Chemical burns of the esophagus - Treatment

Treatment of chemical burns of the esophagus. The tactics of treatment measures are determined by the stage of the lesion, its clinical form, the time of first aid or the arrival of the victim at the emergency room or hospital, elapsed since the poisoning, the amount, concentration and type of caustic liquid (acid, alkali, etc.).

Based on the time frame for providing medical care, treatment of chemical burns of the esophagus is divided into emergency treatment at the acute stage (between the 1st and 10th day after the burn), early treatment at the subacute stage or before the stage of stricture formation (10-20 days), and late treatment for chronic post-burn esophagitis (after 30 days).

Emergency treatment is divided into local and general, includes the administration of painkillers and antihistamines in the form of injections and antidotes in the form of liquids that neutralize the caustic substance: in case of alkali poisoning, weak solutions of acids (acetic, citric, tartaric) and beaten egg whites are given orally; in case of acid poisoning - magnesium oxide, chalk, a solution of baking soda (1 teaspoon per 1/2 glass of warm boiled water), protein liquid - 4 beaten egg whites per 500 ml of warm boiled water, mucous decoctions. These remedies are ineffective 4 hours after poisoning, since a burn of the esophagus occurs immediately; they are aimed, rather, at neutralizing and binding the toxic liquid that has entered the stomach and possibly further into the intestines. Gastric lavage for chemical burns of the esophagus is practically not recommended due to the risk of esophageal perforation, but if it is indicated for one reason or another, for example, if there is evidence that the victim has swallowed a large amount of caustic liquid (which happens when a person deliberately inflicts an injury on themselves), then a light thin probe and water at room temperature are used in an amount depending on the age of the victim.

To absorb toxic substances in the gastrointestinal tract, activated carbon is used, which is mixed with water and in the form of a gruel and taken orally, 1 tablespoon before and after gastric lavage.

In cases of general intoxication, forced diuresis is used. The method is based on the use of osmotic diuretics (urea, mannitol) or saluretics (lasix, furosemide), which promote a sharp increase in diuresis, due to which the elimination of toxic substances from the body is accelerated by 5-10 times. The method is indicated for most intoxications with predominant elimination of toxic substances by the kidneys. It consists of three successive procedures: water load, intravenous administration of a diuretic and replacement infusion of electrolyte solutions. Hypovolemia developing in severe poisoning is preliminarily compensated by intravenous drip administration of plasma-substituting solutions (polyglucin, hemodez and 5% glucose solution in a volume of 1-1.5 l) over 1.5-2 hours. At the same time, it is recommended to determine the concentration of the toxic substance in the blood and urine, the hematocrit number (normally 0.40-0.48 for men, 0.36-b.42 for women) and perform continuous catheterization of the bladder to measure diuresis hourly.

Urea in the form of a 30% solution or a 15% solution of mannitol is administered intravenously by jet stream in the amount of 1-2 g/kg for 10-15 minutes, lasix (furosemide) - in a dose of 80-200 mg. After the diuretic administration is completed, an intravenous infusion of an electrolyte solution is started (4.5 g of potassium chloride, 6 g of sodium chloride, 10 g of glucose per 1 liter of solution). If necessary, the cycle of these measures is repeated after 4-5 hours until the toxic substance is completely removed from the blood. However, it should also be taken into account that part of the toxic substance can be deposited in the parenchymatous organs, causing their dysfunction, therefore, it is advisable to carry out appropriate treatment for symptoms of such dysfunction. The amount of the administered solution should correspond to the amount of urine excreted, reaching 800-1200 ml/h. During forced diuresis and after its completion, it is necessary to monitor the content of ions (potassium, sodium, calcium) in the blood, acid-base balance and promptly compensate for disturbances in water-electrolyte balance.

If there are signs of traumatic (pain) shock, anti-shock treatment is prescribed (caffeine and morphine are contraindicated), blood pressure is restored by intravenous administration of blood, plasma, glucose, blood-substituting fluids (reogluman), rheopolglucin, polyamine.

Early treatment is carried out after the acute period to reduce the likelihood of cicatricial stenosis of the esophagus. Treatment begins in the so-called post-burn "light" period, when the reaction to the burn and inflammation has decreased to a minimum, body temperature has returned to normal, the patient's condition has improved, and dysphagia has been minimized or has disappeared completely. Treatment consists of esophageal bougienage, which is divided into early, before cicatricial stenosis has formed, and later, after the stricture has formed.

The method of bougienage involves the introduction of special instruments (bougies) into certain tubular organs (esophagus, auditory tube, urethra, etc.) to expand them. The use of bougienage has been known since ancient times. A. Gagman (1958) writes that during excavations in Pompeii, bronze bougies for the urethra were found, very similar to modern ones. In the old days, wax candles of different sizes were used for bougienage. There are various methods of bougienage of the esophagus. Usually, bougienage in adults is carried out using elastic bougies of a cylindrical shape with a conical end or under the control of esophagoscopy or a metal bougie equipped with an olive. If damage is found on the mucous membrane of the esophagus during early bougienage, the procedure is postponed for several days. Contraindication to bougienage of the esophagus is the presence of inflammatory processes in the oral cavity and pharynx (prevention of infection in the esophagus). Before esophageal bougienage, the elastic probe is sterilized and immersed in sterile hot water (70-80°C) to soften it. The bougienage, lubricated with sterile vaseline oil, is inserted into the patient's esophagus on an empty stomach in a sitting position with a slightly tilted head. Before esophageal bougienage, 1 ml of 0.1% atropine sulfate solution is administered subcutaneously to the patient 10 minutes before, and 2-3 ml of 1% diphenhydramine solution is administered intramuscularly, the root of the tongue and the back wall of the pharynx are lubricated with 5% cocaine hydrochloride solution or 2% da-caine solution. We recommend giving the patient a suspension of anesthesin powder in vaseline oil per os 10-15 minutes before bougienage at a rate of 1 g of the drug per 5 ml: in addition to the anesthetic effect, coating the esophageal wall with oil facilitates the advancement of the bougie in the stricture area.

Early bougienage begins 5-10 days (up to the 14th day) after the burn. A preliminary X-ray examination of the esophagus and stomach is performed, which is often affected together with the esophagus. According to a number of specialists, bougienage of the esophagus is advisable to perform even in the absence of noticeable signs of the onset of stenosis of the esophagus, which, as their experience shows, slows down and reduces the severity of subsequent stenosis.

In adults, bougienage is started with bougies No. 24-26. The bougienage is inserted carefully to avoid perforation of the esophagus. If the bougienage does not pass through the stricture, a thinner bougienage is used. The bougienage inserted into the stricture is left in the esophagus for 15-20 minutes, and if there is a tendency for narrowing - up to 1 hour. The next day, a bougienage of the same diameter is inserted for a short time, followed by a bougienage of the next number, leaving it in the esophagus for the required time. If a painful reaction, signs of malaise, or an increase in body temperature occur, bougienage is postponed for several days.

Previously, bougienage was performed daily or every other day for a month, even in the absence of signs of esophageal stenosis, and then for 2 months, 1-2 times a week, and, as experience shows, it is possible to perform it with bougie No. 32-34.

Early bougienage in children is aimed at preventing the development of narrowing of the lumen of the esophagus in the phase of reparative processes and scarring of its affected wall. According to the author, bougienage started in the first 3-8 days after the burn is not dangerous for the victim, since morphological changes in this period extend only to the mucous and submucous layers, and therefore the risk of perforation is minimal. Indications for early bougienage are normal body temperature for 2-3 days and the disappearance of acute phenomena of general intoxication. After the 15th day from the moment of the burn, bougienage becomes dangerous for both the child and the adult, as the scarring phase of the esophagus begins, it becomes rigid and slightly pliable, and the wall has not yet acquired sufficient strength.

Esophageal bougienage is performed with soft elastic blunt-ended bougies and polyvinyl chloride, reinforced with silk cotton fabric and covered with varnish, or a soft gastric tube. The bougie number must necessarily correspond to the child's age.

Before blocking, the child is wrapped in a sheet with arms and legs. The assistant holds him firmly on his knees, clasping the child's yogis with his legs, with one hand - the child's body, and with the other - fixes the head in an orthograde (straight) position. The bougie is prepared according to the above method. The bougie is passed along the esophagus, without allowing violence, and left in it from 2 minutes (according to S.D. Ternovsky) to 5-30 minutes. Bougie of children is carried out in a hospital 3 times a week for 45 days, gradually increasing the size of the bougie corresponding to the normal diameter of the esophagus of a child of this age. Upon achieving a positive result, the child is discharged for outpatient treatment, which consists of weekly one-time bougie for 3 months, and in the following 6 months bougie is carried out initially 2 times a month, and then 1 time per month.

Complete recovery from early esophageal blockage occurs in the vast majority of cases, facilitated by the use of antibiotics that prevent secondary complications and steroid drugs that inhibit fibroplastic processes.

Late treatment of chemical burns of the esophagus. It is necessary in the absence of early treatment or its irregular implementation. In most such cases, cicatricial stenosis of the esophagus occurs. In such patients, late bougienage is performed.

Late esophageal bougienage is performed after a thorough general clinical examination of the patient, X-ray and esophagoscopic examination. Bougienage begins with bougies No. 8-10, gradually moving on to bougies of a larger diameter. The procedure is performed daily or every other day, and upon achieving a sufficient effect - 1-2 times a week for 3-4 months, and sometimes up to six months or more. It should be noted, however, that due to the density of scar tissue and the intractability of the stricture, it is not always possible to bring the bougie to the last numbers and it is necessary to stop at bougies of medium sizes, which pass liquefied and crushed dense food products, and during a control X-ray examination - a thick mass of barium sulfate. It should also be noted that interruptions in treatment by bougienage have a detrimental effect on the achieved result, and the esophageal stricture narrows again. Even with a good and relatively stable result achieved with bougienage, the stricture has a tendency to narrow, so patients who have suffered chemical burns of the esophagus and treatment with bougienage should be monitored and, if necessary, undergo repeated courses of treatment.

In case of sharp and tortuous cicatricial stenosis of the esophagus, adequate nutrition of patients through the mouth is impossible, as is effective bougienage in the usual way. In these cases, to establish adequate nutrition, a gastrostomy is inserted, which can also be used for bougienage by the “endless” method. Its essence lies in the fact that the patient swallows a strong nylon thread through the mouth, which is brought out into the gastrostomy, a bougie is tied to it, and the end of the thread coming out of the mouth is tied to its other end. By traction on the lower end of the thread, the bougie is inserted into the esophagus, then through its stricture and gastrostomy it is brought out; the cycle is repeated several times for many days in a row, until bougienage in the usual way becomes possible.

The same method is also applicable to a number of sick children with late bougienage, in whom it is not possible to widen the stricture to an acceptable diameter that would ensure satisfactory nutrition even with liquid food. In this case, in order to save the child, a gastrostomy is inserted, through which feeding is carried out. After the child's condition improves, he is given a 1 m long #50 silk thread to swallow with water; after this, the gastrostomy is opened, and the thread is released along with the water. The thin thread is replaced with a thick one. The upper end is passed through the nasal passage (to avoid biting the thread) and tied to the lower one. A bougie is tied to the thread and pulled through from the side of the mouth or retrogradely from the side of the fistula. Bougienage "by the thread" ("endless" bougienage) is performed 1-2 times a week for 2-3 months. Once stable patency of the esophagus is established, the thread is removed and bougienage is continued through the mouth on an outpatient basis for 1 year. Considering the possibility of stricture recurrence, the gastrostomy is closed 3-4 months after thread removal if the esophagus remains patent.

Surgical treatment of post-burn strictures of the esophagus is divided into palliative and pathogenetic, i.e. elimination of stenosis by plastic surgery methods. Palliative methods include gastrostomy, which is performed in cases where bougienage does not bring the desired result. In Russia, V.A. Basov was the first to impose a gastrostomy on animals in 1842. The French surgeon I. Sediyo was the first to impose a gastrostomy on a human in 1849. With the help of this surgical intervention, a gastrostomy is created, which is a fistula of the stomach for artificial feeding of patients with esophageal obstruction. Gastrostomy is used in cases of congenital atresia of the esophagus, its cicatricial stenosis, foreign bodies, tumors, fresh burns and wounds of the masticatory, swallowing apparatus and esophagus, in surgical interventions on the esophagus for plastic elimination of its obstruction and bougienage "without end". A gastrostomy intended for feeding must meet the following requirements: the fistula must tightly fit the rubber or polyvinyl chloride tube inserted into the stomach and not leak when the stomach is full, it must pass a sufficiently, but not too thick, tube so that the patient can eat not only liquid but also thick food, it must not pass food from the stomach if the tube is temporarily removed or falls out on its own. There are various methods of gastrostomy that meet these requirements. For clarity, we provide a diagram of gastrostomy according to L.V. Serebrennikov.

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