This case report describes a 10 yo with multiple medical problems with an expanding G-tube site with mucosal prolapse “where the G-tube balloon easily fell out of her gastrocutaneous fistula.”
The site was treated with three modalities, though the authors attribute the improvement to the use of sucralfate:
Removal of Gastrostomy tube for 5 days
Sucralfate: “1 gram tablet, ½ tablet crushed sprinkled around the ostomy site 3 times a day. Powder was used to fill in the defect and any residual powder medication was gently cleaned off before the next application”
Images showing improvement noted below
The authors provide pathophysiological reasons for sucralfate’s effectiveness:
The week that the U.S. President suggested that using disinfectants to treat the coronavirus could be helpful, there was a spike in calls to poison control centers: Calls to poison control centers spike after Trump disinfectant comments. In addition, coincidentally, a review article was published: Ingestion of Caustic Substances (RS Hoffman et al. NEJM 2020; 382: 1739-48).
Chevalier Jackson (1865-1958), an otolaryngologist and often called the ‘father of endoscopy,’ advocated for warning labels on bottles that contained caustic agents.
U.S. Federal Caustic Poison Act 1927 mandated labeling and U.S. Poison Prevention Packaging Act 1970 mandated child-resistant containers
Currently, poison control centers in the U.S. advise storage “up and away” of caustic agents (Great website for families: www.upandaway.org)
Nearly 1000 children are hospitalized each year with caustic ingestions.
In younger children, ingestions typically involve smaller amounts than in adolescents and adults (in which ingestions are usually deliberate attempts at self-harm)
GI: Caustics (both acid and alkali) may result in esophageal perforations with mediastinitis, as well as bowel perforation and bleeding. Esophageal strictures can develop weeks to months afterwards
ENT: May compromise airway
Eye/Skin: Splash may cause eye injuries and skin burns
Approach to Management:
The authors present an algorithm (Figure 1) –Key points:
For adults and adolescents, when there are oropharyngeal findings with intentional ingestions, there is a high likelihood of gastroesophageal injury. In younger children, the presence of oropharyngeal findings is much less likely to be associated with gastroesophageal injury due to smaller ingested quantities.
The authors advocate a selective approach towards endoscopy in young children. “For children with only vomiting or drooling and those who refuse to drink, overnight observation is routine, and endoscopy is performed only if symptoms persist and the child remains unable to take oral fluids” If there is vomiting and drooling or stridor alone, endoscopy is recommended.
Endoscopy, when indicated, “should be performed in the first 24 to 48 hours.” Delayed endoscopy may increase the risk of perforation.
Clinical attempts to empty the stomach can potentially increase injury. However, “use of water immediately after ingestion (usually at home) to irrigate adherent materials” may be useful if patient can swallow safely and breathe without difficulty.
Grading Esophageal Injury -Zargar Classification:
For patients too ill to undergo endoscopy, CT is an alternative
Use of Corticosteroids:
This issue is discussed at length. Though routine use of steroids failed to show benefit in several (underpowered) studies, the authors not that Usta et al (Pediatrics 2014; 133: E1518-24) “randomly assigned children with grade 2B esophageal injuries to 3 days of methylprednisolone ( 1 g per 1.73m2 of BSA per day) or placebo, plus 1 week of ceftriaxone and ranitidine…A significant benefit was reported in the methylprednisolone group.” Thus, “patients with grade 2B injuries, who have a high risk of progression to stricture and a low risk of perforation, are most likely to benefit from…glucocorticoid therapy.” The authors state this is in agreement with current guidelines (JPGN 2017; 64: 133-53).
Consider placement of nasogastric tube at time of endoscopy
Sucralfate has been shown to help with esophageal healing
Mitomycin C has been studied and has some data indicating fewer dilatations were needed for caustic-induced strictures. Long-term risk of malignancy with mitomycin C is uncertain.
My take: Most children with caustic ingestions will not need endoscopy. Sucralfate is a useful adjunct. A subset of children may benefit from 3 days of methylprednisolone.
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