Burns of a gullet arise at hit in it caustic chemicals at accidental intake or owing to suicide attempts.
Epidemiology From total number of victims of corrosive burns of a gullet about 70 — 75% are the share of children aged till 10 flyings, 25 — 30% are made by adults. Frequency of corrosive burns of a gullet at children speaks, on the one hand, a habit of children (especially early age) to take everything in a mouth, on the other hand — negligence of adults at storage of the caustic chemicals applied in life; in some cases burns arise at accidental reception of these substances instead of drugs or drink. At adults corrosive burns of a gullet owing to a home accident make about 25% of total number of victims.
Etiology and pathogeny More often burns arise at reception of caustic natron (the caustic soda, sodium a hydroxide), strong solutions sulfuric, hydrochloric, acetic (acetic essence) acids, burns are less often observed by phenol, lysol, spirit solution of iodine (iodic tincture), corrosive sublimate.
In addition to a gullet, at intake of caustic substances also the stomach suffers; changes find on a mucous membrane of an oral cavity and a throat. It is considered to be that at reception of strong acid the most expressed changes develop in a gullet, and at reception of caustic alkali — in a stomach (as the mucous membrane of a stomach is to some extent steady against effect of acid). Extent of defeat depends on concentration, character and amount of the drunk substance. The mucous membrane of a stomach is surprised less if the stomach is filled with liquid and food. Deep necroses of an esophageal wall can lead to perforation of a gullet, formation of esophageal and bronchial or esophageal and tracheal fistula, a mediastinitis.
Classification Allocate 3 degrees of a burn of a gullet. At a burn of 1 degree only blankets of a mucous membrane of a gullet are surprised; at a burn of the II degree defeat extends to its muscular coat, at a burn of the III degree defeat of all layers of an esophageal wall, and also paraezofagealny cellulose and surrounding bodies is observed. At a burn of the III degree in addition to local also the general phenomena caused by intoxication and shock are expressed. At burns of II and especially the III degree (if the patient manages to be rescued) cicatricial changes in a gullet, strictures, cicatricial shortening of a gullet, in some cases — a chronic ulceration of a wall of a gullet develop.
At a gullet burn in typical cases the current is subdivided into 3 periods: the 1st — acute (to 1 — 1 1/2 weeks), shown a hyperemia, hypostasis, a necrosis and ulcerations of a mucous membrane, during this period because of severe pain swallowing is impossible; the 2nd — subacute (1 1/2 — 3 weeks), the period of granulation and gradual recovery of an opportunity to accept liquid and food; the 3rd — chronic, the period of scarring, the accruing esophageal stenosis and resuming of a dysphagy.
Approximate formulation of the diagnosis: 1. Gullet burn severity concentrated sulphuric acid III. Extensive necrosis of a wall of a gullet, mediastinitis, acute period. 2. Gullet burn severity concentrated sulphuric acid II, acute period.
Clinical picture, preliminary diagnosis The preliminary diagnosis is established on the basis of the anamnesis and an assessment of weight of the general condition of the patient. Character of the caustic liquid accepted by the patient can be established or from his words, or on the remains of the liquid which is in the capacity (a cup, a bubble, a bottle) from which the patient drank it. It must be kept in mind, however, that the text on a bottle or a bottle not always corresponds to character of its contents (caustic substance can be stored due to negligence in accidental, unadapted ware).
The first and the brightest symptoms — strong burning and a stomatalgia, drinks, behind a breast and in epigastric area, arising right after a proglatyvaniye of caustic substance. Quite often there is vomiting. Lips swell.
In hard cases shock, a loss of consciousness develop. If within 1 — 2 days the death of the patient did not occur, appear the expressed asthma owing to throat hypostasis, vomiting slime and blood, in emetic masses it is possible to define pieces of a mucous membrane. Body temperature increases. Swallowing is impossible. Owing to deep defeat of a wall of a gullet the esophageal bleedings, symptoms caused by development of a mediastinitis or other complications, renal failures are possible (owing to their toxic defeat).
In moderately severe cases in several days pain decreases, however swallowing is complicated, the raised sialosis, vomiting bloody separated are noted. At survey of an oral cavity traces of a burn of a mucous membrane are visible. In 10 — 20 days ability to swallow liquid and liquid food is gradually recovered, however swallowing long remains painful. During scarring, in several weeks the dysphagy renews; at a sharp stenozirovaniye of a gullet of the patient cannot accept liquid and food, exhaustion develops.
At a serious poisoning caustic substances patients die owing to intoxication, shock, development of purulent complications (a mediastinitis, abscess and gangrene of a lung, pleurisy). From complications can to be observed heavy esophageal bleedings, perforation of a gullet, to develop esophageal and tracheal and esophageal and bronchial fistulas. The most frequent late complication of corrosive burns of a gullet is development of Cicatricial narrowings (stenoses) of a gullet, its cicatricial deformations and shortening.
Differential diagnosis, verification of the diagnosis The final diagnosis is established when it is possible to define precisely extent of defeat and the arisen complications. X-ray inspection of a gullet in the first days should not be conducted, it is necessary to achieve stabilization of a condition of the patient. In several days after a burn (at moderately severe defeats) at the concentrated X-ray inspection it is possible to note puffiness of a mucous membrane of a gullet and local spasms. During later periods informational content of X-ray inspection is much higher: it is possible to define places, extent and expressiveness of cicatricial narrowings and deformations of a gullet.
Ezofagoskopiya in the first days is contraindicated, further is possible only in the period of scarring and epithelization of a mucous membrane, at the same time it is necessary to see off it extremely carefully. Ezofagoskopiya allows to determine defeat extent, to track dynamics of process, to timely reveal the forming strictures (they are more often formed in a distal piece of a gullet, over a cardial sphincter; slightly more rare in the field of pharyngoesophageal connection and at the level of bifurcation of a trachea).
Treatment, secondary prevention, rehabilitation, forecast Emergency treatment; urgent hospitalization, parenteral administration of anesthetics (for fight against shock), introduction of the gastric tube which is plentifully oiled for removal of gastric contents and a gastric lavage for the purpose of neutralization of caustic substance are necessary. At poisonings with alkalis the stomach is washed out divorced solution of acetic acid (3 — 6%) or vegetable oil, at poisonings with acids — weak (2%) Natrii hydrocarbonas solution. In doubtful cases the stomach is washed out milk. Before introduction of a probe appoint plentiful drink of weak solutions of acetic acid or hydrosodium carbonate (depending on character of poison) or milk (1/g — 2 glass to the adult). Washing by means of a probe is carried out after preliminary introduction under skin of narcotic analgetics (Promedolum of 1 ml of 2% of solution) and Atropini sulfas (1 ml of 0,1% of solution), and also local anesthesia of an oral cavity and a throat of 2% by Dicainum solution. The gastric lavage is effective only in the first 6 h after poisoning. Disintoxication therapy is necessary. Parenterally enter Haemodesum, reopoliglyukin, saline solutions. For prevention and treatment of infectious complications appoint parenterally antibiotics of a broad spectrum of activity (ampicillin sodium salt, ampioks, Gentamycini sulfas, Cefamezinum, etc.). To reduce development of cicatricial changes in a gullet, appoint drugs of adrenal hormones parenterally. Depending on character of the accepted poison and features of a clinical picture apply the means normalizing activity of cardiovascular system, function of kidneys at considerable blood loss carry out haemo static and blood-substituting therapy etc.
Administration of liquid inside in the first 1 — 3 days is excluded, and in more hard cases this prohibition proceeds till 5 — 7 days, then in the fractional portions in small amounts allow reception of cream, milk, crude eggs, warm broth. Gradually the diet is expanded. At heavy burns of a gullet for ensuring food of the patient in 7 — 10 days impose a gastrostomy.
After subsiding of the acute inflammatory phenomena at burns 2 — the 3rd degree for the purpose of early prevention of development of stenoses begin bougieurage of a gullet which is continued by several weeks. If development of a stenosis does not manage to be prevented, resort to operational treatment — creation of an artificial gullet. At timely begun treatment favorable results are observed in 90% of cases. Prevention of burns of a gullet first of all consists in the correct storage of caustic substances in the places not available to children. On ware with these substances there has to be a bright label with a text "Poison, dangerously!".