Ingestion of caustic substances and its long-term effect on the gastrointestinal system maintain its place as an important public health issue in spite of the multiple efforts to educate the public and contain its growing number. This is due to the ready availability of caustic agents and the loose regulatory control on its production. Substances with extremes of pH are very corrosive and can create severe injury in the upper gastrointestinal tract. The severity of injury depends on several aspects: Concentration of the substance, amount ingested, length of time of tissue contact, and pH of the agent. Solid materials easily adhere to the mouth and pharynx, causing greatest damage to these regions while liquids pass through the mouth and pharynx more quickly consequently producing its maximum damage in the esophagus and stomach. Esophagogastroduodenoscopy is therefore a highly recommended diagnostic tool in the evaluation of caustic injury.
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CONTEXT: Caustic substances cause tissue destruction through liquefaction or coagulation reactions and the intensity of destruction depends on the type, concentration, time of contact and amount of the substance ingested. Stenosis was classified as mild, moderate or severe according to the radiological findings. Stenosis was mild in The incidence of stenosis was Among subjects who ingested one or more tablespoonfuls, There was no correlation between the intensity of lesions of the esophagus and of the stomach.
Progression to cancer of the esophagus occurred in 1. Small amounts caused esophagitis or stenosis and large amounts increased the risk of fistulas, perforations and death. Caustic substance ingestion. Inflammatory lesions of the upper digestive tract. Caustic stenosis. The severity of lesions produced by caustic substances on tissue depends on the type, quantity and concentration of the caustic substance ingested, as well as on the time of contact with the mucosa.
Alkalis and acids have a great potential for tissue destruction. Due to their mechanisms of action, acids form scars on necrotic tissue, a fact that prevents their action at a greater depth.
However, the inability of gastric juices to neutralize these substances contributes to the onset of lesions in various organs such as the stomach and intestine, in addition to the mouth and the esophagus. On the other hand, the action mechanism for alkaline agents causes them to combine with tissue proteins to form proteinates, and with fats to form soap in addition to water.
Thus, liquefaction necrosis occurs. The products formed favor the penetration of the remaining alkali into the tissue by increasing the solubility of the caustic soda, causing the alkalis to reach deeper tissue layers, consequently producing lesions in the entire thickness of the organ exposed to the substance. Alkalis promote blood thrombosis in blood vessels by base absorption, impairing irrigation of the esophagus.
However, alkali can be neutralized, at least in part, by gastric secretion, with a consequent reduction of its action on the mucosa of the stomach. For this reason, acids usually provoke the most severe lesions, especially in the antropyloric region. It should be remembered, however, that some individuals have achlorhydria, a situation in which the destruction produced by alkali is quite extensive. With respect to the relationship between the severity of the lesion and the concentration of the substance ingested, it has been observed that the higher the concentration of the product, the greater its ability to provoke severe injury.
In a study on rabbits, 1 it was observed that the ingestion of a 3. The effect of the time of contact of the caustic substance with tissue is similar to the effect of its concentration. In this respect, Holinger 2 stated that one hour after accidental ingestion of a watch battery there were lesions of the mucosa; two to four hours later the lesion reached the muscle layer, and 8 to 12 hours later there was perforation of the esophagus.
The effect of time of contact was also noted in different organs or even in different areas of the same organ. The esophagus, in contrast to the pharynx, is the organ presenting the most severe lesions, perhaps because the esophagus is of smaller caliber, with a consequent increase in time of contact.
Since in children the thymus compresses the esophagus, in the case of ingestion of caustic substances the tendency is towards more severe lesions in the upper third of the esophagus, as this compression delays the descent of the substance at this point.
In contrast, in adults these lesions are more common in the area of compression provoked by the aortic-bronchial bifurcation and in the cardia area, which are more salient during this phase of life.
Other factors seem to contribute to the increase in time of contact between the caustic agent and the mucosa. In this respect, a study on rabbits 4 showed that gastroesophageal reflux retarded scarring of the lesion caused by the caustic agent. A direct relationship is known to exist between the quantity of caustic substances ingested and the intensity of injury to the digestive tube. However, this conclusion was reached only in experimental studies, as it is difficult to determine the quantity of caustic substances ingested by patients, especially when a liquid product was ingested.
The objective of the present study was to investigate the complications observed in patients who ingested caustic soda and who were admitted to the University Hospital of FMRP-USP, and to correlate them with the amount ingested. Of these, had ingested caustic soda. The medical records of the patients were surveyed in order to obtain information about the complications observed during the different phases of ingestion of caustic substances.
To determine the quantity of ingested caustic substance per patients, each patient was asked to compare the amount with an equivalent amount of crystal sugar measured in tablespoonfuls, considering that a tablespoonful contains 22 g of commercial caustic soda. This comparison was possible only because the patients had prepared their own "cocktail" using granulated caustic substances.
When the patient reported that the ingested quantity was much less than 22 g, we defined this amount as "fragments" since it was impossible to determine exactly the amount ingested.
Examples of these situations were children who had drunk water from a glass dirty with caustic soda, or children who had placed some flakes of caustic soda into their mouth. We analyzed the possible complications according to different age ranges: years, years, years, and more than 30 years and, when of interest, we compared them between 2 groups children and adults. To facilitate the process of description and the analysis of the degree of stenosis provoked in the esophagus by the caustic agent ingested, we prepared the classification described below.
Our basis was a radiological study by means of a barium-swallow esophagogram performed immediately before the dilatations, i. To determine the sites of these lesions, we divided the esophagus into imaginary parts, i. The patients were divided into groups according to the following classification:. The stomach and duodenum were studied in 93 patients by radiography, gastroscopy, or macroscopically during laparotomy. Data were processed and analyzed by descriptions of frequency and percentages and by statistical tests.
To permit this, the patients were considered to be a sample of the population. The data were fed into a PC computer using the D Base software. Data analysis was performed using the EPI-5 software and, when necessary, the chi-squared test on a 0. Fisher's exact test was used for data concerning less than 20 subjects. Among the patients for whom there was full information, progressed with complications related to esophageal lesions in of them, and the last 2 died 0.
The patients with some type of esophageal injury progressed in different manners according to the severity of the injury. A total of cases Most of these patients None of them had drunk more than three tablespoonfuls of caustic substance.
Stenosis occurred in In the present study, radiological examination permitted us to identify the sites of esophageal injury in patients. Most of them had lesions in more than one esophageal third, with a In Thus, the lesions were slightly more frequent in the middle esophageal third. Stenosis of the esophagus was frequent in the different age ranges. The age group most frequently involved was from 11 to 20 years, with Among adult patients, only Patients with stenosis of the esophagus concomitantly presented a 4.
These complications occurred in The stomach was examined in 93 patients by radiography or gastroscopy or during laparotomy, among which lesions were detected in Among these, This type of injury occurred in We also observed that the ingestion of fragments was not sufficient to cause stomach injuries.
The ingestion of one tablespoonful provoked lesions in Similarly, Incidence of injuries to the lower digestive tract was found to be Of the patients who drank caustic soda, 4 of them 1. One was a male and three were females, with a mean age of 51 years. Among the four patients who acquired cancer of the esophagus, two ingested the caustic soda accidentally and the others while attempting suicide; these patients ingested amounts ranging from fragments to as much as three tablespoonfuls.
Two were classified as having moderate stenosis and two as having severe stenosis. Stenosis was localized in the middle or lower third or in the entire organ and was dilated with Hurst, Plummer, Jackson and Tucker tubes and for this reason the patients kept a gastrostomy for periods of between 3 and more than 10 years.
It can be seen that the correlation between stenosis of the esophagus and injuries to the stomach and duodenum is not always present since two patients whose esophagus was preserved had lower lesions and, conversely, of 17 patients with severe esophageal injuries, 9, i.
Only one patient with injuries to both the stomach and duodenum had injuries in the middle and upper thirds of the esophagus, while the remaining ones had stenosis in the middle and lower third or throughout the extension of the organ Table 6.
The physiopathological characteristics of the caustic lesions undergo transformation over the following four phases:. During the first hours there is eosinophilic necrosis with edema and intense hemorrhagic congestion caustic esophagitis. During the first days the ulcerations are covered with a leukocytic fibrinous layer. Perforation will occur if ulceration exceeds the muscle plane.
Fibroblasts reach the site after about 4 days. On the 5 th day, a mold of the lesion is formed and when the lesion is extensive, covering the entire esophagus, the esophageal mold is formed. The mold consists of dead cells, secretions and food remains. Repair occurs during the first weeks, especially after the 10 th day.
Edema will persist in the submucosa, together with lymphatic ectasia. Sclerosis sets in at the muscle level and the autonomic nervous plexus is destroyed. Fibrosis occurs in layers whose depth depends on the severity of the caustic injury caustic stenosis. During the first month, epithelialization of the mucosal ulcerations occurs with difficulty due to the vascular lesions.
For the rest of their lives, these patients may present new ulcerations followed by re-epithelialization due to small traumas provoked by food.
These traumas increase the scars, reducing even more the lumen of the organ. These are the mechanisms of late stenosis and of the recurrence of previously dilated stenoses. Only studies carried out in Turkey 5 and Denmark 6 have identified such high levels of injury as observed here, i. In contrast, the incidence reported in Finland 7 was extremely low, since the cited authors stated that the commerce of caustic soda was prohibited in Finland in These investigators reported 98 cases of children who ingested soap and vinegar, with only 20 of them suffering esophageal injury, but with no stenosis of the organ in any case.
Management of esophageal caustic injury
Corrosive esophagitis usually occurs from accidental or suicidal ingestion of caustic substances e. The stomach is not affected as the gastric acid can neutralize these substances, however, in cases of acidic corrosives, the esophagus can be spared while the stomach is severely injured. It usually affects the middle and lower third of the esophagus. Water-soluble contrast medium is preferred in the acute stage.