Akzidentielle und suizidale Verätzungen des oberen Gastrointestinaltraktes

Zusammenfassung

Das Verschlucken von Säuren oder Laugen kann schwerwiegende Schäden verursachen. Am Anfang steht die übliche Notfalltherapie (Sicherung der Atemwege, Volumensubstitution, Analgesie) im Vordergrund. Diagnostikum der Wahl ist die frühe Endoskopie. Von der Gabe von Wasser oder Milch zur Verdünnung oder Aktivkohle wird abgeraten. Der Nutzen der systemischen Gabe von Steroiden ist nicht belegt, eine Antibiotikaprophylaxe bei höhergradigen Verätzungen erscheint sinnvoll. Wichtigster Prognosefaktor bezüglich der initialen Mortalität ist die verspätete Diagnose und Behandlung transmuraler ösophagogastraler Nekrosen, deshalb sollte beim Hinweis auf eine Perforation eine schnellstmögliche chirurgische Exploration durchgeführt werden. Da es trotz endoskopischen Befundes oft schwierig ist, intraoperativ das genaue Ausmaß der Verletzung abzuschätzen, müssen im Zweifel alle möglicherweise von höhergradigen Verätzungen betroffene Abschnitte reseziert werden. Die Rekonstruktion erfolgt frühestens nach 4 Monaten. In Anhängigkeit von der initialen Resektion kann dann die Rekonstruktion geplant werden (z. B. Magenhochzug, Koloninterponat). Strikturen sind das häufigste Problem im Langzeitverlauf und werden im Regelfall interventionell therapiert. Da aber besonders höhergradige Strikturen auch auf wiederholte Dilatationen therapierefraktär sind, sollte hier frühzeitig eine Resektion in Erwägung gezogen werden. Eine regelmäßige endoskopische Nachsorge ist aufgrund der deutlich erhöhten Gefahr der Entwicklung eines Ösophaguskarzinoms zu empfehlen.

Abstract

Caustic ingestion can cause sever damages. Immediate management should be directed to airway securing, intravenous fluid replacement and pain relief. Early endoscopy is regarded as the most appropriate method based on which further clinical decisions are made. The effectiveness of dilution by milk or water has not been proven and might aggravate the damage. The use of systemic corticosteroids should also be abandoned as they do not prevent the development of strictures and may cause serious adverse effects. The most important prognostic factor concerning early mortality is the delayed diagnosis and therapy of full thickness esophageal or gastric necrosis. Patients with evidence of perforation require immediate surgery. Since it can be very difficult to classify the exact extent of damage intraoperatively according to the endoscopic findings, a resection of all high grad damaged segments should be performed in doubt. Reconstructive surgery should not be performed earlier then 4 months after the initial event. The used technique depends on the extent of the initial damage and surgery. Development of strictures is the most important physical consequence in burned areas in survivors. Short strictures are mainly treated by endoscopic dilatation. In cases of higher graded strictures, when repeated dilatations are often ineffective, early resection should planned. Because of the high incidence of esophageal cancer among victims of caustic strictures, routine endoscopic follow up is recommended.

Schlüsselwörter

Säure - Lauge - Verätzung - Komplikation - Chirurgie - Therapie

Key words

Acid - lye - caustic ingestion - complication - surgery - therapy

Literatur

• 1 Anderson KD, Rouse TM, Randolph JG. A controlled trial of corticosteroids in children with corrosive injury of the esophagus.  N Engl J Med. 1990;  323 ((10)) 637-640
• 2 Mamede RC, De Mello Filho FV. Treatment of caustic ingestion: an analysis of 239 cases.  Dis Esophagus. 2002;  15 ((3)) 210-213
• 3 Symbas PN, Vlasis SE, Hatcher Jr CR. Esophagitis secondary to ingestion of caustic material.  Ann Thorac Surg. 1983;  36 ((1)) 73-77
• 4 Tewfik TL, Schloss MD. Ingestion of lye and other corrosive agents-a study of 86 infant and child cases.  J Otolaryngol. 1980;  9 ((1)) 72-77
• 5 Gumaste VV, Dave PB. Ingestion of corrosive substances by adults.  Am J Gastroenterol. 1992;  87 ((1)) 1-5
• 6 Dantas RO, Mamede RC. Esophageal motility in patients with esophageal caustic injury.  Am J Gastroenterol. 1996;  91 ((6)) 1157-1161
• 7 Poley JW, Steyerberg EW, Kuipers EJ, Dees J, Hartmans R, Tilanus HW. et al . Ingestion of acid and alkaline agents: outcome and prognostic value of early upper endoscopy.  Gastrointest Endosc. 2004;  60 ((3)) 372-377
• 8 Hugh TB, Kelly MD. Corrosive ingestion and the surgeon.  J Am Coll Surg. 1999;  189 ((5)) 508-522
• 9 Kochhar R, Sethy PK, Kochhar S, Nagi B, Gupta NM. Corrosive induced carcinoma of esophagus: report of three patients and review of literature.  J Gastroenterol Hepatol. 2006;  21 ((4)) 777-780
• 10 Ramasamy K, Gumaste VV. Corrosive ingestion in adults.  J Clin Gastroenterol. 2003;  37 ((2)) 119-124
• 11 Arevalo-Silva C, Eliashar R, Wohlgelernter J, Elidan J, Gross M. Ingestion of caustic substances: a 15-year experience.  Laryngoscope. 2006;  116 ((8)) 1422-1426
• 12 Kao WF, Dart RC, Kuffner E, Bogdan G. Ingestion of low-concentration hydrofluoric acid: an insidious and potentially fatal poisoning.  Ann Emerg Med. 1999;  34 ((1)) 35-41
• 13 Zargar SA, Kochhar R, Mehta S, Mehta SK. The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns.  Gastrointest Endosc. 1991;  37 ((2)) 165-169
• 14 Vancura EM, Clinton JE, Ruiz E, Krenzelok EP. Toxicity of alkaline solutions.  Ann Emerg Med. 1980;  9 ((3)) 118-122
• 15 Mattos GM, Lopes DD, Mamede RC, Ricz H, Mello-Filho FV, Neto JB. Effects of time of contact and concentration of caustic agent on generation of injuries.  Laryngoscope. 2006;  116 ((3)) 456-460
• 16 Goldman LP, Weigert JM. Corrosive substance ingestion: a review.  Am J Gastroenterol. 1984;  79 ((2)) 85-90
• 17 Turner A, Robinson P. Respiratory and gastrointestinal complications of caustic ingestion in children.  Emerg Med J. 2005;  22 ((5)) 359-361
• 18 Maull KI, Osmand AP, Maull CD. Liquid caustic ingestions: an in vitro study of the effects of buffer, neutralization, and dilution.  Ann Emerg Med. 1985;  14 ((12)) 1160-1162
• 19 Vale JA. Position statement: gastric lavage. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists.  J Toxicol Clin Toxicol. 1997;  35 ((7)) 711-719
• 20 Oakes DD. Reconsidering the diagnosis and treatment of patients following ingestion of liquid lye.  J Clin Gastroenterol. 1995;  21 ((2)) 85-86
• 21 Rappert P, Preier L, Korab W, Neubauer T. Diagnostic and therapeutic management of esophageal and gastric caustic burns in childhood.  Eur J Pediatr Surg. 1993;  3 ((4)) 202-205
• 22 Sugawa C, Lucas CE. Caustic injury of the upper gastrointestinal tract in adults: a clinical and endoscopic study.  Surgery. 1989;  106 ((4)) 802-806 , discussion 806-7
• 23 Kirsh MM, Ritter F. Caustic ingestion and subsequent damage to the oropharyngeal and digestive passages.  Ann Thorac Surg. 1976;  21 ((1)) 74-82
• 24 Hawkins DB, Demeter MJ, Barnett TE. Caustic ingestion: controversies in management. A review of 214 cases.  Laryngoscope. 1980;  90 ((1)) 98-109
• 25 Keh SM, Onyekwelu N, McManus K, McGuigan J. Corrosive injury to upper gastrointestinal tract: Still a major surgical dilemma.  World J Gastroenterol. 2006;  12 ((32)) 5223-5228
• 26 Sarfati E, Jacob L, Servant JM, d’Acremont B, Roland E, Ghidalia T. et al . Tracheobronchial necrosis after caustic ingestion.  J Thorac Cardiovasc Surg. 1992;  103 ((3)) 412-413
• 27 Chiu HM, Lin JT, Huang SP, Chen CH, Yang CS, Wang HP. Prediction of bleeding and stricture formation after corrosive ingestion by EUS concurrent with upper endoscopy.  Gastrointest Endosc. 2004;  60 ((5)) 827-833
• 28 Tseng YL, Wu MH, Lin MY, Lai WW. Massive upper gastrointestinal bleeding after acid-corrosive injury.  World J Surg. 2004;  28 ((1)) 50-54
• 29 Zhou JH, Jiang YG, Wang RW, Lin YD, Gong TQ, Zhao YP. et al . Management of corrosive esophageal burns in 149 cases.  J Thorac Cardiovasc Surg. 2005;  130 ((2)) 449-455
• 30 Lai KH, Huang BS, Huang MH, Huang MS, Wu JK, Liu M. et al . Emergency surgical intervention for severe corrosive injuries of the upper digestive tract.  Zhonghua Yi Xue Za Zhi (Taipei). 1995;  56 ((1)) 40-46
• 31 Sarfati E, Gossot D, Assens P, Celerier M. Management of caustic ingestion in adults.  Br J Surg. 1987;  74 ((2)) 146-148
• 32 Cattan P, Munoz-Bongrand N, Berney T, Halimi B, Sarfati E, Celerier M. Extensive abdominal surgery after caustic ingestion.  Ann Surg. 2000;  231 ((4)) 519-523
• 33 Wu MH, Lai WW. Surgical management of extensive corrosive injuries of the alimentary tract.  Surg Gynecol Obstet. 1993;  177 ((1)) 12-16
• 34 Gossot D, Sarfati E, Celerier M. Early blunt esophagectomy in severe caustic burns of the upper digestive tract. Report of 29 cases.  J Thorac Cardiovasc Surg. 1987;  94 ((2)) 188-191
• 35 Wu MH, Lai WW, Hwang TL, Lee SC, Hsu HK, Lin TS. Surgical results of corrosive injuries involving esophagus to jejunum.  Hepatogastroenterology. 1996;  43 ((10)) 846-850
• 36 Ganepola GA, Bhuta K. A case of total esophago-gastro-duodeno-jejunectomy and partial pancreatectomy for lye burns, and reconstruction with colon interposition.  J Trauma. 1984;  24 ((10)) 913-916
• 37 Fisher RA, Eckhauser ML, Radivoyevitch M. Acid ingestion in an experimental model.  Surg Gynecol Obstet. 1985;  161 ((1)) 91-99
• 38 Reddy AN, Budhraja M. Sucralfate therapy for lye-induced esophagitis.  Am J Gastroenterol. 1988;  83 ((1)) 71-73
• 39 Pelclova D, Navratil T. Do corticosteroids prevent oesophageal stricture after corrosive ingestion?.  Toxicol Rev. 2005;  24 ((2)) 125-129
• 40 Kochhar R, Ray JD, Sriram PV, Kumar S, Singh K. Intralesional steroids augment the effects of endoscopic dilation in corrosive esophageal strictures.  Gastrointest Endosc. 1999;  49 ((4 Pt 1)) 509-513
• 41 Chien KY, Wang PY, Lu KS. Esophagoplasty for corrosive stricutre of the esophagus: an analysis of 60 cases.  Ann Surg. 1974;  179 ((4)) 510-515
• 42 Chaudhary A, Puri AS, Dhar P, Reddy P, Sachdev A, Lahoti D. et al . Elective surgery for corrosive-induced gastric injury.  World J Surg. 1996;  20 ((6)) 703-706 , discussion 706
• 43 DeMeester TR, Johansson KE, Franze I, Eypasch E, Lu CT, McGill JE. et al . Indications, surgical technique, and long-term functional results of colon interposition or bypass.  Ann Surg. 1988;  208 ((4)) 460-474
• 44 Popvici Z. Pharyngeal-oesophageal reconstruction with laryngeal preservation following severe caustic injury to the pharynx and oesophagus. In: Hennessy T, Cuschieri A, editors. Surgery of the oesophagus. Oxford: Butterworth-Heinemann 1992 p. 328
• 45 Wang RW, Zhou JH, Jiang YG, Fan SZ, Gong TQ, Zhao YP. et al . Prevention of stricture with intraluminal stenting through laparotomy after corrosive esophageal burns.  Eur J Cardiothorac Surg. 2006;  30 ((2)) 207-211
• 46 Mutaf O, Genc A, Herek O, Demircan M, Ozcan C, Arikan A. Gastroesophageal reflux: a determinant in the outcome of caustic esophageal burns.  J Pediatr Surg. 1996;  31 ((11)) 1494-1495

Korrespondenzadresse