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					Title: Esophageal emergencies: things that will wake you up from a sound sleep
Authors: Duncan M and Wong R
Journal: Gastroenterology Clinics of North America

Key Points
         •    Esophageal emergencies include caustic ingestions, esophageal perforations, and foreign body impaction.
         •    Caustic injuries can cause perforation early in the course and stricture formation late.
         •    Esophageal perforation can lead to mediastinitis and sepsis and should be treated aggressively with empiric antibiotics and drainage
              or by surgical repair.
         •    Foreign bodies should be identified and removed promptly whenever possible.

Clinical Conclusions
           •   Esophageal injury can lead to severe and at times life-threatening situations which must be recognized early and treated
               aggressively to minimize morbidity and mortality.

Section Highlights
Caustic Ingestions
          •    The amount of injury with ingestions is dependent on the characteristics of the ingested substance (corrosive properties, amount
                                                                                                1, 2
               ingested, concentration, and physical form) and its duration of mucosal contact.
          •    Alkali ingestions result in more esophageal injury and can lead to esophageal stricture long after the initial injury.
          •    Acid ingestion is more likely to damage the stomach than the esophagus.
                                                                                                                           3, 4
          •    An endoscopic grading system is useful because it can predict subsequent clinical outcomes and course.           Table 1
          •    Patients with grade 2b and 3a injuries develop strictures in 70-100% of cases and patients with a 3b classification have 65% mortality
               and may need esophageal resection as a life-saving measure.

Esophageal Perforations
        •    Esophageal perforation can range from small rents to transmural tears which can leak contents and lead to mediastinitis and sepsis.
        •    Symptoms depend on the level of injury but can include such things as dysphagia, odynophagia, dyspnea, and subcutaneous or
             mediastinal emphysema.
        •    Esophageal perforation can occur from the passage of any instrument or object (Table 2) with iatrogenic perforation accounting for
             33-75.5% of cases.
        •    Any foreign body can cause perforation and the risk increases the greater the time the foreign body remains because of pressure
        •    Contrast esophagography is commonly the preferred imaging modality with CT used in negative cases with a strong clinical
        •    Esophagoscopy has a high sensitivity and specificity but risk enlarging the perforation.
        •    Treatment for small focal tears found early without severe symptoms can be treated non-operatively with empiric antibiotic
             coverage and drainage.
        •    Many cases require surgical treatment with primary closure, esophagectomy, exclusion and diversion, and/or drainage with or
             without a T tube.

Esophageal Foreign Bodies
        •    The most common cause of obstruction is food bolus (34-59%) with other common causes including bones (16-18%), coins (2%), pills
             (3%), dental hardware (2-10%), and batteries (1%).
        •    Symptoms include dysphagia, odynophagia, and chest pain with signs and symptoms of airway obstruction when there is
             compression on the trachea.
        •    The major complications of foreign body ingestions include perforation, aortoesophageal fistula, tracheoesophageal fistula, and
                                 9, 10
             abscess formation.
        •    Less than 1% of all foreign bodies lead to perforation but sharp objects have a much higher rate (15-35%) so every effort should be
             made to try to remove any sharp foreign body.
        •    Treatment of foreign bodies includes flexible endoscopy which is the mainstay for removal of these objects although other options
             include surgical removal and the use of glucagon to relax the lower esophageal sphincter.
        •    Button batteries should be similarly removed as these can lead to direct corrosion, voltage burns, or pressure necrosis.

                                                                  Key References

1.       Wasserman R.L. and Ginsburg C.M., Caustic substance injuries. J Pediatr, 1985. 107(2): p. 169-74.
2.       Goldman L.P. and Weigert J.M., Corrosive substance ingestion: a review. Am J Gastroenterol, 1984. 79(2): p. 85-90.
3.       Zargar S.A., Kochhar R., Mehta S., and Mehta S.K., The role of fiberoptic endoscopy in the management of corrosive ingestion and
         modified endoscopic classification of burns. Gastrointest Endosc, 1991. 37(2): p. 165-9.
4.    Zargar S.A., Kochhar R., Nagi B., Mehta S., and Mehta S.K., Ingestion of strong corrosive alkalis: spectrum of injury to upper
      gastrointestinal tract and natural history. Am J Gastroenterol, 1992. 87(3): p. 337-41.
5.    Williamson W.a.E., H, Esophageal perforation, in Esophageal Emergencies, T. MB, Editor. 1997, Williams & Wilkins: Baltimore. p. 31-49.
6.    Webb W.A., Management of foreign bodies of the upper gastrointestinal tract: update. Gastrointest Endosc, 1995. 41(1): p. 39-51.
7.    Mosca S., Manes G., Martino R., Amitrano L., Bottino V., Bove A., Camera A., De Nucci C., Di Costanzo G., Guardascione M., Lampasi F.,
      Picascia S., Picciotto F.P., Riccio E., Rocco V.P., Uomo G., and Balzano A., Endoscopic management of foreign bodies in the upper
      gastrointestinal tract: report on a series of 414 adult patients. Endoscopy, 2001. 33(8): p. 692-6.
8.    Chaikhouni A., Kratz J.M., and Crawford F.A., Foreign bodies of the esophagus. Am Surg, 1985. 51(4): p. 173-9.
9.    Brady P.G., Esophageal foreign bodies. Gastroenterol Clin North Am, 1991. 20(4): p. 691-701.
10.   Takano H., Okada A., Monden Y., Nakahara K., and Kawashima Y., Unusual case of acquired benign tracheoesophageal fistula caused by
      an esophageal foreign body. J Thorac Cardiovasc Surg, 1990. 99(4): p. 755-6.

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