1. Who can be defeated medicinal esophagus?
People of all ages receiving chemically aggressive (annoying) drugs. We describe the cases of medicinal lesions in patients aged 5 to 89 years. The ratio of morbidity of women and men in this is 1,5:1. Often swallowed pills adhesive to normal mucous esophagus. In one study shows that 36 of the 49 healthy volunteers who zapivali nekleykie barievye tablets round 15 ml of water, then took a horizontal position, pills detained in the digestive cavity at 5-45 min. More adhesive gels capsule remained in the cavity of the esophagus more than 10 minutes for more than 50% of healthy volunteers who took capsules in a horizontal position. Clear connection between medicines damage to the esophagus and violations of his physical activity or organic diseases (ring and esophageal stricture) is not detected.
2. What factors contribute to delays in the clearance of drugs esophagus?
Clearance (speed purification) esophagus is determined by several factors, some of them may be influenced to reduce the risk of drug damaged esophagus. The vertical position of the patient contributes easier evacuation drugs from the esophagus. The volume of water taken in conjunction with the pill, also affects the esophagus clearance, although exact figures as to which liquid is needed to ensure the passage of the digestive tablets, no. In one study reported that 11 of 18 patients had a delay in the esophagus barium zapivanii their capsules with 15 ml water and 3 of the 18 patients - when they zapivanii 120 ml of water. Other factors that influence the passage of the digestive tablets are anatomical anomalies esophagus, such as rings (hauling), and stricture; in patients with this pathology, if necessary, running esophageal dilatation. Violations of physical activity esophagus somewhat tailored pharmaceuticals, but the medication in patients with esophageal lesion its motor activity in the normal manometry no different from any normal. Zapivanie pills (pills) insufficient and the adoption of a horizontal fluid situation immediately after taking the drug - the only clearly identifiable risk factor for the majority of patients with esophageal lesion medication.
3. List the risk factors for the emergence of drug esophageal lesions.
Risk Development heavy dosage of esophageal lesions is particularly high in patients with structural anomalies (anatomical) esophagus - as a pathological (stricture, tumor, rings), and physiological (hernia aperture diaphragm dysfunction; narrowing of the esophagus that occurs as a result of a second brain of his leftist predserdiem, arch aorta and the left essentially bronhom). Heart Disease Risk Factors belong to the development of medicinal esophageal lesions, due to the possibility of expanded compression esophagus predserdiem leftist and frequent application of chemically aggressive drugs (aspirin, potassium chloride, quinidine). In patients underwent torakotomiyu, the risk of esophageal lesions drug also increased. This is due to the fact that they are in a long time supine position while welding can be shaped to keep the esophagus between aorta and the spine, which increases the likelihood of its enlarged brain leftist predserdiem and thus worsens clearance (clearance) esophagus. Patients who immediately after taking the drugs taken horizontally, also violated esophageal clearance and increases the risk of drug failures. Adhesive surface capsules (pills, tablets), some irritant effect of the drug ingredients and the amount of liquid quantity simultaneously determine the risk of developing esophageal lesions drug. U older patients and patients with diarrhoeal pischevodnym reflux drug risk of esophageal lesions increases. When diarrhoeal pischevodnom Wednesday reflux in the esophagus becomes more acidic. It is known that many drugs, including non-steroid anti-vehicle (CNS), are weak acids, so their tissues absorption increases in acid solution.
4. What are the typical clinical manifestations of drug esophageal lesions?
In typical cases of drug esophageal lesions in patients who do not have any indication of esophageal diseases in history, suddenly appears zagrudinnaya pain from which they could wake up (especially if the medication was zapito little water and lying in regulation), it is possible more strengthening in swallowing . Pain intensity can be varied - from minor to express when swallowing impossible. In typical cases, the intensity of pain during the 3-4 days growing, and then gradually decreases. Bezbolevaya rare dysphagia (20% of cases), while in patients possible presence of other diseases. Less frequent clinical evidence of drug esophageal lesions are dehydration, reduction of body weight, fever and vomiting blood. In patients with existing esophageal diseases such as diarrhoeal esophageal reflux, often there is a growing heartburn, regurgitation, and dysphagia.
5. How can diagnose esophageal lesions drug?
The presence of drug in patients esophageal lesions can be marked by history features only in the case where a typical clinical symptoms appear suddenly, shortly after taking the drug, capable of causing damage to the esophagus. In typical, uncomplicated cases, there is no need for invasive diagnostic tests - a diagnosis based on the medical history and objective survey. Implementation of the additional diagnostic procedures should be expressed with clinical symptoms that persist for 3-4 days, with atypical symptoms or suspected development of complications (strictures, bleeding), and if history on the basis of data suggesting that there may be another disease (foreign body obstruction of the esophagus , infection in patients with esophagitis violations immune status). Endoscopic study upper esophagus is the most sensitive method, with the changes found almost all patients with esophageal lesion medication. In addition, this method enables to study the differential diagnosis of esophageal lesions drug with other diseases such as diarrhoeal esophageal reflux, esophagitis infection or malignant esophageal neoplasms.
6. What is a typical endoscopic picture medicinal esophageal lesions?
Typical medicinal esophageal lesions represent one or more lesions located separately surrounded intact mucous membrane. Size varies from ulcers pin head, a circular before, the entire circumference exciting esophagus; their length is sometimes a centimetre. Peptic ulcers can be surrounded by inflammatory roller. In craters ulcers often found particles pills (pills).
7. List potential complications of drug esophageal lesions.
In typical cases, ulcers affect only esophageal mucosa, but sometimes found deeper lesions. Profuse bleeding arise from the erosion of blood vessels. We describe the cases of penetration in the right predserdie ulcers and orgānu. Deep circular ulcers can lead to a circular pathological esophageal strictures. There are reports that this complication has less than 10% of the total. It may actually develop esophageal stricture even rarer, as described in the literature mostly heavy or atypical cases.
8. What medications are more likely to produce medicinal defeat esophagus?
In most cases (more than 50%), medicinal tablets cause esophageal lesion forms of antibiotics, due to the frequent their appointment and chemically aggressive nature of the drugs. The results of one study, doxycycline and tetracycline drug had caused the defeat of the esophagus 293 from 454 patients. Despite this, antibiotics are rarely causes complications in the defeat of the esophagus. Patients with esophageal lesions caused by the action of antibiotics, there is almost always acute intense pain and localized pitting circular mucosa. Believed that ulcers can appear even when a single reception of the drug.
Cardiovascular means, including hypotensive and Antirheumtics prepataty represent a large group of chemically aggressive drugs. We describe 13 cases of drug esophageal lesions associated with hosting hinidina; in 7 of 13 patients subsequently developed esophageal stricture, which quinidine regarded as the most dangerous drug. The feature hinidinovogo defeat of the esophagus is a tendency to produce abundant, thick, gagging secret (cumulative uneven in length esophagus) that when rentgenokontrastnoy abnormalities seen as a filling defect and is often regarded as esophageal cancer.
Antiinflammatory drugs relatively rare cause for the development of drug esophageal lesions. In recent studies only documented case of 71 medicinal drugs damage the esophagus of the group. Partly because of their widespread use of allocated 22 different anti-drug cause damage to the esophagus, but more than 45% of cases of esophageal lesions associated with the use of aspirin, and dolerona indometacin. Distinctive features of lesions caused by drugs, no.
On frequency of esophageal lesions and the unusual arrangement damage allocated antiholinergichesky drug emeproniya bromide (which does not apply in the United States). Recent studies show that the percentage of esophageal lesions emeprony indicator stands in second place after doxycycline. Emeprony often appointed irritated with urinary bladder to reduce the frequency of urination, it must be taken at night, a little water melon. Hydrophilic substances that make up the pills lead to a rapid dissolving it in water. If the tablet does not zapivaetsya sufficient quantity of the liquid, it sticks to the damp mucous esophagus, causing drying and damage the latter. Moreover, in connection with antiholinergicheskim effect, which includes reducing the amplitude of muscle cuts and the allocation of saliva esophagus, esophageal clearance is reduced, resulting in a delay in the clearance of its drugs.
9. What other mechanisms exist development of drug damage the esophagus?
Experiments on animals have shown that direct contact with certain medications mucous membrane of the esophagus causes pitting. Similar results were obtained with and ezofagogastroduodenoskopicheskom study (EGDS) in humans, with esophageal ulcers found containing particles of the drug (or located around the site of localization medicinal particles). The researchers argue that ulcers are formed only under the influence of drugs with high chemical activity. Tablets forms of drugs (such as doxycycline, tetracycline, ascorbic acid, iron sulfate) can cause local acid burns when dissolution data drugs in 10 ml of water is formed from acid pH <3. Phenytoin, dissolved in 10 mL of saliva, increases to 10.4 pH, which could lead to the development of alkaline burns. Other possible mechanisms of mucosal damage to the esophagus include induction diarrhoeal esophageal reflux (theophylline and antiholinergicheskie drugs) and the development of local giperosmolyarnosti, which causes drying of tissue and vascular damage (potassium chloride). Finally, some medical drugs locally absorbed by mucous membrane esophagus, which leads to their accumulation in vnutrislizistomu toxic concentrations (doxycycline, non-steroid anti-money alprenolol).
10. What is the mechanism for esophageal mucosa damage to non-steroid antiinflammatory drugs?
Non-steroid anti means taking a daily 30 million people, approximately 16% of them develop side effects from the gastrointestinal tract. The most frequently noted defeat stomach, although the cases described and damage the esophagus. In one study, all patients with lesions of the esophagus caused by the action of non-steroid anti-drugs, with 24 - hour monitorirovanii pH was detected diarrhoeal esophageal reflux. When combined diarrhoeal esophageal reflux and pH <4 non-steroid anti-drugs can infiltrate the esophageal mucosa and have a direct toxic effects. Non-steroid anti means causing damage, inhibition of prostaglandin synthesis mucous esophagus. It is known that prostaglandins have tsitoprotektivnoe effect on the gastric mucosa, but it was not clear if the same effect with respect to the esophagus. Protective role of bicarbonate and mucus layer in the esophagus is also not clear. However, given the data on the harmful effects of non-steroid anti-drugs slimy barrier to stomach arising in response to the inhibition of prostaglandin synthesis, it can be assumed the existence of a similar mechanism in the esophagus. Finally, nesteroid anti-governmental funds adversely affects the function of pressure and the lower esophageal sphincter, increasing thus diarrhoeal esophageal reflux and increasing the likelihood of drug absorption and accumulation of mucous in the esophagus.
11. What localization physiological narrowing of the esophagus?
In normal esophagus, there are sites (usually small), where the external compression esophagus. In these places, as well as in the sphincter, clearance narrowed the esophagus, so there often delayed preparations tablets, resulting in damage to mucous membranes. External pressure on the esophagus can have a bone Eimeria spine, become more pronounced with age, as well as with degenerative diseases. Duga aorta and the left main bronchi also can cause compression esophagus. The size of the left ventricle vary depending on the cardiac expression, it can also tightened esophagus. Compressions, in the latter case is especially dangerous, because the drugs prescribed for diseases of heart, accompanied by an increase in the left ventricle, including potassium chloride, in conjunction with diuretics and quinidine (at fibrillation), which have expressed chemical aggressiveness.
Localisation physiological narrowing of the esophagus
12. Does alcohol plays a role in the development of esophageal lesions medicinal?
Alcohol increases the effect of chemically aggressive preparations causing damage to the esophagus. According to the study, in which healthy volunteers within 2 weeks of taking aspirin with EGDS they did not reveal any damage esophageal mucosa. When combined admission single-dose aspirin with alcohol 33% of the volunteers have flushing and / or mucous hemorrhage in the esophagus. Alcohol has a damaging effect on the esophagus by violating clearance, increasing, thus, the time of contact with the mucous membrane of aspirin. It is believed that alcohol reduces the primary and secondary reduce the esophagus.
13. What methods for the treatment of esophageal lesions medicinal?
In most cases, damage to the esophagus medicines do not require active intervention and Heal in the schedule of 3 days to a few weeks. Drug treatment of esophageal lesions starts with the lifting of the drug, causing damage to mucous membranes, it is also desirable to refrain from accepting other chemically corrosive substances. If you do not lifting drugs every effort should be directed at preventing the development of re-injury. To use this elixir and other liquid dosage forms, take drugs upright, their melon at least 4 ounces of liquid. Vertical position retain at least 10 minutes after taking the drug.
Frequently used tools linking acid (buffer solutions) that reduce their products and create a safety barrier on the mucous (ante-tsidnye drugs, H2-receptor blockers histamine, sukralfat), but their effectiveness remains doubtful, in all cases, except for their impact on the undoubted expressivity diarrhoeal symptoms of reflux esophagitis. Admission anes-tetikov local actions in various combinations (bemilid-Benadryl, milantai lidocaine in equal doses) reduces symptoms of esophageal lesions, but their use is limited due potential for development of systemic toxic effects.
Some patients symptoms of esophageal lesions expressed so much that they could not take food or drink sufficient liquids. If these symptoms persist a long time, there is a need for parenteral nutrition or analgesia. Other disorders may require activities in the treatment of various complications (for example, the introduction of blood products with bleedings and antibiotics in the development of bacterial superinfection).
Acute inflammation esophageal stenosis can be regressing spontaneously, but it is possible strictures chronic execution repeated esophageal dilatation. When shown the ineffectiveness of repeated dilatation surgery, but such cases were very rare.
14. What epidemiology chemical damage the esophagus in the United States?
Chemical damage to the esophagus remains an important issue, despite the creation of ever more sophisticated packaging containers (such as containers to the protection of children), and plates to the name of the drug and precautionary measures. Every year there is almost 26000 new cases of chemical damage to the esophagus. Adolescents and adults with suicide attempts are caustic substances in large quantities, so they develop more severe lesions than in children who take irritating substances casually and often handle their spit, not swallowing. The children often identified minimal damage to the esophagus, while the defeat of the mouth, pharynx and larynx are much heavier. Nearly 80% of lesions of the esophagus chemical linked with a casual reception noxious substances (for a house cleaning) in children younger than 5 years.
15. Think of chemicals, most often causing damage to the esophagus. Where are they found?
Aggressive (caustic) of a substance found in many of chemical agents used in the home. The severity of damage is determined mainly by aggressiveness and the concentration of substances taken. Chemically aggressive substances, causing heavy damage to the esophagus, are concentrated alkaline detergent and liquid soap. Heavy alkaline burns arose when promatyvanii diskovidnyh batteries containing concentrated sodium chloride or potassium. Concentrated acid also can damage the esophagus, but because they are rarely used in the home, they practically do not take into account. The severity of lesions of the esophagus and stomach, developing after taking caustic substances depends not only on the degree of their aggressive actions and concentration, but also on the number taken.
16. Alkali (sodium hydroxide) was the most frequently taken inside the caustic chemical. It changed its formulations containing the last 30 years? How these changes affected the harmful effects?
Prior to 1960, household goods or crystalline solid containing sodium concentrations of> 50%. They have expressed the corrosive effect and caused extensive damage on contact with mucous membrane. However, the emergence of instant pain in burn oral mucosa prompted the victim immediately spit corrosive substance, and the damage is usually limited to oral cavity, pharynx and esophagus, almost without affecting the stomach. Frequent complications with a perforation of the esophagus and copper-astinit (although their rate of occurrence of different sources vary). Based on this information, it could be argued that damage to the esophagus and stomach alkali comparable to that from the effects of acids.
Contents chemically corrosive chemical substances in household sredstvahKLASS CHEMICALS CHEMICALLY AGRESSIVNOE SUBSTANCE TOOL OF HOUSEHOLD CHEMISTRY
Strong alkali Ammonia Soda (gidorhlorid sodium, potassium hydrochloride) Tablets cleaners Klinitest Diskovidnye batteries Funds for prochischeniya pipes Nefosfatnye detergent (washing powder) solvents for paints Washing powder
Strong acid Hydrochloric acid
Nitric acid Oxalic acid Phosphoric acid Sulfuric acid Hydrochloric acid Payalnaya Means acid washing tubs and pools funds for cleaning toilets Funds for cleaning weapons Antikorrozionnye means Funds for cleaning toilets in acid batteries Funds for cleaning toilets
Other Gidrohlorid Liquid sodium bleachers
This approval does not apply to liquid means of containing high concentrations of sodium, which suppressed easier and faster than substance containing crystalline alkali. At the end of 1960 - ies. They were represented by the means for cleaning pipes with alkali concentrations of 25-30%, okazyvavshimi devastating effect. Complications with the ingestion of such solutions included the defeat of the respiratory organs, the esophagus and stomach perforation, septitsemiyu and death. U survivors often develop late complications in the form of esophageal strictures. By mid-1970 - ies. liquid funds in the United States with a high concentration of alkali has been replaced by a means for prochischeniya pipes with its lower concentrations (<10%). If swallowed, these substances in sufficient quantity is the development of heavy damage the esophagus and stomach, including perforation. More often, however, swallowed a small amount of the compound, and the patients underwent acute damage to the esophagus, recovering. Nevertheless, in distant time frame they can emerge esophageal strictures. Caustic materials used in industry, the difference between the higher concentrations than used in the home. Especially detergents containing acid or alkali in high concentrations, accidentally fall into the hands of children playing on farms, construction sites and in the pools.
17. Describe the pathogenesis of acute alkali esophagitis.
When contacted tissue with strong alkalis immediately arises kollikvatsionny necrosis complete destruction of all cells and their membranes. Cell membranes are destroyed as the saponification of their denaturirovaniya cellular lipids and proteins. Local thrombosis of blood vessels also cause damage to tissues. Destruction of tissues and organs of the destruction of the wall of a rapidly progressive, until the alkali is not divorced and rarely tissue fluids. When contact with strong alkalis growing rapidly transmural necrosis bodies. In an experimental exposure in the esophagus Cats 5 ml 30.2% solution of sodium hydroxide for 3 with developed esophageal perforation and death. Chemical damage to the esophagus damage divided into first, second and third degrees of severity (by analogy with those with skin burns). The table below degree chemical burns correlated with endoscopic and pathological changes. With endoscopic study conducted during the first 24 h after burns, it is possible to overlook the severity of damage to the esophagus.
DEGREE OF CHANGES ENDOSKOPICHESKIE MORPHOLOGICAL CHANGES
The first Flushing mucosal edema and exclusion of the surface layer of abrasion -
Second ulcer covered with fluid Dissemination of anthrax in the mucosa, and the muscular layers podslizity
Third Deep black ulcer penetration Transmuralnoe damage, damage to organs or abdominal mediastinum
18. List the three phases of damage and recovery in esophageal lesions caused by the admission of alkali.
In the experiment damage to the esophagus caused by the admission of alkali can be divided natri stages: acute, or kollikvatsionnaya (about 1-4 hours), podostraya or reparativnaya, and the formation of the scar, or the healing phase. Acute phase characterized by the development of necrosis kollikvatsionnogo, vascular thrombosis and progressive inflammation. There were expressed by hyperemia and edema mucosa, but even with heavy strup tissue lesions and ulcers in the first 24 hours does not always occur. Subacute phase, characterized by a rejection of tissues and education strupa necrosis at the site and the availability of developing ulcers formed granulation tissue. There fibroblasts. Pick collagen synthesis is in the second week and could last several months. It starts reepitelizatsiya esophageal wall which in this period is very thin and most vulnerable. Phase healing, which comes at the end of the second week after the burns are characterized by the continued proliferation of fibroblasts and the further accumulation of collagen. Earlier reduced collagen formed in a circular and longitudinal direction, resulting in a shortening of the esophagus and the formation of strictures. Reepitelizatsiya completed within 1-3 months after injury. The table below shows the development phase of the esophagus damage caused by the admission of soda. The development of pathological processes, and if swallowed healing fluids containing sodium defined range of events, which do not always occur in the above periods.
Phase Development alkali damage pischevodaFAZY PATOMORFOLOGICHESKIE TIME CHANGES COMMENTS
Acute from 1 to 4 day Kollikvatsionny necrosis
Vascular thrombosis Progressive Ottorzhenie tissue inflammation and mucosal pitting detected no earlier than 24 hours
Podostraya from 5 to 14 day strupa Education Development granulation tissue emergence fibroblast collagen deposition Istonchenie walls of the esophagus
Phase healing from 15 days to 3 months Proliferation fibroblast collagen deposition Further Reepitelizatsiya within 1-3 months stricture formation
19. What is the difference between defeat of the esophagus caused by acids and alkalis?
Concentrated solutions of acids in contact with mucous membrane, oropharynx trigger more intense pain than alkali solutions. Therefore, the solution of alkali patients often manage to swallow even before srabotayut protective mechanisms to limit the flow of the esophagus and stomach acid accidentally empty. In the past decade, there were often cases of severe stomach acid defeat, while alkali affected mainly the esophagus. This observation is more related to the fact that the crystalline solid or alkali suppressed, usually in small numbers, and do not reach the stomach in an amount sufficient to cause heavy damage. Highly liquid alkaline solutions produced in 1970 - ies. Possess the ability to cause profound damage to the walls of the esophagus, and stomach. Currently, funds are issued containing acid and alkali in varying concentrations, which are less likely to lead to perforation of organs, but more often - to the formation of obstructions.
In histological study of tissues, exposure to the acid, detected koagulyatsionny necrosis with aggregation of cells and decreased their cytoplasm. The boundaries are usually distinguishable cells, in contrast to their complete destruction when kollikva-tion necrosis arising under the influence of alkali. Forming a dense strupa necrosis occurs when koagulyatsionnom partly by the spread of the connective tissue, vascular thrombosis and blood protein aggregation. Coagulation limits the penetration depth of acid. However described cases of esophageal perforation and with the acidic burn.
20. Do early to predict the severity of clinical symptoms and the incidence of esophageal lesions?
In the examination of patients with esophageal chemical burns clinicians must keep in mind that the early clinical manifestations can not be considered accurate indicators of the gravity of chemical damage. When contact chemically corrosive substances (acids and alkalis crystalline) with mucous membrane oropharynx pain often occurs immediately, resulting in the deletion of caustic substances from the oral cavity before swallowing. Therefore, in patients who have taken such substances can be detected symptoms defeat oropharynx without signs of damage to the esophagus. On the contrary, incompatible with the life of esophageal burns sometimes combined with minimal signs of damage to mucosal oropharynx. Thus, the symptoms of defeat oropharynx are not credible signs of the gravity of the esophagus and gastric lesions. The prevalence and severity of lesions caused by the acids and alkalis, it is equally depends on the chemical characteristics (solid or liquid, fly or not, what titer acid or alkali) and proglochennogo of volume and duration of contact with the mucous membrane substances.
21. Describe the typical clinical picture of chemical damage to the esophagus.
The typical clinical picture uncomplicated chemical burns the esophagus characterized by three phases, so similar in experimental chemical damage: acute, latent and reparativnaya. Accompanying the acute phase of the emergence of instant burning pain in the mouth often limits the proglatyvaemogo chemical means. Chemical burns nadgortannika larynx and frequently lead to the emergence of an immediate or deferred breathlessness, cough, stridora, ohriplosti vote pectoris or apnea. Pectoris can also result from aggressive aspiration of the substance, which develops bronchial tree damage and lung parenchyma. If swallowed considerable amount of a chemical containing sodium, in the chest pain, dysphagia, or equal-fagiya appear after a few minutes. Perhaps violation of saliva secretion (uncontrolled excessive salivation) in damage and swelling of the posterior pharyngeal wall. Also, are the urge to vomiting and vomiting, laxatives in the masses is not possible presence of blood or tissue particles. The pain and dysphagia that when uncomplicated esophageal lesions are mainly related to violations of their physical activity and edema, sometimes persist for 3-4 days.
Patients with complications during chemical burns the esophagus may be additional burdensome symptoms and clinical course. Standing zagrudinnaya pain or back pain often point to a third-degree burns to the esophagus involvement in the pathologic process mediastinum. Perforation stomach or esophagus can lead to peritonitis with the emergence of strain muscles of the abdominal wall and symptoms of irritation ventral. Perforation occurs mostly in the first few days, and is characterized by the increasing pain, fever and the development of shock.
22. Think of the most characteristic features of the clinical course of severe alkaline burns.
The initial pain and dysphagia reduced in a few days, signalling a latent phase of the beginning. And when a doctor and patient is often misled, and are false calm. During the third phase of chemical burns retraction occurs (provision) scars. The third phase begins at the end of the second week after burns and lasts several months. Clinically diagnosed stricture developed from 10-30% of patients with chemical burns the esophagus. 80% strictures manifested through 2-8 weeks, but sometimes clinical signs of Education esophageal strictures observed in patients after many months after the injury. Very often arose early esophageal stricture growing progressively, accompanied by first light disfa-tasting, and then complete inability to swallow saliva, all of this is happening in the next few days. So patients need to be quick diagnosis and treatment to prevent the formation of dense, thick, suzhivayuschih clearance esophageal scarring. The method of choice in this situation is cautious buzhirovanie esophagus, which allows him to restore throughput.
23. What mortality in the chemical damage the esophagus?
Over the past 30 years mortality in the chemical esophageal lesions significantly decreased (from 20 to 1-3%). Perhaps this is due to the emergence of more effective treatments (antibiotic, transmission and zondovoe food), modern advances in surgery, anesthesiology and intensive care, as well as less acids and alkalis in the household chemicals, compared with such substances, published in 1950-ies. and earlier.
24. What is the risk of neoplastic in patients with esophageal strictures, formed after alkaline burns?
There is a close link between cancer and chemical damage to the esophagus.
In patients with chemical burns esophageal cancer develops more frequently than in the rest of the population. Approximately 1-7% of patients with esophageal tumor in history, there are indications moved chemical burns the esophagus. Very long latent period, according to one study, it is an average of 41 years. There are currently no skrinigovyh survey methods recommended for use in patients, endured alkaline burn the esophagus.
25. Think urgent actions to be carried out with chemical burns the esophagus.
Initial activities used in patients with an alleged chemical damage to the esophagus are similar with those in the interior of any ingested toxic substances. In the first place need to cross the respiratory tract, adequate breathing and blood circulation. Patients with esophageal chemical burns respiratory distress may require tracheal intubation with a view to restoring patency of the respiratory tract and provide adequate tissue oxygenation. Intubation conducted under visual control, rather than blindly. Further, if there is a need for the development of hypotension infuzionnuyu adequate therapy and, if necessary, carry out resuscitation event. If there are clear signs of peritonitis mediastinita or in the case of alleged esophageal or gastric perforation patient in need of urgent surgical treatment.
When respiration and circulation rates have stabilized, and the patient’s condition does not cause fear, should determine the number and type of alcohol distilled chemical time of his admission, as well as find out whether the simultaneous reception of multiple substances (often with suicidal attempts). Worth to take a sample of chemical irritant in the test tube and to establish its composition and concentration of active substances. If the physician is unfamiliar with the treatment interventions with alcohol poisoning or a combination of means unknown, it is advisable to contact the Centre for the treatment of poisoning. It can not be artificially induce vomiting, because resumed contact with the esophageal mucosa and possibly larynx with caustic substances. If swallowed, crystalline substance, several gulps of water allow it to remove particles from the surface of esophageal mucosa and dissolve them in a large volume of water in tolstostennom stomach. But, of course, this manipulation is contraindicated in patients with a high risk of aspiration or clinical evidence of perforation.
At the time of the treatment to a doctor to reduce internal burns, as a rule, has not been able to. In connection with the rapid Action neutralizing alkali attempts do not result in limiting the incidence of injury. Moreover, such attempts are even dangerous. When neutralizing alkali allocated significant amounts of heat and there is additional damage to the thermal wall body. The introduction of any substance through the mouth also increases the risk of vomiting and aspiration. In acidic damage to the reception of milk or water in large quantities for a few minutes after poisoning allows divorced and neutralize acid.
26. Would it be useful to carry out washing the stomach in patients who have taken corrosive chemical?
On this issue there is no single answer. It also is an effective washing stomach, predprinimaemogo immediately after taking the chemical means, when a large number of his remains in the stomach. Moreover, in patients who have taken large quantities of drugs, the improvement due to the fact that the stomach washing reduces their absorption. The benefits of washing the stomach, usually outweighs the risk vozniknovniya complications in the procedure. Introduction nazogastralnogo probe may cause nausea and vomiting, leading to the re-contact with the esophagus and oropharynx caustic substances. During the introduction, there is a risk of perforation probe esophageal or gastric wall, so there is a good reason for the application of X-ray control. When the probe is installed, prior to the washing should aspirirovat gastric stomach contents. Stomach advised to wash in cold water to neutralize the heat escaping.
27. What is the role of endoscopic studies in patients with chemical burns the esophagus?
Endoscopic study of upper gastrointestinal flexible endoscope is playing an important role in diagnosing and treating patients with chemical burns early, urgency, and later, subacute, periods. Patients with esophageal perforation (diagnosed and radiographic and clinical) requires surgical intervention, which is preceded by liver disease, to determine the prevalence of defeat. For example, in patients with intact esophagus can be damaged stomach, hence the volume of transactions will limit the abdominal cavity. Although ezofagogast-roduodenoskopii and risky, but it helps determine the volume of surgical intervention.
If such was not shown, endoscopic study carried out in order to identify, not whether a long-patient surveillance, and to determine the degree burns. The timing of endoscopy depends on the severity of esophageal lesions. In the absence of clear signs of its damage EGDS runs in the earlier possible for quick diagnosis, which allows the patient to avoid a long stay in hospital. More than 50% of patients with a history of indications transferred chemical damage the esophagus, while endoscopic examination revealed no changes. If there is suspicion of damage to the stomach or esophageal perforation and the absence of symptoms EGDS execution should be postponed until the development of inflammatory changes, ie up to 48-72 h (slight inflammation already appearing for the first night) that accurately determine the prevalence of defeat. With the help of endoscopic studies able to identify damaged mucosa, but it does not allow to establish the depth of defeat. Endoscopic classification of damage done on the three criteria (see Table.). They determine the period of stay of patients in hospital and the risk of esophageal strictures.
Endoscopic chemical classification povrezhdeniyENDOSKOPIChESKIE CHANGES DATE OF RISK OF CREATING GOSPITALIZITSII STRIKTUR
Hospitalization is not required Missing
No injuries Monitoring 24-48 h Missing
Your stomach just Linear longitudinal Monitoring 24-48 h Low
Circular damage to the esophagus Monitoring at least within 48 hours High
28. What is the role of hormone therapy kortikosteroidnymi or antibiotics in the treatment of chemical damage the esophagus?
In patients with confirmed Endoscopic polutsirkulyarnymi circular burns the esophagus or a high risk of developing obstructions. Since 1950 - ies. corporate tikosteroidnye hormones used as a means of prevention education scars. The feasibility of their application based on the results of studies carried out on animals, which show that started no later than 24 hours after an alkaline burns 6-8 - kortikosteroidnaya weekly therapy reduces the frequency of development of strictures by braking education granulation tissue. However, the period of observation in the experiment was short of the same animals more often died of septicaemia. Prospective, randomized, controlled study of children with chemical burns the esophagus spent Anderson (Anderson) in 1990, revealed that the use of corticosteroid hormone does not reduce the frequency of Education strictures. Single views on this matter has not yet exist. Appointment of steroid hormones appear only patients with circular burns esophagus, in which the risk of the greatest obstructions. Dose and duration of drug therapy is not clearly defined. Recommended admission in a dose prednisone 1,5-2,0 mg / kg / day dose, with a gradual decline in 2 months. In patients with signs of respiratory tract lesions that have accepted large numbers of chemical etching tools kortikosteroidnymi hormone therapy helps reduce inflammatory reactions bronchial tree. Code-metazon (0,5-1,0 children in a dose mg / kg / day; adults in a dose 2,0-3,0 mg / kg / day) introduced intravenously in the case of life-threatening respiratory distress when intubation may be required trachea, or krikotirotomiya tracheotomy to restore patency of the upper respiratory tract.
Grounds for empirical antibiotic even less. Anti-biotikoterapiya was proposed, as an early experiment antibiotics reduce mortality in animals with burns esophagus, patients kortikosteroidnymi hormones. The greatest effect of the use of antibiotics against the backdrop of hormone treatment kortikosteroidnymi achieved in patients who have there is a big risk of systemic infections. The most frequently encountered with gram-positive microorganisms; described, but rather a wide range of pathogens.
29. What is the role of buzhirovaniya pischevodnyh and install stents in preventing the development of esophageal strictures?
Another complication at the end of the period of severe damage is the formation of obstructions in patients with esophageal circular mucosal lesions. In the absence of preventive treatment can be established long strictures almost obturiruyuschie clearance esophagus. Such strictures defy dilation and require surgical intervention. To avoid the formation of esophageal stricture, patients spend preventive esophageal dilatation through dilatatora Malone (Maloney), or the establishment of esophageal stent. Dilatation of the esophagus should not be held during the acute phase of injury, when the manipulation is accompanied by a high risk of perforation. Dilatation of the esophagus performed in patients with circular burns mucosa of the third week after burns, ie until the strictures and will be set up in the appropriate clinical symptoms. Dilation is a one-time introduction to the esophagus dilatatora with sufficiently large diameter (42 Fr), repeat the procedure several times a week. If the doctor feels the introduction dilatatora resistance, no need to try to overcome it by force. Instead, the appropriate recourse to the so-called progressive dilatation of therapeutic, starting with the expansion of the esophagus dilatatora smallest diameter that can easily pass through narrow place. This way you can fully restore throughput esophagus. Although esophageal dilation associated with some risk, in many cases, it prevents the development of long expressed strictures, emerging with the chemical damage the esophagus. An alternative method of prevention dilation - Questions and long observation of patients with dilatation when symptoms compatible with a narrow esophagus. Unfortunately, many patients with chemical burns the esophagus is too young and not inclined to cooperate with the doctor, so they have to apply this method is not always possible. The feasibility of the installation of preventive purpose pischevodnyh stents to restore patency of the esophagus mixed; this intervention is carried out in the centres where there are experienced in this field are professionals and research. Stents are conducted through the endoscope or during operations and retained in the esophagus for about 3 weeks. There is a theory that the stent promotes healing of the esophagus without education and stenosing gross scarring. After 3 weeks stents removed. Stents very inconvenient, their installation and disposal associated with certain risks. Randomized studies to assess the effectiveness of stents pischevodnyh exists, but there is information that the majority of patients in the future, there is a need in the discharge of esophageal dilatation.
30. Give a brief evaluation and give the disputed facts concerning the various methods of treatment of patients with chemical burns the esophagus.
Currently, there are various invasive and noninvasive methods for the treatment of esophageal chemical damage. Fortunately, the number of serious chemical burns the esophagus is gradually decreasing. In view of the limited experience and ethical problems that arise in the experimental treatments on people, only a few carefully audited data can be used by doctors as clinical guidelines. Therapeutic intervention without informing the patient also has its negative, in terms of ethics, the nuances.
Introduction nazogastralnogo probe (NGZ) has several positive features. Nazogastralny probe set to ensure adequate power supply and the introduction of drugs. Nazogastralny probe also provides a sort of “vacation” esophagus and prevents it traumatization in passing edible stomach. Finally, Nazogastralny probe can be used as a subsidiary method with esophageal dilatation. Disadvantages of this technique are that the probe can cause irritation and inflammation of a long wall of recovering the esophagus, which leads to increased fibrosis processes and education obstructions. Ultimately, input under X-ray control of a flexible probe Nazogastralny should keep no more than 2 weeks from heavy patients in need of adequate nutrition.
Full transmission food (PPP) is used to ensure complete rest and nutrition esophagus during healing. Reasonable evidence of the feasibility of a PPP in all patients with chemical burns the esophagus does not exist. Candidates for such treatment are patients with a high risk of aspiration, as well as those who are contraindicated installation nazogastralnogo probe in connection with pronounced esophageal lesions. It is believed that antibiotics reduce the risk of developing esophageal strictures late, but to reproduce this effect in animal studies and in humans failed. The use of antibiotics may be appropriate to reduce septicaemia in patients with a high risk of infection on the background of steroid hormone treatment. The advantage of the empirical treatment to the dynamic observation of the patients, and the appointment of broad-spectrum antibiotics for as long as there is not shown signs of infection. In the case of empirical antibiotic selection, it should be changed if after 5-7 days of no clinical signs of improvement.
The effectiveness of empirical kortikosteroidnymi hormone therapy, but raises some questions proved in the experiment. In animal studies, it was repeatedly shown that the frequency of formation of early esophageal strictures reduced if hormone therapy kortikosteroidnymi begin within 48 hours and continue 4-7 days after swallowing chemical irritant. Based on the results of experiments on animals and uncontrolled studies of people it can be concluded that hormone therapy kortikosteroidnymi shows patients with circular burns esophagus, which is very high risk of stricture. Disadvantages kortikosteroidnymi hormone treatment is that when their appointment increases the risk of infection and the emergence of systemic side effects, which should also be kept in mind. In addition, the results of a controlled study, kortikos-teroidnye hormones do not reduce the frequency of formation posleozhogovyh strictures in children. The study, however, there are very few patients. Nevertheless, despite the fact that corticosteroids reduce the frequency of hormones is not creating obstructions, the percentage of patients who require compliance depressed, was smaller in the group, received corticosteroids hormones (4% compared with 7% in the group of untreated patients).
And finally, the last question - about the time and duration of the prevention of esophageal dilatation. Most doctors agree that esophageal dilatation is the main way to prevent obstructions education. Others argue that repeated trauma esophageal mucosa causing fibrosis and strengthening processes contribute to the formation of obstructions. No need for preventive dilation all patients with chemical burns the esophagus, because this procedure is potentially dangerous. However, the issue is still controversial. Strictures are rarely less than two weeks after the injury, so it is prudent to start buzhirovanie esophagus 10-14