Iranian Journal of Toxicology Volume 6, No 19, Winter 2013

Ingestion of Caustic Substances in Adults: A Review Article Andon Chibishev1*, Zanina Pereska 1, Vesna Chibisheva 2, Natasa Simonovska1 Received:22.06.2012 Accepted: 05.09.2012 ABSTRACT Background: Ingestion of caustic agents can cause serious damages of the upper gastrointestinal tract and in some cases this kind of poisoning may have fatal outcomes. Acute caustic intoxications are one of the main problems in the modern clinical toxicology since they mainly affect young people with psychic disorders, suicidal intent, and alcohol addiction. Text: In diagnostic evaluation of this kind of poisoning, different procedures are used. Today’s golden standard for determination of the grade and extent of the lesion is esophagogastroduodenoscopy (EGD) performed in the first 12-24 hours following corrosive ingestion. In some patients, some late complications, such as esophageal stenosis and gastric stenosis, which are the most common, as well as carcinoma of the upper gastrointestinal tract, which is rarely seen, can be detected. Acute caustic poisonings are treated with specific kinds of protocols. According to them, first, an attempt is made to neutralize the poison. Combinations of antibiotics, anti-secretory drugs, and collagen synthesis inhibitors are used. As a support therapy, nutritional liquids can be utilized, and in the most unmanageable cases, , stent placement and surgery are used. Conclusion: In the future, caustic poisonings will remain a serious socio-medical issue, due to the difficult clinical presentation, expensive diagnostic protocol, extended hospitalization, and possible permanent disability. Keywords: Caustic agents, Esophageal Lesions, Esophagogastroduodenoscopy, Post-Corrosive Injuries. IJT 2013; 723-734

along the entire particularly in INTRODUCTION the middle and distal part, more precise at According to the annual report of the the level of physiological narrowing. Also, American Association of Poison Controls, they can appear in the gastric antrum and there are about 200,000 caustic pylorus (4,5). Caustic poisonings are intoxications annually, most commonly related to numerous complications which with acid and alkaline substances that are can cause fatal outcomes, most often seen regularly used as cleansing agents in the during the acute phase of the intoxication. households (1,2). In Republic of Esophageal carcinoma may develop Macedonia, about 75-80 caustic as a late complication, which its onset is intoxications are recorded per year. They observed 40-60 years after caustic are more often detected among women and ingestion (6- 8). in 95% of the cases they are with suicidal Caustic poisonings occur after intent (3). Post-corrosive injuries with ingestion of caustic substances, such as different degrees of severity can occur acids (acetic, hydrochloric, sulfuric, lactic,

1- Clinical Center, University Clinic of Toxicology, Skopje, Republic of Macedonia. 2- Faculty of Medicine, Saints Cyril and Metodius University, Skopje, Republic of Macedonia. *Corresponding author: E-mail: [email protected] Iranian Journal of Toxicology Andon Chibishev et al oxalic), alkalis (sodium and potassium reactions which lead to tissue damage. agents, soaps, detergents), heavy metal Acids cause injuries due to coagulation salts, formalin, and many other chemical necrosis, transformation of proteins, and agents. Lye is a general term in the hemoglobin. Alkalis cause transformation American literature, denoting strong alkali of tissue proteins into proteinates and fats found in cleansing agents (9, 10). into soaps which result in liquefaction The most commonly abused necrosis (15). substance among acids is hydrochloric Corrosive substances with a pH of acid. It is often used in countries like India less than 2 or greater than 12 are highly and Taiwan as opposed to the USA where corrosive and can cause tissue necrosis. A its abuse is less than 5%. In Republic of concentrated solution of Macedonia, this acid is easily accessible as (22.5% and 30%) can cause perforation of a sanitary cleansing agent and it is used as the esophageal wall, mediastinitis, and an oral poison in more than 50% of the fatal outcome within seconds (16). cases. Hydrochloric acid causes severe Caustic agents can affect the entire damages of the upper gastrointestinal tract, gastrointestinal tract and the severity of the usually gastric stenosis (11). We have post corrosive lesions is determined by the recorded some uncommon poisonings in nature of the caustic substance, pH value, which our patients abused agents such as quantity ingested, concentration of the cleaning products that contain sodium solution, duration of exposure, and the act hypochlorite (NaClO). Atypical are also of swallowing. Also, different forms of some serious injuries caused by acetic acid caustic substances cause post corrosive (CH3COOH) usually used in preparation of injuries on different gastrointestinal areas. food. It is often abused during autumn Ingestion of agents in solid or gel forms when people prepare conserved vegetables causes injuries of the oropharynx and for winter. There are a small number of proximal esophageal segment, while liquid exceptional intoxications caused by substances cause injuries on the middle ingestion of battery fluids (sulfuric acid), and distal segments of the esophagus and antirust compounds (oxalic acid), stomach (10). household bleaches and hydrogen peroxide Acute caustic intoxications cause a (12). All these unusual poisonings rarely particular histological appearance of the cause severe and serious injuries of the esophageal and gastric walls where upper gastrointestinal tract. thrombosis of the small vessels can be Alkalis, such as sodium hydroxide predominantly seen. (NaOH) and potassium hydroxide (KOH), The cells develop high temperature are also being abused. They have high pH due to metabolic changes, and after a few values and can be found in the market as days, they are overtaken by bacterial components of soaps, detergents, cleaning invasion(17). The healing process begins tablets, and cosmetics. Their abuse is more three weeks after ingestion with collagen frequent in the USA and member states of deposition in the first week; later with the European Union. As acids, they also development of granulation tissue and cause severe post corrosive injuries of the fibrosis, which leads to the incidence of upper gastrointestinal tract and late post esophageal and/or stomach strictures corrosive complications. The most within the next 8 weeks to 8 months.(18) common complications are esophageal and Esophageal stenosis most frequently gastric stenosis, which are found in greater develops at the cricopharyngeal area, at the percentages than in poisonings with acid level of the aortic arch and tracheal substances (13, 14). bifurcation and the lower esophageal Pathophysiology of this kind of sphincter. Gastric stenosis mostly occurs in poisoning describes the cascade of the atrium and pylorus. 724 Volume 6, No 19, Winter 2013; http://www.ijt.ir Ingestion of Caustic Substances in … Iranian Journal of Toxicology

Caustic substances cause three bleeding. Absence of extensive different degrees of post-corrosive injuries, oropharyngeal injuries does not rule out where the third degree is characterized by severe injuries of the lower segments. In perforation of the wall of the esophagus or 10% to 30% of patients with severe stomach ( 19). esophageal post-corrosive burns, there are no local changes in the oropharynx. One MAIN TEXT survey showed the 37% presence of Patients with acute caustic esophageal injuries (II and III degree) intoxications present a unique clinical state among patients that had not developed due to the injuries in the upper evident oropharyngeal damages (22- 23 ). gastrointestinal tract. They have constant By contrast, some reviews reported that burning pain in the mouth, throat, and 70% of patients with severe oropharyngeal chest and severe pains in the stomach injuries did not have noticeable esophageal followed by nausea and vomiting. damages. Therefore, injuries of the Symptoms usually appear right after oropharynx are not a reliable indicator for caustic ingestion, rarely after a couple of the eventual burns located in the esophagus hours and they last several days or weeks. (23). Regular findings are ulcers or whitish Perforation of the gastrointestinal plagues in the oral cavity, palatal mucosa, wall may be the most serious complication and pharynx which lead to edema, in the acute phase and it requires hypersalivation, and difficulty in immediate consultation with an abdominal swallowing (20). During the acute phase, surgeon. Generally, gastric perforation the patients are in a very serious condition occurs and patients are immediately because they have developed transferred for an emergency abdominal laryngospasm with dyspnea, tachypnea, surgery. dysphonia, and aphonia. Among the most Post-corrosive injuries usually critical cases are those with endotracheal appear in the first 48 hours or they may be or bronchial necrosis with mediastinitis, delayed until the 14 days after caustic due to substance aspiration, and they may ingestion (24). often have fatal endings (21). General condition of the patient can Lesions in the oral cavity are very be complicated by a large liquid loss, painful and they often express contact metabolic acidosis, and renal failure.

Figure 1. A patient with widespread oral post-corrosive lesions

http://www.ijt.ir ; Volume 6, No 19, Winter 2013 725 Iranian Journal of Toxicology Andon Chibishev et al

In long-term management of patients pressure behind the sternal bone. These with acute caustic intoxications, some symptoms indicate narrowing of the difficulties related to the late complications esophagus. They may appear three weeks exist. They happen very often and are after caustic ingestion, during the first usually quite extensive. Advanced three months or, according to some diagnostics and modern approaches have authors, even after one year following reduced the percentage of post-corrosive caustic ingestion (Figure 2). Stenosis is late complications of the upper more commonly associated with ingestion gastrointestinal tract. Nevertheless, they of caustic poison in liquid form than in still present a major medical and social crystal form. issue, both by their clinical presentation Onset of symptoms, like full and therapeutic protocols. Also, post- stomach, nausea, vomiting, and extreme corrosive late complications restrict the weight loss, suggest gastric obstruction, patients’ everyday life. with development of stenosis of antrum or The most common late pylorus. It commonly happens in the first 5 complications are esophageal strictures and to 6 weeks after intoxication and according stenosis, gastric stenosis of the antrum and to some authors even after several years, pylorus, and esophagus and stomach but yet rarely compared with esophageal cancer (25, 26). stenosis (Figure 3). It is most frequently Patients with strictures and stenosis found after acid ingestion although many of the esophagus usually complain about cases of gastric stenosis have been reported difficult swallowing and also a feeling of after alkaline ingestion.

Figure 2. Late post-corrosive changes in the mid and low parts of the esophagus

726 Volume 6, No 19, Winter 2013; http://www.ijt.ir Ingestion of Caustic Substances in … Iranian Journal of Toxicology

Figure 3. Late post-corrosive complications located in the antropyloric and pyloric gastric areas

Managing such intoxications may be described as air in the mediastinum or very difficult, but still quite motivating. It under the diaphragm. must start right after admission to hospital. Esophagogastroduodenography with Earlier protocols suggested immediate use gastrographin performed 25-30 days after of milk and water during the acute phase, caustic ingestion may provide useful in the first couple of hours, but to date their information about the changes in the advantage has not been proven in esophageal and gastric lumen. Some controlled studies. On the other hand, milk authors prefer barium sulfate as less can cause some additional post-corrosive irritant, especially immediately after lesions due to the chemical reactions and ingestion, for monitoring the development further problems in performing an urgent of complications, or when the urgent esophagogastroduodenoscopy (27). esophagogastroduodenoscopy is absolutely Patients should be rapidly sent to a contraindicated. Nonetheless, this radiological examination, starting with procedure is not suggested during the acute plain radiography of the chest and phase, especially in cases with suspicion of abdomen. These investigations can provide eventual perforation (28,29). helpful information about the mediastinal Esophagogastroduodenoscopy, on processes and they can show us signs of the other hand, is a very sophisticated and esophageal or gastric perforation, sovereign method for diagnostic evaluation of acute caustic intoxications and lesions http://www.ijt.ir ; Volume 6, No 19, Winter 2013 727 Iranian Journal of Toxicology Andon Chibishev et al of the upper gastrointestinal tract. The endoscopy in all poisonings with caustic most optimal time frame for urgent substances (30). esophagogastroduodenoscopy is in the first Today’s modern approach 12-24 hours after ingestion of the caustic recommends performing urgent substance. This diagnostic procedure esophagogastroduodenoscopy after should be avoided between the 4th and the previous sedation, general anesthesia, and 14th days after ingestion because of intense endotracheal intubation. During the inflammatory changes, vascular procedure, several complications might be thrombosis and healing process of the post- faced, among which the iatrogenic corrosive lesions (11). perforation is the most severe, but luckily Unfortunately, there are still very rare. Introduction of flexible controversial opinions about the timing and endoscopic tubes has made this invasive method of performing this procedure. method quite safer. Some suggest that all patients with discrete Esophagogastroduodenoscopy gives symptoms of caustic ingestion have to be us useful data on the existence of post- subjected to endoscopy. In patients with no corrosive injuries and if they are symptoms and no signs of oropharyngeal documented, an adequate treatment has to injuries, endoscopy should not be be initiated as soon as possible (31). performed, but they should still be Endoscopic classification of post- admitted to hospital and set under an corrosive injuries in the upper intensive monitoring during the first 48 gastrointestinal tract is of paramount hours after ingestion. importance in diagnosis and treatment of However, the fact that even 20% of acute corrosive intoxications. Kikendall post-corrosive poisonings pose no signs of (32) suggested a classification in four oropharyngeal injury as well as the grades (Table 1). unproved correlation between the Besides this classification, some symptomatology and the severity of post- authors use the classification made by corrosive injuries advocate a legitimate Zargar (33) (Table 2). need, with no exception, of upper

Table 1. Kikendall’s classification GRADE I: edema and erythema of the mucosa GRADE II A: hemorrhage, erosions, blisters, superficial ulcers GRADE III B : circumferential lesions GRADE III: deep grey or brownish-black ulcers GRADE IV: perforation

Table 2. Zargar’s classification GRADE 0: normal mucosa GRADE I: edema and erythema of the mucosa GRADE II A: hemorrhage, erosions, blisters, superficial ulcers GRADE II B: circumferential lesions GRADE III A: focal deep gray or brownish-black ulcers GRADE III B: extensive deep gray or brownish-black ulcers GRADE IV: perforation

728 Volume 6, No 19, Winter 2013; http://www.ijt.ir Ingestion of Caustic Substances in … Iranian Journal of Toxicology

Endoscopic ultrasound and Antibiotics are often employed in computerized tomography are useful treatment of acute caustic intoxications but procedures in diagnosis that can more their regular use and benefits of their use precisely determine the depth of the are still controversial. Since there is not a corrosive injuries. sufficient number of controlled studies that The aim of therapy is to prevent would confirm the need for using perforation and to avoid progressive antibiotics, many authors do not fibrosis and stenosis of the esophagus and recommend them. Some investigations on stomach. animal models have shown that post- First line of treatment includes the corrosively injured mucosa is always emergency surgical interventions that are attacked by bacteria that causes severe indicated in cases of esophageal or gastric inflammation of the tissue followed by perforation. They are really difficult to granulation and fibrosis. This is the main predict and can be treated only surgically. reason why antibiotics should be used in Patients with shock, coagulation disorders patients with acute caustic poisonings, or acidosis and those who have ingested a especially broad spectrum antibiotics like large quantity of corrosive substances tend those from penicillin family (37). to develop severe post-corrosive injuries Another category of drugs used in and laparotomy and resection of damaged treatment of these kinds of poisonings are segments may be beneficial in their corticosteroids but their use is also treatment. Modern surgical approaches questionable. One big survey involved 361 suggest placing of gastrostoma or cases and reported 19% of esophageal and jejunostoma for artificial nutrition. stomach stenosis in patients who received In one of his studies, Zargar corticosteroids and 41% of stenosis in (33)suggests prompt surgical intervention those who were not treated with in patients with severe post-corrosive corticotherapy. Individuals included in this injuries (grade IIIB) for decreasing study received either dexamethasone (1 mortality and morbidity in these patients. mg/kg/day) or prednisolone (2 mg/kg/day) Some scholars are strongly in opposition to (23). this method of treatment because they find Several other studies showed determining the grade of post-corrosive increased risk of complications, such as lesions really difficult (34,35). and mediastinitis, in group of In some protocols, neutralization of patients who were under corticotherapy caustic substances can be viewed as one of and there was no relationship between its the first steps for treating caustic use and reduced occurrence of stenosis. A intoxications. In order to be effective, similar multicentric study comprising 572 neutralization should be used within the patients conducted at the same time in first hour after ingestion of caustic poison. several European countries indicated that However, many other researchers state that corticosteroids have no significant this procedure is contraindicated because it influences on prevention of post-corrosive produces additional heat in the tissues and stenosis in acute corrosive poisonings (37). increases the risk of further new lesions. Post-corrosive extensive injuries of Generally, alkalis can be neutralized with the upper gastrointestinal tract hinder lemon or orange juice and mild vinegar, physiological nutrition in these patients and acids with milk, eggs or antacids. and they become candidates for artificial Emetics are contraindicated because of re- nutrition. Very soon these patients exposition to the corrosive substance suddenly fall into a severe general leading to the exacerbation of the injury. condition due to hypercatabolic state and Activated charcoal is also contraindicated begative alkali balance (5). Several modern (36). types of artificial nutrition can be used and http://www.ijt.ir ; Volume 6, No 19, Winter 2013 729 Iranian Journal of Toxicology Andon Chibishev et al the most appropriate one should be chosen veins. Esophageal rest is explained with according to the degree of esophageal and the fact that food particles enter the gastric damages revealed via urgent granulocytes of the esophageal wall and endoscopy. worsen the inflammation (16). Esophageal In patients with grade I and grade II rest may last until the 10th day after A of damages, total parenteral nutrition corrosive ingestion or, according to some (TPI) in the first 24-48 hours, followed by authors, until the 15th day or the first liquid diet until the 10th day should be endoscopic control. used. Afterwards, food intake can be in a Intensive hyperalimentation and more liberal regimen. esophageal rest may decrease the number In patients with grades II B and III of late post-corrosive complications damage, the so-called “esophageal rest” is (stenosis and strictures), although this state recommended. This means that patient has not been clearly described and must not take any food per os (nill per os- confirmed in controlled studies (38,39). NPO). During the NPO period, the patient If the patient can swallow his/her receives nutritional liquids given through own saliva, several scholars recommend nasogastric and nasoenteral tubes, taking liquids (nutritional solutions, milk) gastrostoma or jejunostoma. Despite 48 hours after caustic ingestion. (Figure 4, enteral nutrition, the patients can also be 5) fed parenterally by peripheral and central

Figure 4. The patients with a nasojejunal tubes, who were fed enterally by enteroport pump system

Figure 5. A patient with gastro-jejunal stoma

730 Volume 6, No 19, Winter 2013; http://www.ijt.ir Ingestion of Caustic Substances in … Iranian Journal of Toxicology

In some patients, retrograde of controlled studies has not given intraluminal esophageal dilation can be substantial support to this method (42). performed for prevention or dilation of the At last, surgical intervention is already created esophageal narrowing. This indicated in cases with complete stenosis procedure can be done immediately after that cannot be treated with usual intoxication or 15 days later. It is safest to conservative methods; esophageal or start the esophageal dilatation 6 weeks gastric defects noticed on plain after ingestion. Then it is performed every radiography; and when patients develop 2 to 3 months in several consecutive time some kind of fistula. During surgical intervals (40). intervention, jejunum and colon are the In spite of the presented positive most commonly used organs for experiences, this method is not esophageal replacement. Esophagectomy recommended by many authors because it with colon interposition is the most can traumatize the esophagus, cause frequently applied method in serious bleeding and esophageal perforation, and esophageal lesions (43). Gastric increase predisposition to fibrosis transposition is more recommended for formation (Figure 6). children although there are data on high Some studies also show the benefit mortality rate (5%), anastomotic leakage of using sucralfate in treatment of caustic (12%), and postoperative dilation due to poisonings. They have shown its role in onset of strictures (20%) (44). reducing the percentage of post-corrosive stenosis in the upper gastrointestinal tract Predictions in acute caustic (41). poisonings are very alterable and they In patients with IIB and III grades of depend on the degree of esophageal and esophageal injuries, a specially designed gastric lesions as well as the general health intraluminal stent can be placed under condition of the patient. The highest endoscopic control preventively or after mortality rate has been recorded as a result the onset of stenosis. The limited number of perforation and mediastinitis.

Figure 6. X-ray findings of narrowed mid- and distal esophagus and dilated proximal esophagus and X-ray findings of esophagus after retrograde intraluminal dilation http://www.ijt.ir ; Volume 6, No 19, Winter 2013 731 Iranian Journal of Toxicology Andon Chibishev et al

CONCLUSION 3. Chibishev A, Simonovska N, Shikole A. Post-corrosive injuries of upper Acute caustic poisonings are a gastrointestinal tract. Contributions. serious socio-medical issue, both from the 2010;31(1):297-316. sense of clinical presentation and the 4. Bremholm L, Winkel R, Born P, Suku M. therapeutic approach. These poisonings Acute esophageal necrosis. Ugeskrift for cause severe chemical damages of the laeger. 2009;171(45):3282-3. upper gastrointestinal tract, most 5. Zwischenberger JB. Clare Savage, Akhil commonly localized to the esophagus and Bidan. Surgical Aspects of Esophageal stomach, presented with serious clinical Disease. Am J Respir Crit Care Med. signs and symptoms. Clinical examinations 2002; 8: 1037-40 6. Bozinovska C. Xenotic changes in acute are hard to perform; hence, the treatment corrosive intoxications. Archives of and outcome are often uncertain. Toxicology, Kinetics and Xenobiotic They are most commonly detected Metabolism. 1998;3:115-7. among young people in their most 7. Kochhar R, Sethy PK, Kochhar S, Nagi B, productive and active period of life. At the Gupta NM. Corrosive induced carcinoma same time, they present a significant of esophagus: report of three patients and economic burden on the community due to review of literature. Journal of expensive diagnostic and therapeutic and hepatology. programs and extended hospitalization. 2006;21(4):777-80. Treatment of such intoxications 8. Alinejad A. Caustic injury to the upper requires modern medical approaches gastrointestinal tract. . Shiraz e medical journal. 2003;4(1). Available from: because of the severe clinical presentation http://www.sinatrc.ac.ir/_databank/_stdb/ in the acute phase and the need for MAINview.asp?x_search=&No=1&key1= extended evaluation, severe post-corrosive 1208. complications, and possibility of a life- 9. Ramasamy K, Gumaste VV. Corrosive time disability. ingestion in adults. Journal of clinical gastroenterology. 2003;37(2):119-24. In the next five years, it would be 10. Kardon E. Caustic ingestion.Emergency necessary to study the problem with more Medicine Toxicology. Available from: controlled clinical surveys, which will look http://www.medicine.medscape.com. for new ways of reducing the high 11. Poley JW, Steyerberg EW, Kuipers EJ, percentage of post-corrosive stenosis of the Dees J, Hartmans R, Tilanus HW, et al. upper gastrointestinal tract and Ingestion of acid and alkaline agents: development of more efficient treatment outcome and prognostic value of early protocols. upper endoscopy. Gastrointest Endosc 2004;60(3):372-7. REFERENCES 12. Cibisev A, Nikolova-Todorova Z, 1. Bronstein AC, Spyker DA, Cantilena Jr Bozinovska C, Petrovski D, Spasovski G. LR, Green J, Rumack BH, Heard SE. 2006 Epidemiology of severe poisonings caused annual report of the American Association by ingestion of caustic substances. Prilozi. of Poison Control Centers' National Poison 2007;28(2):171-83. Data System (NPDS). Clinical Toxicology. 13. Triadafilopoulos G. Caustic esophageal 2007;45(8):815-917. injury in adults.Available from: 2. Litovitz TL, Klein-Schwartz W, White S, http://www.uptodate.com/contents/caustic- Cobaugh DJ, Youniss J, Omslaer JC, et al. esophageal-injury-in-adults. 2000 Annual report of the American 14. Katzka DA. Caustic injury to the Association of Poison Control Centers esophagus. Current treatment options in Toxic Exposure Surveillance System. gastroenterology. 2001;4(1):59-66. American Journal of Emergency Medicine. 15. Christesen H. Ingestion of caustic agents. 2001;19(5):337-95. Epidemiology, pathogenesis, course,

732 Volume 6, No 19, Winter 2013; http://www.ijt.ir Ingestion of Caustic Substances in … Iranian Journal of Toxicology

complications and prognosis]. Ugeskrift 28. Sarfati E, Gossot D, Assens P, Celerier M. for laeger. 1993;155(31):2379-82. Management of caustic ingestion in adults. 16. Schild JA. Caustic ingestion in adult British journal of surgery. 1987;74(2):146- patients. Laryngoscope. 1985; 8. 95(10):1199–201 29. Chibishev A, Chibisheva B, Bozinovska C, 17. Zargar SA, Kochhar R, Nagi B, Mehta S, Naumovski J. Oesophageal and gastric Mehta SK. Ingestion of corrosive acids. stenoses are common complications after Spectrum of injury to upper acute oral poisoning with corrosive agents. gastrointestinal tract and natural history. Maced J Med. 2005;51(1-2):139-46. Gastroenterology. 1989;97(3):702-7. 30. Hao-Tsai C, Chi-Liang C, Cheng-Hui L, 18. Martins O Thomas, Ezekiel OOgunleye, Jui-Hsiang T, Yin-Yi C, Nai-Jen L, et al. Oladapo Somefun. Chemical injuries of Caustic ingestion in adults: The role of the oesophagus: aetiopathological issues in endoscopic classification in predicting Nigeria,J Cardiothorac Surg. 2009;4:56. outcome. BMC Gastroenterology. 2008; 8: 19. Christesen H. Diagnosis and treatment of 1-7. caustic ingestion]. Ugeskrift for laeger. 31. Munoz-Bongrand N, Gornet JM, Sarfati 1994;156(28):4125-6. E.[Diagnostic and therapeutic management of digestive caustic burns]. J Chir (Paris). 20. Satar S, Topal M, Kozaci N. Ingestion of caustic substances by adults. American 2002;139(2):72-6. journal of therapeutics. 2004;11(4):258-61. 32. Kikendall J. Caustic ingestion injuries. 21. Arévalo-Silva C, Eliashar R, Gastroenterology Clinics of North America. 1991;20(4):847-57. Wohlgelernter J, Elidan J, Gross M. 33. Zargar SA, Kuchhar R, Mehta S, Kumar Ingestion of caustic substances: a 15-year Mehta S. The role of fiberoptic endoscopy experience. The Laryngoscope. in the management of corrosive ingestion 2006;116(8):1422-6. 22. Rakhmetov NR, Zhetimkarimov DS, and modified endoscopic classification of burns. Gastrointestinal endoscopy. Khrebtov VA, Aĭmagambetov MZh, 1991;37(2):165-9. Bylegenov TA. [Surgical treatment of 34. . Dzhafarov CM, Dzhafarov EC. Surgical combined burn strictures of the esophagus treatment of cicatricial stricture of the and the stomach]. Khirurgiia (Mosk). esophagus and stomach after chemical 2003;11:17-9. burn. Khirurgiia. 2007(1):25-8. 23. Korolev MP, Fedotov LE, Makarova OL. 35. Abakumov M, Pinchuk T. Is antisecretory [Treatment of patients with combined burn therapy of patients with chemical burn of strictures of the esophagus and stomach]. the esophagus mandatory?. Khirurgiia. Vestn Khir Im I I Grek. 2005;164(2):70-2. 2007(1):20-4. 24. Mamede R, De Mello Filho F. Treatment 36. Peter M, Loeb-Abram M, Eisenstein. of caustic ingestion: an analysis of 239 Caustic injury to the upper gastrointestinal cases. Diseases of the Esophagus. tract. In :Sleisenger and fordtran's 2002;15(3):210-3. gastroincestinal and liver disease. 6th 25. Atiq M, Kibria RE, Dang S, Patel DH, Ali edition. WB Saunders company . 1998; SA, Beck G, et al. Corrosive injury to the 335-42. GI tract in adults: a practical approach. 37. Pelclova D, Navratil T. Do corticosteroids Expert Review of Gastroenterology and prevent oesophageal stricture after Hepatology. 2009;3(6):701-9. corrosive ingestion? Toxicological 26. Berthet B, Bernardini D, Lonjon T, reviews. 2005;24(2):125-9. Assadourian R, Gauthier A. Treatment of 38. Muñoz Botero NA, Pérez Cano AM, caustic stenoses of the upper digestive Rodríguez Herrera R, Rojas Gómez MP, tract]. Journal de chirurgie. Soler Páez FA.Nutrition therapy for adult 1995;132(11):447-50. patients with caustic injuries to 27. Fridtjof H, Knut H, Mari B, Anne N, Jose gastrointestinal tract. Nutr Hosp. 2010 F, Oivind E, et al. Pre-hospital treatment of ;25:231-7. acute poisonings in Oslo. BMC 39. Chibisev A. Post-corrosive Late Emergency Medicine. 2008;8:15. Complications in Esophagus and http://www.ijt.ir ; Volume 6, No 19, Winter 2013 733 Iranian Journal of Toxicology Andon Chibishev et al

Stomach–Role of the Esophageal Rest. 42. Brankov O. Severe combined corrosions of Med Arh. 2010;64:320-3. the esophagus and stomach-diagnostic and 40. Kochhar R, Kochhar S. Endoscopic treatment]. Khirurgiia. 2003;59(5):7-10. balloon dilation for benign gastric outlet 43. Chirica M, de Chaisemartin C, Goasguen obstruction in adults. World Journal of N, Munoz-Bongrand N, Zohar S, Cattan P, Gastrointestinal Endoscopy. 2010;2(1):29- et al. Colopharyngoplasty for the treatment 35. of severe pharyngoesophageal caustic 41. Temir ZG, Karkıner A, Karaca İ, Ortaç R, injuries: an audit of 58 patients. Annals of surgery. 2007;246(5):721-7. Özdamar A. The effectiveness of 44. Cattan P, Munoz-Bongrand N, Berney T, sucralfate against stricture formation in Halimi B, Sarfati E, Celerier M. Extensive experimental corrosive esophageal burns. abdominal surgery after caustic ingestion. Surgery today. 2005;35(8):617-22. Annals of surgery. 2000;231(4):519-23.

734 Volume 6, No 19, Winter 2013; http://www.ijt.ir