Esophageal disorders acquired corrosive strictures

3.ACQUIRED

The acquired disorders may present in childhood or in adult  life

and  manifest  most  often  with  complaints  of  difficulty   in

swallowing(dysphagia).

 

  * The complaint  may  follow  a history of having  swallowed  a

    chemical   (corrosive  stricture)  or  it  may  be   a   slow

    progressive   dysphagia   (aclasia,   reflux    oesophagitis,

    carcinoma)

 

  * The  other  complaints  in disorders of  the  oesophagus  are

    related to the under nutrition as a result of the dysphagia.

 

  * The retained contents of the oesophagus can also be aspirated

    into  the  lungs  resulting  in  infection  and   respiratory

    insufficney.

 

2.2.1 CORROSIVE STRICTURES

These are caused by alkalies (sodium hydroxide, sodium carbonate)

and acids (hydrochloric, nitric, sulphuric) they are used in  the

households for cleaning purposes and may be accidently  ingested.

   - In  these  cases strictures may form at any  site  from  the

     oropharynx  to  the  small intestines  in  addition  to  the

     oesophagus.

 

   - It  is  important  that the chemical be  identified  by  the

     history,  examination of the container or from  analysis  of

     the contents of the container.

 

  * Neutralisation  can only be possible if the patient  is  seen

    within the hour after ingestion.

  * Inducing vomitting or gastric lavage are contraindicated.

  * If the patient has stridor, hoarseness dyspnoea or shows sign

    of  burns  in  the mouth and pharynx the  patient  should  be

    admitted.

  * To prevent excessive inflammation and oedema treatment should

    be started with antibiotics and steroids.

  * In  cases of increasing  respiratory  difficulty,tracheostomy

    may be required.

  * X-ray of the chest and abdomen should be studied for evidence

    of  perforation into the mediastinum and into the  peritoneal

    cavity (air leak)

On diagnosis of burns further treatment consists of :

  * Medical treatment with antibiotics and steroids (3 weeks)  to

    minimise fibrous tissue laying down and

    Dilation and splinting of the burn segment so as to  maintain

    the lumen of the oesophagus

In cases where inspite of above regime strictures form.

  * Gastrostomy may be required to maintain nutrition.

  * This is followed by dilatation using direct visualisation  of

    the  stricture  through an  oesophaguscope  or  alternatively

    retrograde dilatation through a gastrostomy.

  * Savary-Gilliard bougies are another dafe method.  A guide wire

    is  introduced through the instrument channel of  a  flexible

    esaphagoscope.  The scope is then removed and savary dilaters

    threaded over the guide wire.

 *  In   some   cases   of   extensive   persistent   strictures,

    reconstrcution  of  oesophagus by  interposition  of  colonic

    segment may be required.

 

 

Operative intervention is indicated when

-         there is complete stenosis in which all attempts at dilatation have failed

-         severe periesophageal reaction or mediastinitis develops with dilation

-         a fistula forms

-         the patient is unable to undergo repeated dilation for a prolonged period of time

 

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