The Relationship between Clinical Findings and Esophageal Injury Severity in Children with Unintentional Ingestion of Caustic Agents

Research Article

Austin J Gastroenterol. 2019; 6(2): 1104.

The Relationship between Clinical Findings and Esophageal Injury Severity in Children with Unintentional Ingestion of Caustic Agents

Fariborzi M1, Aflatoonian M2, Abeshoori EJ1, Mohamadi S3, Mohammadinia A4 and Kiumarsi A *

1Department of Pediatric Gastroentrology, Bushehr University of Medical Sciences, Bushehr, Iran

2Department of Pediatrics, Growth Disorders of Children Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

3Assistant Professor of Community Medicine, Bushehr University of Medical Sciences, Bushehr, Iran

4General practitioner, Bushehr University of Medical Sciences, Bushehr, Iran

5Raha Qmarsi, Department of Pediatry, St AliAsghar Children’s Hospital, University of Medical Sciences, Iran

*Corresponding author: Azadeh Kiumarsi, Department of Pediatry, St AliAsghar Children’s Hospital, University of Medical Sciences, Iran

Received: September 11, 2019; Accepted: October 22, 2019; Published: October 29, 2019

Abstract

Background: Corrosive ingestion can produce severe upper gastrointestinal tract injury with long-lasting suffering and even death. Early assessment of the extent of damage is important for deciding about the necessity of hospitalization and type of treatment. The present study has investigated the clinical indicators of corrosive esophageal injury severity in children.

Methods: Data from children who accidentally ingested corrosive substance over a five-year period in two tertiary care university hospitals were reviewed. Patients were divided into two groups as low-grade and high-grade esophageal injuries according to the findings of endoscopic evaluation. Statistical correlation of common signs and symptoms and with low- and high-grade esophageal injury were analyzed.

Results: A total of 47 consecutive children with a caustic ingestion who underwent diagnostic endoscopy were included in our study. Endoscopies revealed low-grade injury in 80.9% of cases. There were no significant differences in age, sex and type of corrosive substance between low-grade and high-grade injury groups (p›0.05). The majority of patients (83%) had at least one symptom at the initial examination. Endoscopies in all of the asymptomatic patients revealed low-grade injuries, but no significant relation was found between symptomatic and grading of the injury in endoscopic examination (p=0.323). The mean WBC counts did not differ significantly between the two grading groups.

Conclusion: Our study showed a significant correlation between having no clinical symptom and low grade esophageal injury in endoscopic examination of children with corrosive substance ingestion and appears to confirm that in limited resourced centers, endoscopy could be deferred in asymptomatic patients.

Keywords: Corrosive; Esophagus; Caustic agent; Endoscope; Pediatric

Introduction

Unintentional ingestion of corrosive continues to be a significant public health issue in children despite regulatory and other preventive efforts. These injuries are more common in developing countries due to social, economic, and educational variables [1-4]. Household cleaning products containing alkali, acid, and detergents have variable biological damage patterns. Alkaline substances cause saponification or liquefaction necrosis, whereas acid causes coagulation necrosis. Clinical presentation in children differ from asymptomatic to sever complications and is influenced by a number of elements such as type of substance, concentration, physical form, amount, and intent [5]. However, no definite clinical sign or laboratory test is offered to specify the severity of esophageal injury [6]. Since prompt assessment of the degree of injury is imperative for deciding about the necessity of endoscopy, hospitalization and treatment, many studies have attempted to validate the correlation between clinical characteristics and the severity of esophageal caustic injury [7-15]. In this study, we aimed to explore the predictive value of clinical symptoms and signs of our pediatric patients in estimating the severity of their esophageal injury after corrosive agent ingestion.

Materials and Methods

In this study, from January 2012 to January 2017, pediatric cases of corrosive ingestion managed in two tertiary care hospitals in two different cities of Iran, Shohadaye Khalije Fars Hospital in Bushehr and Shahid Sadoughi hospital in Yazd, formed the study group. The characteristics of patients including age, sex, symptoms, and types of corrosive agents were recorded. Physical examinations, as well as complete blood counts were evaluated. Flexible endoscopic examination was performed under local anesthesia in all patients within 12 to 36 hours after admission. The severity of upper gastrointestinal injury was classified according to Zargar [16]: grade 0 (negative finding), grade 1 (edema and hyperemia of the mucosa), grade 2 (non-circumferential [2a] or circumferential [2b] friability, hemorrhage, erosion, blisters, whitish membrane, exudates and superficial ulcer), and grade 3 (multiple ulcerations and areas of necrosis). Patients were divided into two groups as low-grade (grade 0, 1 and 2a lesions) and high-grade (grade 2b and 3 lesions). The relations between signs, symptoms and WBC count and the severity of esophageal injury were analyzed statistically. The correlations were analyzed using Chi-square or Fisher exact test or unpaired t-test as applicable. A p-value of ‹0.05 was considered statistically significant. Statistical analysis was performed using SPSS 23.0 for Windows. The study was performed after obtaining appropriate informed consent.

Results

A total of 47 consecutive children with a caustic ingestion who underwent diagnostic endoscopy were included in our study. Among them, 28 cases were referred to Shohadaye Khalije Fars Hospital in Bushehr and 19 cases were referred to Shahid Sadoughi hospital in Yazd. The clinical characteristics and mean WBC count of patients are offered in Table 1. Male-to-female ratio was 1.4:1, and mean age was 35.8 months. The most common caustic substance was alkaline, reported in 51.1% patients, followed by acid (48.9%). Endoscopies revealed low-grade injury in 80.9% of cases, among which 55.3% were due to acid agents. Among patients with high-grade injury, 77.8% of cases were due to alkaline agent ingestion. Analyzing clinical characteristics according to groups, there were no significant differences in age and sex between low-grade and high-grade injury groups (p>0.05). The majority of patients (83%) had at least one symptom at the initial examination. Endoscopies in all of the asymptomatic patients revealed low-grade injuries, but no significant relation was found between symptomatic and grading of the injury in endoscopic examination (p=0.323). The most common symptom was vomiting (48.9%). The presence of vomiting in children with high-grade injury was more frequent but there was no statistically significant difference (p=0.286). Drooling saliva and oral lesions were found 44.7% of cases and had no significant relation with grading of the injury (p=0.263). The mean WBC counts was 10.49×103/μL and it did not differ significantly between the two grading groups. The presence of symptoms has a high sensitivity (100%) but low PPV. On the other hand, having no symptom was associated with low specificity but high NPV (100%). The predictive values of initial symptoms and mean WBC count are shown in Table 2.

Table 1: Data of Patients with Different Degrees of Esophageal Injury.





  

    
Demographic Data

    
Severity    of esophageal injury, n (%)

    
P-value

  

  

    
Low    grade (N=38)

    
High    grade (N=9)

  

  

    
Gender (male: female)

    
22 (58%) : 16 (42%)

    
6 (66%) : 3 (34%)

    
0.12

  

  

    
Age (month)

    
33.4±17.4

    
45.11±37.8

    
0.4

  

  

    
Caustic agents (alkali: acid)

    
17 (45%) : 21 (55%)

    
7 (78%) : 2 (22%)

    
0.137

  

  

    
Vomiting

    
17 (44.7%)

    
6 (66.6%)

    
0.286

  

  

    
Drooling saliva & Oral    lesion

    
15 (39.5%)

    
6 (66.6%)

    
0.263

  

  

    
Respiratory symptom

    
5 (13%)

    
0

    
0.567

  

  

    
WBC count (x103/μL)    (mean ±SD)

    
13 (35.1%)

    
5 (55.6%)

    
0.284

  










Table 1: Data of Patients with Different Degrees of Esophageal Injury.

Table 2: Sensitivity, specificity, positive predictive value, and negative predictive value for symptoms and WBC count.





  

    
Value

    
Sensitivity

    
Specificity

    
PPV

    
NPV

  

  

    
Vomiting

    
0.66

    
0.6

    
0.26

    
0.78

  

  

    
Drooling saliva & Oral    lesion

    
0.66

    
0.6

    
0.28

    
0.88

  

  

    
Respiratory symptom

    
0

    
0.6

    
0

    
0.78

  

  

    
WBC count (x103/μL)    (mean ±SD)

    
0

    
0.64

    
0.27

    
0.85

  










Table 2: Sensitivity, specificity, positive predictive value, and negative predictive
value for symptoms and WBC count.

Discussion

Corrosive ingestion is a common public health issue across the globe mostly seen in developing countries [17]. When unintentional caustic ingestion in children occurs, an spectrum of chemical upper gastrointestinal tract injury could ensue, ranging from no apparent injury to hazardous outcomes due to respiratory and gastrointestinal burns, lifelong complications and potentially fatal sequelae [18]. In general, in order to evaluate the degree of injury, consultation with a specialist for endoscopic evaluation would be compulsory. However, particularly when signs and symptoms are absent, the consultant faces a dilemma in deciding about performing endoscopy, hospitalization and the necessity of treatment strategies. Historically, most experts advised routine endoscopic evaluation for all patients after presumed caustic ingestion. Endoscopy performed soon after the corrosive ingestion is considered helpful to assess the extent of injury, to plan for appropriate management and to predict the outcome [19]. However, recent studies suggest that endoscopy in children who have no signs and symptoms could be deferred [20-22].

Our present study included 47 pediatric cases of corrosive ingestion over a period of 5 years in order to decide whether endoscopy could be suspended in asymptomatic patients or not. We observed that endoscopies in all of the asymptomatic patients revealed low-grade esophageal injuries. However, as other studies have advocated [23-25], we did not find significant relation between being symptomatic and the degree of esophageal harm in endoscopic examination.

In a study by Lamireau et al. [26] it was recommended not to perform endoscopy for asymptomatic children living in developed countries. Betalli et al. [27] proposed that the risk of severe esophageal injury increases proportionally with the number of the signs and symptoms. Kaya et al. [28] revealed that an association was found between drooling saliva and oral lesion and high-grade esophageal injury and similar to our study, they proofed that absence of clinical findings indicated no or low-grade esophageal injury.

It is offered that as an inflammatory corrosive response to esophageal injury, mobilization of the leukocyte marginal pool could happen and an increase in WBC level could potentially occur due to bacterial translocation. A small number of studies have revealed a significant correlation between WBC count and the degree of upper gastroesophageal injury [29-31]. In our study, mean WBC counts did not differ significantly between the two injury grading groups.

Conclusion

In conclusion, accidental caustic ingestion continues to be a major concern for pediatric emergency department clinicians. The present study showed a significant correlation between having no clinical symptom and low grade esophageal injury in endoscopic examination of children with corrosive substance ingestion. Our study appears to confirm earlier works that in limited resourced centers and developing countries where endoscopy is not readily available, clinical features can help estimate the degree of injury and endoscopy could be deferred in asymptomatic patients. There is a pressing prerequisite for non-invasive diagnostic modalities to evaluate the complications associated with corrosive ingestion in pediatric population.

References

  1. Ghelardini C, Malmberg-Aiello P, Giotti A, Malcangio M, Bartolini A. Investigation into atropine-induced antinociception. Br J Pharmacol. 1990; 101: 49-54.
  2. Contini S, Swarray-Deen A, Scarpignato C. Oesophageal corrosive injuries in children: a forgotten social and health challenge in developing countries. Bull World Health Organ. 2009; 87: 950-954.
  3. Ekpe EE, Ette V. Morbidity and mortality of caustic ingestion in rural children: experience in a new cardiothoracic surgery unit in Nigeria. ISRN Pediatr. 2012; 2012: 210632.
  4. Sarioglu-Buke A, Corduk N, Atesci F, Karabul M, Koltuksuz U. A different aspect of corrosive ingestion in children: socio-demographic characteristics and effect of family functioning. Int J Pediatr Otorhinolaryngol. 2006; 70: 1791-1798.
  5. Riffat F, Cheng A. Pediatric caustic ingestion: 50 consecutive cases and a review of the literature. Dis Esophagus. 2009; 22: 89-94.
  6. Otçu S, Karnak I, Tanyel FC, Senocak ME, Büyükpamukçu N. Biochemical indicators of caustic ingestion and/or accompanying esophageal injury in children. Turk J Pediatr. 2003; 45: 21-25.
  7. 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? Pediatr Emerg Care. 1990; 6: 176-178.
  8. Gorman RL, Khin-Maung-Gyi MT, Klein-Schwartz W, Oderda GM, Benson B, Litovitz T, et al. Initial symptoms as predictors of esophageal injury in alkaline corrosive ingestions. Am J Emerg Med. 1992; 10: 189-194.
  9. Gupta SK, Croffie JM, Fitzgerald JF. Is esophagogastroduodenoscopy necessary in all caustic ingestions? J Pediatr Gastroenterol Nutr. 2001; 32: 50-53.
  10. Lamireau T, Rebouissoux L, Denis D, Lancelin F, Vergnes P, Fayon M. Accidental caustic ingestion in children: is endoscopy always mandatory? J Pediatr Gastroenterol Nutr. 2001; 33: 81-84.
  11. Havanond C, Havanond P. Initial signs and symptoms as prognostic indicators of severe gastrointestinal tract injury due to corrosive ingestion. J Emerg Med. 2007; 33: 349-353.
  12. Betalli P, Falchetti D, Giuliani S, Pane A, Dall’Oglio L, de Angelis GL, et al. Caustic ingestion in children: is endoscopy always indicated? The results of an Italian multicenter observational study. Gastrointest Endosc. 2008; 68: 434-439.
  13. Kay M, Wyllie R. Caustic ingestions and the role of endoscopy. J Pediatr Gastroenterol Nutr. 2001; 32: 8-10.
  14. Chen TY, Ko SF, Chuang JH, Kuo HW, Tiao MM. Predictors of esophageal stricture in children with unintentional ingestion of caustic agents. Chang Gung Med J. 2003; 26: 233-239.
  15. Crain EF, Gershel JC, Mezey AP. Caustic ingestions. Symptoms as predictors of esophageal injury. Am J Dis Child. 1984; 138: 863-865.
  16. Zargar SA, Kochhar R, Nagi B, Mehta S, Mehta SK. Ingestion of corrosive acids. Spectrum of injury to upper gastrointestinal tract and natural history. Gastroenterology. 1989; 97: 702-707.
  17. Otçu S, Karnak I, Tanyel FC, Senocak ME, Büyükpamukçu N. Biochemical indicators of caustic ingestion and/or accompanying esophageal injury in children. Turk J Pediatr. 2003; 45: 21-25.
  18. Ayesh K, Sultan MI. Caustic Ingestions in Pediatric Patients. J Gastric Disord Ther. 2017; 3.
  19. Zargar SA, Kochhar R, Mehta S, Mehta SK. The role of fiber optic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns. Gastrointestinal endoscopy.1991; 37: 165-169.
  20. De Lusong MAA, Timbol ABG, Tuazon DJS (2017) Management of esophageal caustic injury. World J Gastrointest Pharmacol Ther. 2017; 8: 90-98.
  21. Nuutinen M, Uhari M, Karvali T, Kouvalainen K. Consequences of caustic ingestions in children. Acta Paediatr. 1994; 83: 1200-1205.
  22. Gorman RL, Khin-Maung-Gyi MT, Klein-Schwartz W, Oderda GM, Benson B, Litovitz T, et al. Initial symptoms as predictors of esophageal injury in alkaline corrosive ingestions. Am J Emerg Med. 1992; 10: 189-194.
  23. Gaudreault P, Parent M, McGuigan MA, Chicoine L, Lovejoy FH, Jr. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics. 1983; 71: 767-770.
  24. Zargar SA, Kochhar R, Nagi B, Mehta S, Mehta SK. Ingestion of strong corrosive alkalis: spectrum of injury to upper gastrointestinal tract and natural history. Am J Gastroenterol. 1992; 87: 337-341.
  25. Wani MA, Shah TH, Javid G, Zargar SA, Yatoo GN, Shah A, et al. SPECTRUM OF INJURY TO UPPER GASTROINTESTINAL TRACT DUE TO CORROSIVE INGESTION. 10 YEAR EXPERIENCE. International Journal of Scientific Research. 2019; 8.
  26. Lamireau T, Rebouissoux L, Denis D, Lancelin F, Vergnes P, Fayon M. Accidental caustic ingestion in children: is endoscopy always mandatory? J Pediatr Gastroenterol Nutr. 2001; 33: 81-84.
  27. Betalli P, Falchetti D, Giuliani S, Pane A, Dall’Oglio L, de Angelis GL, et al. Caustic ingestion in children: is endoscopy always indicated? The results of an Italian multicenter observational study. Gastrointest Endosc. 2008; 68: 434-439.
  28. Kaya M, Ozdemir T, Sayan A, Arikan A. The relationship between clinical findings and esophageal injury severity in children with corrosive agent ingestion. Ulus Travma Acil Cerrahi Derg. 2010; 16: 537-540.
  29. Havanond C, Havanond P. Initial signs and symptoms as prognostic indicators of severe gastrointestinal tract injury due to corrosive ingestion. J Emerg Med. 2007; 33: 349-353.
  30. Chen TY, Ko SF, Chuang JH, Kuo HW, Tiao MM. Predictors of esophageal stricture in children with unintentional ingestion of caustic agents. Chang Gung Med J. 2003; 26: 233-239.
  31. Kaya M, Ozdemir T, Sayan A, Arikan A. The relationship between clinical findings and esophageal injury severity in children with corrosive agent ingestion. Ulus Travma Acil Cerrahi Derg. 2010; 16: 537-540.

Citation: Fariborzi M, Aflatoonian M, Abeshoori EJ, Mohamadi S, Mohammadinia A and Kiumarsi A. The Relationship between Clinical Findings and Esophageal Injury Severity in Children with Unintentional Ingestion of Caustic Agents. Austin J Gastroenterol. 2019; 6(2): 1104.