Title: Predictors of esophageal injury in caustic ingestion?<br/>Author: Hong Kim<br/><a href='http://umem.org/profiles/faculty/526/'>[Click to email author]</a><hr/><p>
        Caustic ingestion can potentially cause significant esophageal and/or gastric injury that can lead to significant morbidity, including death.</p>
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        Endoscopy is often performed:</p>
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        ·      To determine the presence of caustic injury.</p>
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        ·      To determine the severity of caustic injury (grade: I to III).</p>
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                                        Grade</p>
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                                        Tissue finding</p>
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                                        Sequela</p>
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                                        I</p>
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                                        •  Erythema or edema of mucosa</p>
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                                        •  No ulceration</p>
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                                        No adverse sequela</p>
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                                        IIa</p>
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                                        •  Submucosal ulceration and exudates</p>
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                                        •  <strong>NOT</strong> circumferential</p>
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                                        No adverse sequela</p>
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                                        IIB</p>
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                                        •  Submucosal ulceration and exudates</p>
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                                        •  <strong>Near or circumferential</strong></p>
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                                        Stricture > 70%</p>
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                                        IIII</p>
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                                        •  Deep ulcers/necrosis</p>
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                                        •  Periesophageal tissue involvement</p>
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                                        <u>Acute</u></p>
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                                        Perforation and death</p>
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                                        <u>Chronic </u></p>
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                                        Strictures and increased cancer risk</p>
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        ·      Placement of orogastric or nasograstic tube for nutritional support if needed (grade IIb and III)</p>
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        Evidence for predictor of esophageal injury (frequently cited) comes from mostly studies involving pediatric population and unintentional ingestion:</p>
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        1.     Gaudreault et al. Pediatrics 1983;71:767-770.</p>
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        o   Studied signs/symptoms: nausea, vomiting, dysphagia, refusal to drink, abdominal pain, drooling or oropharyngeal burn</p>
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        o   Presence of symptoms: Grade 0/I lesion: 82%; Grade II: 18%</p>
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        o   Absence of symptoms: Grade 0/I: 88%; Grade II: 12%</p>
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        2.     Crain et al. Am J Dis Child. 1984;138(9):863-865</p>
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        o   Presence of 2 or more (vomiting, drooling and stridor) identified all (n=7) grade II and III lesion.</p>
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        o   Presence of 1 or no symptoms: no grade II/III lesions</p>
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        o   Stridor alone associated with grade II/III lesions (n=2)</p>
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        o   10% of patients without oropharyngeal burns had grade II/III lesions.</p>
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        3.     Gorman et al. Am J Emerge Med 1990;10(3):189-194.</p>
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        o   Two or more symptoms: vomiting, dysphagia, abdominal pain or oral burns</p>
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        o   Sensitivity: 94%; specificity 49%</p>
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        o   Positive predictive value 43% ; negative predictive value: 96%</p>
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        o   Stridor alone (n=3): grade II or greater lesion</p>
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        4.     Previtera et al. Pediatric Emerg Care 1990;6(3):176-178.</p>
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        o   Esopheal injury in 37.5% of patients without oropharyngeal burn</p>
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        o   Grade II/III injury: 8 patients</p>
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        Available data suggests that there are no “good” or reliable predictors for esophageal injury.</p>
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        However, high suspicion for gastrointestinal injury should be considered with GI consultation for endoscopy in the presence of</p>
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        ·      Stridor alone</p>
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        ·      Two or more sx: vomiting, drooling or stridor (Crain et al)</p>
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        ·      Intentional suicide attempt</p>