QUAD #3 Pt.1: Complications of Button Battery & Caustic Ingestion with Dr. Phil Putnam

Globalcast MD. Along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello everyone. This is Kim Priven and I'd like to welcome you back to the continuation of our quad series. In October 2022, Cincinnati Children's hosted the quad conference, which was a combination of four conferences. The International Organization for Esophageal Atresia, the Air Digestive Society Conference, the Cincinnati Children's Airway course, and the Cincinnati Children's Pediatric Dysphasia series. In this session, we hear from pediatric gastroenterologist Dr. Bill Putnam from Cincinnati Children's Hospital about the complications of caustic ingestions in children. We're going to discuss the variables that impact the risk after across over caustic ingestions that predisposed to complications. These variables include the nature of the substance that's ingested, the volume that's ingested, the physical form of the agent and the anatomic distribution of the agent after ingestion. The nature of the ingested material either acidic or alkaline, the volume and the form of the agent are crucial. There's potential exposure to every structure that you can name on the way from lips to duodenum. The depth and distribution of mucosal damage can be anything from very superficial short segment injury to deep penetrating necrosis. Also, there is a big difference between an accidental small ingestion that is spit back out versus an intentional large volume ingestion that exposes more structures with significant risk for damage. Solid forms of material tend to create more oralal exposure because of the time that it spends in the mouth, liquid forms,al, esophageal, gastric and proximal duodeal injury and vapor should be more concerning for the airway. And don't forget that some of the kids who ingest materials, either spit it out, drool it out or may puke it back up. So the skin on the face, chest, abdomen, and legs may also be involved. This is a view of the individual elements of the Zarger grades ranging from normal in the upper left to liquefactive necrosis in the bottom right. It's worth noting that the injuries in B and C will often heal without much in the way of. Whereas 2B and above are very likely to have complications associated with them. Because of this potential for complications, it's important to perform a follow-up endoscopy or contrast exam within 24 hours, paying attention to the area, the airway and the GI mucosa. And remember that use of steroids after injury can help decrease inflammation. There is evidence to support the use of Dexamethason for Zarger grade 2B injuries, grades worse than that tend not to respond because they're too extensive. and grades under that tend not to require steroids because they're more likely to recover on their own. But what do we do if a patient develops a complication such as a stricture? How do we manage those? reassessment of luminal caliber and mucosal healing is important to understand whether a complication is developing like a stricture. And beyond three weeks, it becomes reasonable to attempt dilation if there is stenosis developing. It needs to be done cautiously because in the early periods perforation from even fairly gentle attempts at dilation are still possible. Long segment structures can be difficult to dilate and if there is significant mucosal injury, a surgical approach might be needed. Here's one such case where a surgical intervention provided the best results. This was an accidental sodium hydroxide ingestion back in 2012 that led to an extensive distal half esophageal burn. He underwent serial dilations for stenosis that developed. This endoscopic evaluation at four months after the ingestion still showed that the epithelium within the stenosis was ulcerated, granulation tissue really hadn't recovered at all. On the esophagram, there was a very long segment stricture that failed multiple endoscopic dilations. He underwent a segmental colon interposition with anastomosis at the level of the esophagus. I had the opportunity to see him again a few weeks ago. His interposition looks great and he's actually doing quite well. In summary, complications that arise from caustic ingestions in children are directly related to the nature and the volume of the ingested substance. Depending on the degree of mucosal injury, steroids may be given to decrease inflammation. complications such as long segment structures may require with serial dilations or even surgery. Thank you for watching. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Globalcast MD. Along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.