Guía de práctica clínica Ibero-Latinoamericana sobre la esofagitis cáustica en Pediatría: aspectos terapéuticos (2a. Parte) / Ibero-Latinamerican Clinical Practical Guidelines on pediatric caustic esophagitis: therapeutical aspects (Part 2)

Resumen: La ingestión de cáusticos representa un grave problema médico-social por las consecuencias devastadoras e irreversibles que puede producir en el tracto digestivo superior. En Iberoamérica no se han publicado datos fidedignos sobre la incidencia o la prevalencia de lesiones inducidas por cáusticos. La información disponible sobre la presentación clínica, diagnóstico, tratamiento y pronóstico se basa en series retrospectivas de casos y, de hecho, su manejo clínico se sustenta en muchos casos fundamentalmente en la opinión de expertos. Recientemente como una iniciativa de la Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica (SLAGHNP) y con la co laboración de colegas de la Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediá trica (SEGHNP), hemos diseñado una Guía de Práctica Clínica (GPC) la cual incluye una serie de enunciados y recomendaciones dirigidos a optimizar la atención a los pacientes y que se basan en la revisión sistemática de la evidencia. En dos (2) manuscritos sucesivos nos hemos enfocado primero, en los aspectos fisiopatológicos y de diagnóstico clínico-endoscópico de la esofagitis cáustica en niños (1a. Parte) y en segundo lugar, en los aspectos más relevantes del tratamiento (2a. Parte). Esperamos esta guía se convierta en una herramienta útil para el clínico en el difícil proceso de toma de decisio nes a la hora de evaluar un paciente posterior a la ingesta de una sustancia cáustica.

Abstract: Caustic ingestion represents a serious social-medical problem due to the devastating and irreversible consequences it can produce in the upper digestive tract. In Ibero-America, there are no published reliable data on the incidence or prevalence of caustic-induced injuries, and most of the available information on clinical presentation, diagnosis, treatment, and prognosis is based on retrospective clinical series and, indeed, its clinical management is often based primarily on expert opinion. Re cently as an initiative of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) and with the cooperation of the Spanish Society for Pediatric Gastroente rology, Hepatology and Nutrition (SEGHNP), we have designed a Clinical Practice Guideline that include a series of statements and recommendations aimed at optimizing patient medical care which is based on the systematic review of evidence. Two (2) separate papers focused on the evaluation of physiopathological and clinical-endoscopic diagnostic features of caustic esophagitis in children (1st. Paper) and, on the other hand, the most relevant therapeutic considerations (2nd. Paper). We expect this guideline to become a useful tool for the physician in the difficult decision-making process when assessing patients after caustic ingestion.

Guía de práctica clínica Ibero-Latinoamericana sobre la esofagitis cáustica en Pediatría: fisiopatología y diagnóstico clínico-endoscópico (1a Parte) / Ibero-latinamerican clinical practical guidelines on pediatric caustic esophagitis: physiopathology and clinical-endoscopic diagnosis (1st Part)

Resumen: La ingestión de cáusticos representa un grave problema médico-social por las consecuencias devastadoras e irreversibles que puede producir en el tracto digestivo superior. En Iberoamérica no se han publicado datos fidedignos sobre la incidencia o la prevalencia de lesiones inducidas por cáusticos. La información disponible sobre la presentación clínica, diagnóstico, tratamiento y pronóstico se basa en series retrospectivas de casos y, de hecho, su manejo clínico se sustenta en muchos casos fundamentalmente en la opinión de expertos. Recientemente como una iniciativa de la Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica (SLAGHNP) y con la co laboración de colegas de la Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediá trica (SEGHNP), hemos diseñado una Guía de Práctica Clínica (GPC) la cual incluye una serie de enunciados y recomendaciones dirigidos a optimizar la atención a los pacientes y que se basan en la revisión sistemática de la evidencia. En dos (2) manuscritos sucesivos nos hemos enfocado primero, en los aspectos fisiopatológicos y de diagnóstico clínico-endoscópico de la esofagitis cáustica en niños (1a. Parte) y en segundo lugar, en los aspectos más relevantes del tratamiento (2a. Parte). Esperamos esta guía se convierta en una herramienta útil para el clínico en el difícil proceso de toma de decisio nes a la hora de evaluar un paciente posterior a la ingesta de una sustancia cáustica.

Abstract: Caustic ingestion represents a serious social-medical problem due to the devastating and irreversible consequences it can produce in the upper digestive tract. In Ibero-America, there are no published reliable data on the incidence or prevalence of caustic-induced injuries, and most of the available information on clinical presentation, diagnosis, treatment, and prognosis is based on retrospective clinical series and, indeed, its clinical management is often based primarily on expert opinion. Re cently as an initiative of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) and with the cooperation of the Spanish Society for Pediatric Gastroente rology, Hepatology and Nutrition (SEGHNP), we have designed a Clinical Practice Guideline that include a series of statements and recommendations aimed at optimizing patient medical care which is based on the systematic review of evidence. Two (2) successive papers focused on the evaluation of physiopathological and clinical-endoscopic diagnostic features of caustic esophagitis in children (1st. Paper) and, on the other hand, the most relevant therapeutic considerations (2nd. Paper). We expect this guideline to become a useful tool for the physician in the difficult decision-making process when assessing patients after caustic ingestion.

Hallazgos endoscópicos en el tubo digestivo secundarios a la ingesta de cáusticos en niños atendidos en el Departamento de Urgencias / Endoscopic findings of the digestive tract secondary to caustic ingestion in children seen at the Emergency Department

Antecedentes. La ingesta de sustancias cáusticas en pediatría constituye una causa frecuente de atención médica en Urgencias. El uso indiscriminado de limpiadores químicos y la facilidad de adquisición son factores determinantes para estas lesiones. Población y métodos. Estudio descriptivo analítico. Se incluyeron niños < 16 años, entre enero de 1998 y diciembre de 2017. Se identificó el agente químico cáustico ingerido por el niño como ácido o alcalino. Se realizó una endoscopía digestiva para tipificar el grado de quemadura. Se comparó el grado de quemadura con el tipo de cáustico; por medio de la prueba de chi² o exacta de Fisher, se consideró significativo el valor de P < 0,05. Resultados. Ingresaron 133 niños en Urgencias por ingesta de cáusticos. El agente cáustico fue ácido en el 41 % y alcalino en el 59 %. El agente ácido más frecuente fue el ácido muriático (36,8 %), mientras que el alcalino fue la sosa (soda) cáustica (41,4 %). La quemadura del esófago fue más frecuente en la ingesta de sosa en comparación con otros cáusticos (p= 0,001), mientras que la quemadura del estómago (p= 0,001) y del duodeno (p= 0,002) fue estadísticamente significativa en la ingesta de ácido muriático. El grupo de edad que más frecuentemente ingirió algún cáustico (93,2 %) fueron los menores de 5 años. Conclusiones. El cáustico ingerido con mayor frecuencia fue un agente alcalino, que provocó quemadura esofágica, mientras que un agente ácido provocó quemaduras en el estómago y el duodeno evidenciadas por endoscopía.

Background. Caustic ingestion in pediatrics is a common cause of visits to the Emergency Department. An indiscriminate use of cleaning chemicals and an easy access to them are determining factors for these injuries. Population and methods. Descriptive, analytical study. Children aged < 16 years hospitalized between January 1998 and December 2017 were included. The ingested caustic substance was identified as acid or alkaline. A gastrointestinal endoscopy was done to establish the burn grade. The grade of the burn was compared to the type of caustic substance using the χ² test or the Fisher's exact test; a P value < 0.05 was considered significant. Results. A total of 133 children were admitted to the Emergency Department due to caustic ingestion. The caustic agent was acid in 41 % of cases and alkaline, in 59 %. The most common acid caustic substance was muriatic acid (36.8 %) and the most common alkaline caustic agent was caustic soda (41.4 %). An esophageal burn was the most common consequence of caustic soda ingestion compared to other caustic agents (p = 0.001), whereas muriatic acid ingestion was the most statistically significant cause of stomach burn (p = 0.001) and duodenal burn (p = 0.002). The age group that most commonly ingested some caustic agent (93.2 %) corresponded to children younger than 5 years. Conclusions. The most common type of ingested caustic agent was alkaline, which caused esophageal burn; whereas, the ingestion of an acid caustic substance caused stomach and duodenal burns, as evidenced by endoscopy.

Pharyngo-ileo-colo-anastomosis with micro-vascular blood supply augmentation for esophago-gastric replacement due to esophago-gastric necrosis after caustic ingestion / Faringo-íleo-colo-anastomose com suprimento sanguíneo microvascular para substituição esofagogástrica por necrose esofagogástrica após ingestão cáustica

ABSTRACT Background : Complete esophago-gastric necrosis after caustic ingestion is a challenging surgical scenario for reconstruction of the upper digestive transit. Aim : To present a surgical technique for reconstruction of the upper digestive tract after total esophagectomy and gastrectomy due to esophageal and gastric necrosis Method: The transit was re-established by means of a pharyngo-ileo-colic interposition with microsurgical arterial and venous anastomosis for augmentation of blood supply. Colo-duodeno-anastomosis and ileo-transverse colic anastomosis were performed for complete digestive transit reconstruction. Result: This procedure was applied in a case of 41 years male attempted suicide by ingesting alkali caustic liquid (concentrated sodium hydroxide). Total necrosis of the esophagus and stomach occurred, which required initially total esophago-gastrectomy, closure at the level of the crico-pharyngeal sphincter and jejunostomy for enteral feeding with a highly deteriorated quality of life . The procedure was performed later and there were no major early and late postoperative complications and normal nutritional conditions were re-stablished. Conclusion: The procedure is feasible and must be managed by multidisciplinary team in order to re-establish a normal quality of life.

RESUMO Racional: A necrose esofagogástrica completa após ingestão cáustica é um cenário cirúrgico desafiador para a reconstrução do trânsito digestivo alto. Objetivo: Apresentar uma técnica cirúrgica para reconstrução do trato digestivo superior após esofagectomia total e gastrectomia por necrose esofágica e gástrica. Método: O trânsito foi restabelecido por interposição faringo-íleo-cólica com anastomose arterial e venosa microcirúrgica com aumento do suprimento sanguíneo. Adicionalmente, anastomose colo-duodeno-anastomótica e íleo-transversa foram realizadas para reconstrução completa do trânsito digestivo. Resultado: Este procedimento foi aplicado em um homem de 41 anos com tentativa de suicídio pela ingestão de líquido cáustico alcalino (hidróxido de sódio concentrado). Ocorreu necrose total do esôfago e do estômago, o que exigiu inicialmente esofagogastrectomia total, fechamento ao nível do esfíncter cricofaríngeo e jejunostomia para alimentação enteral produzindo qualidade de vida altamente deteriorada. O procedimento foi realizado mais tardiamente e não houve maiores complicações pós-operatórias precoces e tardias e condições nutricionais normais foram restabelecidas. Conclusão: O procedimento é viável e deve ser manejado por equipe multidisciplinar a fim de restabelecer a qualidade de vida normal.

Evaluación de lesiones esofágicas secundarias a la ingesta de sustancias cáusticas no rotuladas: Serie de casos pediátricos / Evaluation of esophageal injuries secondary to ingestion of unlabeled corrosive substances: pediatric case series

Las lesiones esofágicas o gástricas secundarias a la ingesta de sustancias cáusticas siguen siendo un problema importante en los países en vías de desarrollo. El espectro clínico puede variar desde la ausencia de una lesión en la mucosa hasta complicaciones tales como quemaduras graves, estenosis y perforación. El examen físico y la evaluación endoscópica inicial son sumamente importantes para el diagnóstico. El objetivo de este estudio es presentar los casos de 154 niños sometidos a una endoscopía digestiva alta debido a la ingesta de sustancias cáusticas, entre otras, desincrustante químico, desengrasante, lavandina no rotulada, limpiador de tuberías de desagüe, limpiador de superficies, abrillantador de vajilla y ácido clorhídrico. Se observaron signos orofaríngeos positivos en 69 niños. Con la endoscopía inicial, se hallaron quemaduras en 63 niños; en 40, las quemaduras eran graves. Durante el seguimiento, se produjo estenosis en 20 niños, que fueron incluidos en el programa de dilatación. Entre ellos, fue posible dilatar e inyectar corticoides intralesionales satisfactoriamente a 14 niños. Sin embargo, tres niños fueron sometidos a una interposición de colon, y otros tres, a una gastroduodenostomía y gastroyeyunostomía.

Esophageal or gastric injuries secondary to caustic substance ingestion is still an important issue in developing countries. Its clinical spectrum can vary from absence of mucosal injury to complications such as severe burns, strictures and perforation. Physical examination and first endoscopic evaluation are very important in the diagnosis. The objective of this study is to present 154 children who were undergone upper gastrointestinal endoscopy because of caustic substance ingestion including descaler, degreaser, unlabeled bleach, drain opener, surface cleaner, dishwasher rinse aid, hydrochloric acid. Sixty-nine children had positive oropharyngeal findings. Sixty-three children were found to have burns in the first endoscopic examination and forty of these burns were severe burn. In the follow-up, twenty children developed strictures that were undergone dilatation program. Fourteen children in the dilatation program had successful dilatation and intralesional steroid injection. However three children had undergone colonic interposition and three undergone laparoscopic gastroduodenostomy and gastrojejunostomy.

Ingesta de cáusticos en niños, experiencia de 3 años / Ingestion of caustic substances in children: 3 years of experience

Introdución: La ingesta accidental de cáusticos en pediatría no dispone de un consenso claro de actuación. El objetivo de este estudio fue caracterizar la población pediátrica atendida por ingesta de cáusticos en un centro asistencial. Pacientes y método: Estudio descriptivo de los pacientes atendidos en nuestro hospital por la ingesta de cáusticos durante el período 2008-2011. Resultados: Se atendieron 12 pacientes, edad media de 3,8 años (1-13 años). Predominio de varones (58,8%). Un 58,3% ingirió producto alcalino y un 41,6% ácido. El 58,3% no refería sintomatología, el resto refirió vómitos (33,3%), odinofagia (16,6%), hematemesis (8,3%), sialorrea (8,3%) y dificultad respiratoria (8,3%). El 75% presentaron lesiones en la cavidad oral. Todos, salvo un caso, fueron accidentales. Se realizó endoscopia al 100% entre las 12 y 24 h postingesta con hallazgos patológicos en un 41,6%. En el grupo ingesta de álcalis 2 pacientes presentaron lesiones (16,6%): una esofagitis grado 2B y una grado 3. En el grupo ingesta de ácidos 4 pacientes (33,3%) presentaron lesiones: una esofagitis aguda grado 1-2A, 2 gastritis agudas no erosivas y una gastritis aguda hemorrágica. Se realizó endoscopia de control según los hallazgos endoscópicos previos. Solo 2 presentaron complicaciones posteriores. Conclusiones: Destacamos la valoración endoscópica en las primeras 24 h en todas las ingestas sintomáticas y deliberadas, así como la reevaluación estrecha en las ingestas ácidas, por asociar lesiones diferidas.

Introduction: There is no clear consensus on the management of accidental ingestion of caustic substances in paediatrics. The aim of this study was to determine the profile of the paediatric population treated due to caustic ingestion in a Healthcare Centre. Patients and method: A descriptive study was conducted on patients treated for the ingestion of caustic substances in our hospital during the period 2008-2011. Results: A total of 12 patients were treated, with a mean age of 3.8 years (1-13 years), with the majority males (58.8%). An alkaline product was ingested by 58.3%, and an acid by 41.6%. The majority (58.3%) did not refer to symptoms and the remainder referred to vomiting (33.3%), odynophagia (16.6%), haematemesis (8.3%), hyper-salivation (8.3%) and shortness of breath (8.3%). Oral cavity lesions were observed in 75% of cases. All, except one, were accidental. An endoscopy was performed on all of them (100%) between 12 and 24 hours post-ingestion, with pathological findings in 41.6%. In the group that ingested an alkali, 2 (16.6%) patients had lesions, one a grade 2B and one a grade 3 oesophagitis. In the acid ingestion group, 4 (33.3%) patients had lesions; one grade 1-2A oesophagitis, two acute non-erosive gastritis, and one acute haemorrhagic gastritis. A follow-up endoscopy was performed depending on the previous endoscopic findings. Only two patients presented with complications. Conclusions: Emphasis is placed on the endoscopic evaluation in the first 24 hours of deliberate asymptomatic ingestions, as well as a strict follow-up in those that ingested acids, due to delayed associated lesions.

Intoxicación por ácido fluorhídrico: Presentación de un caso clínico / Hydrofluoric acid poisoning: Case report

El ácido fluorhídrico es una sustancia cáustica muy peligrosa, que tiene aplicaciones industriales y domésticas. Las manifestaciones clínicas asociadas a la intoxicación por este producto dependen de la vía de exposición, la concentración del ácido y la penetrabilidad en el tejido expuesto. En el tubo digestivo, la presencia o la ausencia de síntomas no se correlacionan con la gravedad de la lesión. Es necesario realizar una endoscopia digestiva alta en los pacientes con historia de ingestión de ácido fluorhídrico. Se requiere una inmediata intervención, ya que puede causar toxicidad sistémica. Se presenta el caso de una niña de 5 años que ingirió accidentalmente 5 ml de ácido fluorhídrico al 20%. En la videoendoscopia digestiva alta (VEDA), realizada dentro de las 24 horas, el esófago y el estómago estaban eritematosos, con lesiones erosivas. A los 2 meses se realizó una VEDA de control, que mostró una mucosa normal.

Hydrofluoric acid is a highly dangerous substance with industrial and domestically appliances. Clinical manifestations of poisoning depend on exposure mechanism, acid concentration and exposed tissue penetrability. Gastrointestinal tract symptoms do not correlate with injury severity. Patients with history of hydrofluoric acid ingestion should undergo an endoscopy of the upper gastrointestinal tract. Intoxication requires immediate intervention because systemic toxicity can take place. We present a 5 year old girl who accidentally swallowed 5 ml of 20% hydrofluoric acid. We performed gastrointestinal tract endoscopy post ingestion, which revealed erythematous esophagus and stomach with erosive lesions. Two months later, same study was performed and revealed esophagus and stomach normal mucous membrane.

Finger burns caused by concentrated hydrofluoric acid, treated with intra-arterial calcium gluconate infusion: case report / Queimadura digital por ácido fluorídrico concentrado tratada com infusão intra-arterial de gluconato de cálcio: relato de caso

CONTEXT: Hydrofluoric acid (HF) is widely used in industry and at home. Severe lesions can occur after contact with highly concentrated solutions, leading to tissue necrosis and bone destruction. Specific treatment is based on neutralization of fluoride ions with calcium or magnesium solutions. CASE REPORT: A 41-year-old male was seen at the emergency department 35 minutes after skin contact with 70 percent HF, showing whitened swollen lesions on the middle and fourth fingers of his right hand with severe pain starting immediately after contact. 2.5 percent calcium gluconate ointment was applied. Twenty-four hours later, the patient was still in severe pain and the lesions had worsened. Considering the high concentration of the solution, early start of severe pain, lesion characteristics and impossibility of administering calcium gluconate subcutaneously because of the lesion location, the radial artery was catheterized and 2 percent calcium gluconate was administered via infusion pump for 36 hours, until the pain subsided. No adverse effects were seen during the procedure. Ten days later, the lesions were stable, without bone abnormalities on X-rays. Six months later, a complete recovery was seen. CONCLUSIONS: Intra-arterial calcium gluconate might be considered for finger burns caused by concentrated HF. Complete recovery of wounded fingers can be achieved with this technique even if started 24 hours after the exposure. However, controlled clinical trials are needed to confirm the effectiveness and safety of this intervention.

CONTEXTO: Ácido fluorídrico é largamente usado na indústria e no ambiente doméstico. Lesões graves podem ocorrer depois de contato com soluções altamente concentradas levando a necrose tecidual e destruição óssea. O tratamento específico é baseado na neutralização dos íons de flúor com soluções de cálcio ou magnésio. RELATO DE CASO: Homem de 41 anos foi atendido na sala de urgência 35 minutos depois de contato da pele com ácido fluorídrico a 70 por cento, apresentando lesões esbranquiçadas e edemaciadas nos dedos médio e quarto da mão direita com dor intensa que iniciou logo após o contato. Pomada de gluconato de cálcio a 2,5 por cento foi aplicada. Depois de 24 horas, o paciente continuava com dor mais intensa e as lesões haviam piorado. Considerando a concentração da solução, o início precoce da dor intensa, as características das lesões e a impossibilidade de administrar gluconato de cálcio no subcutâneo devido ao local da lesão, foi inserido cateter na artéria radial para infusão de gluconato de cálcio a 2 por cento com bomba de infusão por 36 horas até melhora da dor. Nenhum efeito adverso foi observado durante o procedimento. Dez dias depois as lesões encontravam-se estáveis, sem alterações dos ossos vistas nos raios-X. Seis meses depois houve recuperação completa. CONCLUSÃO: Gluconato de cálcio intra-arterial pode ser considerado em queimaduras digitais por ácido fluorídrico. Recuperação completa dos dedos acometidos pode ser obtida com essa técnica mesmo que iniciada 24 horas após a exposição. Porém, ensaios clínicos controlados são necessários para confirmar a efetividade e a segurança desta intervenção.

Bovine pericardium in treating large corneal perforation secondary to alkali injury: a case report.

To describe use of a locally processed bovine pericardium (BP) to cover a large central corneal perforation following alkali injury and discuss postoperative outcome. A 27-year-old Malay male patient presented two weeks after alkali splashed in his left eye while working. A clinical diagnosis of left central corneal ulcer with limbal ischemia following alkali injury with secondary infection was made. After failed medical therapy, we performed a Gunderson conjunctival flap under local anesthesia that retracted after one week and resulted in a large central corneal perforation with surrounding stromal thinning. The perforation was covered with a locally processed BP xenograft (Lyolemb) supplied by the National Tissue Bank, University Sains Malaysia. Nine months follow-up showed a well-taken graft without any exposure/dehiscence and minimal inflammation. Amniotic membrane transplantation when used as a patch graft needs an urgent tectonic graft to promote corneal stability in patients with severe corneal thinning. The use of processed BP can be a viable option in treating such cases.

Fístula esôfago-traqueal após ingestão cáustica / Tracheoesophageal fistula after caustic ingestion

As fístulas esôfago-traqueais são incomuns e apresentam diversas etiologias, entre elas, a queimadura química esofágica devida à ingestão cáustica. Relatamos o caso de um paciente de 27 anos com história de ingestão cáustica havia catorze dias, com dor retroesternal em queimação, fraqueza, tosse com escarro purulento e dispnéia associada à rouquidão no último dia. A endoscopia digestiva alta e a broncofibroscopia revelaram fístula esôfago-traqueal. O tratamento consistiu no suporte clínico, drenagem torácica bilateral, exclusão do transito esofágico com esofagostomia cervical terminal e gastrostomia. Houve cicatrização espontânea da fístula esôfago traqueal em seis semanas. Posteriormente, realizou-se a reconstrução do trânsito alimentar através de faringocoloplastia. A evolução pós-operatória foi satisfatória.

Tracheoesophageal fistulas are uncommon and present diverse etiologies, among which is burning of the esophagus due to caustic ingestion. Herein, we report the case of a 27-year-old male patient having ingested a caustic substance 14 days prior and presenting burning retrosternal pain, weakness, productive cough with purulent sputum and dyspnea accompanied by hoarseness for the preceding 24 h. Endoscopy of the upper digestive tract revealed a tracheoesophageal fistula. Treatment consisted of cervical exclusion of the esophageal transit, together with gastrostomy. Subsequently, the nutrient transit was reconstructed through pharyngocoloplasty. The postoperative evolution was favorable.

Button battery ingestion.

Button batteries represent a special category of pediatric ingested foreign body because of the possibility of serious complications particularly if impacted in the esophagus. We report a case of a 3-year-old girl with severe mid esophageal burns due to a lodged battery. More awareness is required amongst physicians to avert such dangers and ensure prompt removal.

A functional study of caustic strictures of the esophagus in children

The objective of the present study was to assess esophageal motor function in 21 children (7.5 ± 2.9 years) with caustic strictures. Esophageal manometry was performed using a water-infusion system interfaced with a polygraph and displayed on a computer screen. The data were compared with those obtained from 9 healthy children. Radionuclide transit was determined by studying deglutition of a single bolus of 99mTc pertechnetate in 10 ml of water. Non-peristaltic low-amplitude and long-duration waves were the most common findings detected in patients with strictures longer than 20 percent of esophageal length (N = 11). Compared with the control group, these patients presented lower mean amplitude and longer mean duration of waves (24.4 ± 11.2 vs 97.9 ± 23.7 mmHg, P < 0.05, and 6.7 ± 2.4 vs 1.6 ± 0.1 s, P < 0.05, respectively). Six patients presented low-amplitude waves just below the constricted site. Ten children presented delayed esophageal transit. There was an association between dysphagia and abnormalities on manometry (P = 0.02) and between symptoms and scintigraphy data (P = 0.01). Dysphagia in caustic strictures is due to esophageal motility abnormalities, which are closely related to the scarred segment.

Surgical management of corrosive strictures of stomach.

BACKGROUND: Corrosive injuries of the upper aero-digestive tract are a frequent cause of morbidity in India. We report here our institution's experience in managing patients with corrosive strictures of the stomach. METHODS: Records of 28 patients who underwent definitive surgery for corrosive strictures of the stomach in our institution over a 15-year period were reviewed. RESULTS: The main presenting complaints were vomiting (75%), dysphagia (46%) and significant weight loss (100%). Pre-operative evaluation included barium and endoscopic studies. Most patients had antro-pyloric strictures (n=22); in 6 patients, however, near-total or total gastric involvement was observed. Thirteen (46%) patients had associated strictures of the esophagus; of these, 7 responded to esophageal dilation. Strictures of the stomach were managed with resectional procedures like distal gastrectomy (n=16), subtotal gastrectomy (1) or total gastrectomy (3) and esophagogastrectomy (1) in 21 (75%) patients. The remaining 7 patients underwent bypass procedures like gastrojejunostomy (5), stricturoplasty (1), and colonic bypass of esophagus and stomach (1). Three patients had entero-cutaneous fistulae in the postoperative period. One patient died in hospital of septicemia and malnutrition. CONCLUSIONS: In patients with corrosive strictures of the stomach, surgery, tailored according to the extent of gastric involvement and presence of associated esophageal strictures, gives excellent results.

Upper aerodigestive tract burn: a case report of firework injury.

The case of a 46 year-old German man with upper aerodigestive burn by firework was reported. He presented with the symptoms and signs of upper airway obstruction. Tracheostomy was done and direct laryngoscopy with microscopic examination revealed swelling and denudation of the mucosa of the oral cavity and supraglottic area. Intravenous steroids and antibiotics were administrated for treatment. It is suggested that proper management needs an understanding of the mechanism and effect of the corrosive agent. Careful airway management resulted in a good outcome in this patient.

Queimadura química de períneo em criança: relato de um caso / Perineal chemical burns inflicted in children: a case report

A incidência do envolvimento do períneo e genitália em pacientes queimados é baixa. Das internações pediátricas nas unidades de queimados, 20 por cento deve-se a abuso infantil ou negligência - hipótese levantada quando a lesão está localizada no períneo, na genitália ou nádegas. O objetivo deste relato é discutir, de acordo com a literatura, aspectos relativos à lesão química - sua localização, tratamento e prevenção

Entrapment of guide-wire during oesophageal dilation.

We report a patient who developed oesophageal stricture after accidental ingestion of acid. During one of the oesophageal dilation sessions, a Savary-Gillard guide-wire got entrapped in the stomach and had to be removed surgically. A Foley catheter, placed for feeding purposes, migrated into the proximal small intestine causing acute intestinal obstruction. The balloon of the Foley catheter had to be punctured using a sclerotherapy needle and the catheter withdrawn.