What is the management and treatment of caustic ingestion that leads to pyloric stenosis?

Management of Caustic Ingestion Leading to Pyloric Stenosis

The management of caustic ingestion leading to pyloric stenosis requires timely endoscopic evaluation within 12-48 hours of ingestion, followed by appropriate surgical intervention for severe cases with transmural necrosis, and endoscopic dilatation for resulting strictures after a 3-week waiting period. 1

Initial Assessment and Diagnosis

• Perform upper gastrointestinal endoscopy within the first 12-48 hours after caustic ingestion to determine the extent of injury and guide management decisions 1
• Consider contrast-enhanced CT examination 3-6 hours after ingestion to evaluate for transmural necrosis and grade the severity of injury 1, 2
• Laboratory evaluation should include complete blood count, electrolytes, renal function, liver function tests, and arterial blood gas to assess systemic effects 2, 3
• CT findings are graded according to a four-stage classification, with Grade III indicating transmural necrosis requiring emergency surgery 2, 3

Management Based on Injury Severity

• Grade I injuries: Patients can be fed immediately and discharged within 24-48 hours as stricture risk is nil 2
• Grade IIa injuries: Patients have low risk (<20%) of stricture formation; oral nutrition can be introduced as pain diminishes 2
• Grade IIb injuries: Patients have high risk (>80%) of stricture formation and may require nutritional support via feeding tube or jejunostomy 2, 1
• Grade III injuries: Emergency surgery is indicated for transmural necrosis 1, 2

Surgical Management for Severe Cases

• Surgery should be performed as soon as possible in patients with caustic necrosis (Grade III injuries) to avoid death 1
• All obvious transmural necrotic tissues should be resected during the initial operation 1
• For isolated pyloric stenosis due to caustic injury, options include:
  • Billroth I or II partial gastrectomy for antropyloric strictures 4
  • Total gastrectomy with Roux-en-Y esophagojejunostomy for extensive gastric damage 1, 5
• A feeding jejunostomy is indicated at the end of the operation to provide nutritional support during recovery 1

Management of Strictures

• Ensure timely management of strictures with dilatation as this significantly affects patient outcomes 1
• Avoid dilatation within the first 3 weeks after caustic ingestion due to increased risk of perforation 1
• Consider a time interval between dilatations of less than 2 weeks 1
• Use either bougie or balloon dilators based on the nature of the stricture (length, location, cause) 1
• For refractory strictures, consider:
  • Intralesional steroid therapy combined with dilatation when there is evidence of inflammation 1
  • Temporary placement of fully covered self-expanding removable stents when previous methods have failed 1
  • Needle knife incision for anastomotic strictures as an alternative to dilatation 1

Nutritional Support

• Oral feeding should be reintroduced as soon as patients can swallow normally in cases of mild injury 1, 2
• Enteral feeding via nasogastric tubes or feeding jejunostomy is recommended in patients unable to eat due to severe injury or ongoing dysphagia 1, 2
• Parenteral nutrition may be necessary in some cases with persistent symptoms 2

Follow-up and Long-term Management

• Schedule follow-up visits at 4-6 months post-ingestion for patients with Grade II injuries, as most strictures develop within this timeframe 2, 1
• Monitor for late complications such as esophageal cancer, which has increased risk in patients with caustic injuries 6
• Psychiatric evaluation is mandatory in all patients prior to hospital discharge to prevent recurrence, especially in cases of intentional ingestion 1, 2

Special Considerations for Pyloric Stenosis

• For isolated pyloric stenosis without esophageal involvement, surgical options include partial gastrectomy with Billroth I or II reconstruction 7, 4
• For combined esophageal and pyloric stenosis, consider transhiatal esophagectomy with gastric pull-up, pyloric exclusion, and Roux-en-Y gastroenterostomy 5
• In cases of severe gastric injury with pyloric stenosis but preserved esophagus, total gastrectomy followed by Roux-en-Y esophagojejunal anastomosis may be required 4