DISORDER OF ESOPHAGUS

GASTROESOPHGEAL REFLUX (GER)

CORROSIVE STRICTURE

Learning ObjectivesDefinition.Incidence.Pathogenesis.Clinical Presentation.Diagnosis.Treatment.Corrosive Stricture.

DefinitionIt is a digestive disorder that

affect lower esophagus sphincter (LES). The ring of muscle between esophagus and stomach. So, Return of the stomach contents back up into esophagus and irritate the esophageal mucosa esophagitis.

Incidence85 % of affected infants (1st week of life).An additional 10 % have symptoms by 6

weeks.Symptoms abate without treat in 60 % by

age of 2 years. The remainder continue to have symptoms until 4 years of age.

The incidence increases in Down Syndrome and C.P, Preterm, Obesity, H.H, Repaired Cong. Diaphragmatic Hernia and Repaired Cong. Esophageal Atresia.

Pathogenesis

Different Between GER & GERD

The difference between GER and GERD is matter of severity and associated consequences to the patient. So, 2-8% of children 3-12 years have GERD which is more serious.

Clinical PresentationRecurrent Vomiting.Persistent Cough or wheezing.Refusal to eat or difficult feeding

or chocking.Abd. pain. Or frequent crying

associating with feeding (Dysphagia).

Poor growth 60% of Pt.Recurrent Pneumonia 30% of Pt.

ContinueEsophagitis.

Hematemesis.5% of untreated develop stricture.Sandifer Syndrome: opisthontons,

abnormal head position.Laryngospasm, Apnea, Brady cardia.

DiagnosisCBC Hb.S. Iron level.Stool Occult blood.PH Probe to confirm.

ContinueBa meal to detect any

abnormality or erosion of esophagus.

Endoscopy.

TreatmentFeeding changes.Thickening milk by rice cereal or AR milk.Semi setting position.Brup after feeding.Avoid overfeeding.Trial of Hydrolyzed milk for 4 weeks if suspect

sensitivity to milk protein. Drugs to reduce stomach acidity.Histamine – 2 blockers.PPI.Surgery if not responding to medication

(Nissan Fundoplication).

CORRESIVE STRICTURE1. Alkalis:

◦ Most cases of caustic injury in western countries◦ Cleaning agents (NaOH), drain openers, bleaches, toilet

bowel cleaners, and detergents…

2. Acids◦ Less frequently in western countries; more common in

countries like India (glacial acetic acid)◦ Toilet bowel cleaners ( sulfuric, hydrochloric ), anti rust

compounds ( hydrochloric, oxalic, hydrofluoric ), swimming pool cleaners ( hydrofluoric )

Alkalis V.S AcidAlkalis

PH > 7 Tasteless, odorless →larger amounts liquefaction necrosis => direct extension, deeper injuries

Solid form : limited quantities, oropharyngal and supraglottic injuries

Liquid form: significant quantities, esophageal injury, extensive, circumferential burns

Acid PH < 7 Pungent odor and noxious taste coagulation necrosis => formation of a coagulum layer : limit

the depth of injury Less esophageal injury More gastric injury

Pathologic severity of injury

Clinical presentation1. Vary widely

◦ Hoarseness, stridor, dyspnea => Airway evaluation◦ Perforation: (During first 2 weeks)

Retro-sternal or back pain Localized abdominal tenderness, rebound, rigidity. Massive hematemesis

◦ Dysphagia, odynophagia, drooling, nausea, vomiting

2. Early signs and symptoms may not correlate with the severity and extent of tissue injury

3. Oropharyngeal burns (-):10-30% esophageal burns(+) Oropharyngeal burns (+): 70% esophageal burns(-)

Diagnosis and staging1. Upper gastrointestinal endoscopy

2. Endoscopic grading system◦ Grade 0: Normal◦ Grade 1: Mucosal edema and hyperemia◦ Grade 2A: Superficial ulcers, bleeding, exudates

=> Excellent prognosis◦ Grade 2B: Deep focal or circumferential ulcers◦ Grade 3A: Focal necrosis

=> Develop strictures: 70-100%◦ Grade 3B: Extensive necrosis

=> Early mortality rate: 65%

Late sequelae1. Stricture formation

◦ Primarily in those with grade 2B or 3 injury◦ Peak incidence: two months◦ Occur as early as two weeks or as late as years after

ingestion

◦

2. Gastric outlet obstruction◦ Early satiety , weight loss◦ Less frequently◦ 5-6 weeks ~ several years ◦ Usually acid ingestion

ManagementIdentify the swallowed toxic agents.Avoid: emetics and gastric lavage.NPO.CXR and abd. XR to R/O perforation.Endoscopy up to 48 hr.Grade 1: Liquid diet.Grade 2: NG feeding.TPN may be used in some patient.Dilatation may be needed later.

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