the evolution of the injury and impending perforations. 0000001107 00000 n Caustic Injury to the Esophagus. Prevention has a paramount role in reducing the incidence of corrosive ingestion especially in children, yet this goal is far from being reached in developing countries, where such injuries are largely unreported and their true prevalence simply cannot be extrapolated from random articles or personal experience. Colon interposition in the treatment of esophageal caustic strictures: 40 years of experience. Damage to the mouth, throat and stomach is immediate. In this case report, two dogs ingested an unknown volume of Clorox Regular-Bleach (The Clorox Company) containing 6.15% sodium hypochlorite and subsequently developed marked hypernatremia and hyperchloremia as well as numerous other biochemical abnormalities. Endoscopy past 48 hours is discouraged because of progressive wall weakening and increased risk of perforation.1 Most agree that strong alkali ingestion mandates endoscopy, while asymptomatic or questionable ingestions may be observed, according to some sources.1,4, Treatment schemes for caustic injuries vary and no consensus exists. ), Transport identification: DOT placard and/or type of rail car or road trailer). Evaluation of esophageal wall caustic damage by endoscopic ultrasound (EUS) using a miniprobe seems safe, though prolongs examination time without showing any difference with endoscopy in predicting early complications[36]. Alkaline disk batteries contain a 45% solution of potassium hydroxide or sodium hydroxide. The administration of broad-spectrum antibiotics is usually advised mainly if corticosteroids are initiated, as well as if lung involvement is identified[53,57].