Chemical burn of the esophagus: treatment

Treatment of chemical burns of the esophagus. The tactics of treatment are determined by the stage of the lesion, its clinical form, the time of first aid, or the arrival of the injured person to the emergency room or the hospital that has passed since the poisoning, the amount, concentration and type of caustic liquid (acid, alkali, etc.).

According to the terms of medical care, the treatment of chemical burns of the esophagus is divided into the acute stage (between the 1 st and 10 th day after the burn), early in the subacute stage or before the stage of stricture formation (10-20 days) and later with chronic post-burn esophagitis (after 30 days).

Emergency treatment is divided into local and general, includes the appointment of analgesics and antihistamines in the form of injections and antidotes in the form of neutralizing corrosives of liquids: for poisoning with alkali, give weak solutions of acids (acetic, lemon, tartaric), beaten egg white; when poisoning with acids - magnesium oxide, chalk, baking soda solution (1 teaspoon per 1/2 cup of warm boiled water), protein liquid - 4 whipped egg whites for 500 ml of warm boiled water, mucous decoctions. These funds are ineffective after 4 hours after poisoning, as the esophagus burns immediately; they are aimed, rather, at neutralizing and binding a poisonous liquid that has got into the stomach and possibly further into the intestine. Rinsing of the stomach with chemical burns of the esophagus is almost not recommended because of the danger of perforation of the esophagus, but if it is for one reason or another shown, for example, if there is evidence that the victim has swallowed a large amount of caustic liquid (what happens when you intentionally injure yourself) for this purpose, use a light thin probe and room temperature water in an amount that depends on the age of the victim.

For the sorption of toxic substances in the gastrointestinal tract, activated charcoal is used, which is mixed with water and in the form of gruel and per os 1 tablespoon before and after washing the stomach.

When common intoxication phenomena apply forced diuresis. The method is based on the use of osmotic diuretics (urea, mannitol) or saluretics (lasix, furosemide), contributing to a sharp increase in diuresis, due to which the excretion of toxic substances from the body is accelerated by 5-10 times. The method is indicated for most intoxications with the primary elimination of toxic substances by the kidneys. It consists of three consecutive procedures: water load, intravenous diuretic and replacement infusion of electrolyte solutions. Precompensate for hypovolemia developing during severe poisoning by intravenous drip during 1,1 / 2-2 hours of plasma-substituting solutions (polyglucin, hemodez and 5% glucose solution in a volume of 1-1.5 liters). At the same time, it is recommended to determine the concentration of a toxic substance in the blood and urine, the hematocrit (normal in men 0.40-0.48, in women - 0.36-b, 42) and conduct a continuous catheterization of the urinary bladder for hourly measurement of diuresis.

Urea in the form of a 30% solution or 15% mannitol solution is injected intravenously in 1-2 g / kg for 10-15 min, lasix (furosemide) in a dose of 80-200 mg. At the end of the introduction of the diuretic, an intravenous infusion of the electrolyte solution begins (4.5 g of potassium chloride, 6 g of sodium chloride, 10 g of glucose per 1 liter of solution). If necessary, the cycle of these measures is repeated after 4-5 hours until the toxic substance is completely removed from the blood. It should, however, be taken into account that part of the toxic substance can be deposited in the parenchymal organs, causing their dysfunction, so it is advisable to carry out appropriate treatment for the symptoms of such dysfunction. The amount of solution administered should correspond to the amount of urine released, reaching 800-1200 ml / h. In the process of forced diuresis and after its termination it is necessary to control the content of ions (potassium, sodium, calcium) in the blood, CBS and timely compensate for water-electrolyte imbalance.

In the presence of signs of traumatic (pain) shock, anti-shock treatment is prescribed (caffeine, morphine is contraindicated), arterial pressure is restored by intravenous injection of blood, plasma, glucose, blood-replacing fluids (reogluman), reoplonglyukin, polyamine.

Early treatment is carried out after a period of acute events to reduce the possibility of scar scarring of the esophagus. Treatment begins in the so-called after-burn "light" gap, when the reaction to burn and inflammation has decreased to a minimum, the body temperature has normalized, the patient's condition has improved and the phenomena of dysphagia have been minimized or disappeared altogether. Treatment consists in buzhirovanii esophagus, which is divided into early, before the formation of cicatricial stenosis, and later - after the formation of stricture.

The method of bougie is to introduce special instruments (buzhe) into some organs of the tubular form (esophagus, auditory tube, urethra, etc.) for their expansion. The use of bougie is known since ancient times. A. Gagman (1958) writes that during the excavation of Pompeii, bronze bougies were found for the urethra, very similar to the modern ones. In the old days, wax suppositories of different sizes were used for bougie. There are various methods of boiling the esophagus. Usually bougie in adults is carried out with the help of elastic bougies of cylindrical shape with a conical end or under the control of esophagoscopy or a metal bougie equipped with olive. If the early buzhirovanii on the mucosa of the esophagus is damaged, the procedure is postponed for several days. Contraindication to the buzzing of the esophagus is the presence of inflammatory processes in the oral cavity and pharynx (prevention of drift of infection into the esophagus). Before the esophagus is baked, the elastic probe is sterilized and lowered into sterile hot water (70-80 ° C) to soften it. Buzh, greased with sterile vaseline oil, is injected into the patient's esophagus on an empty stomach in a sitting position with a slightly tilted head. Before boiling the esophagus, 1 ml of 0.1% solution of atropine sulfate is injected subcutaneously for 10 minutes and intramuscularly 2-3 ml of 1% dimedrol solution, the root of the tongue and the back of the pharynx are smeared with 5% cocaine hydrochloride solution or 2% da-kain solution. We recommend that 10-15 minutes before bougie, give a patient a per os suspension of anesthesin powder in petrolatum oil at the rate of 1 g of preparation per 5 ml: in addition to the anesthetic effect, enveloping the esophageal wall with oil facilitates the progress of the bougie in the stricture area.

Early buzhirovanie begin after 5-10 days (until the 14th day) after the burn. Preliminary X-ray examination of the esophagus and stomach, which is often affected along with the esophagus. In the opinion of a number of specialists, it is expedient to bougain the esophagus even in the absence of noticeable signs of the beginning esophageal stenosis, which, as their experience shows, slows down and reduces the severity of subsequent stenosis.

Buzhirovanie begin in adults buzhami No. 24-26. Bug carefully to avoid perforation of the esophagus. If the bougie does not pass through the stricture, then a thinner bougie is used. The bougaines brought into narrowing are left in the esophagus for 15-20 minutes, and with a tendency to narrow down to 1 hour. The next day, bougie of the same diameter is injected for a short time, followed by the next number, leaving it in the esophagus for the required time . When a painful reaction occurs, signs of malaise, fever, the buzhirovanie is postponed for several days.

Earlier the bougie was performed daily or every other day for a month, even in the absence of signs of narrowing of the esophagus, and then for 2 months 1-2 times a week, and experience shows that it is possible to carry out buzhem No. 32-34.

Early bougie in children is aimed at preventing the development of narrowing the lumen of the esophagus in the phase of reparative processes and scarring of its affected wall. According to the author, bougering started in the first 3-8 days after the burn is not dangerous for the injured, so morphologically the changes in this period extend only to the mucous and submucous layer, and therefore the danger of perforation is minimal. Indications for early bougie are the normal body temperature for 2-3 days and the disappearance of acute phenomena of common intoxication. Later the 15th day from the moment of the burn, the bougie becomes dangerous for the child and for the adult, as well as the phase of scarring of the esophagus, it becomes rigid and less pliable, and the wall has not yet acquired sufficient strength.

Buzhirovanie esophagus is carried out by soft elastic blunt-ended bougies and polyvinylchloride, reinforced with silk cotton cloth and varnished, or a soft stomach probe. The number of bougie must necessarily correspond to the age of the child.

Before blocking the child wrapped with hands and feet in the sheet. The assistant firmly holds him on his knees, clasping the child's yoga with his feet, with one hand - the child's trunk, and the other - fixes the head in the orthograde (forward) position. Booz is prepared according to the method described above. Buzh conduct on the esophagus, not allowing violence, and leave it for 2 minutes (according to SDTernovsky) to 5-30 minutes. Buzhirovanie children spend in the hospital 3 times a week for 45 days, gradually increasing the size of the bougie, corresponding to the normal diameter of the esophagus of a child of this age. Upon reaching a positive result, the child is discharged for outpatient treatment, consisting of weekly weekly bougiee for 3 months, and for the next 6 months bougies are carried out at least twice a month, and then once a month.

Complete recovery in the early blockage of the esophagus occurs in the vast majority of cases, contributes to this use of antibiotics that prevent secondary complications, and steroid drugs that inhibit fibroplastic processes.

Later treatment of chemical burns of the esophagus. The need for it arises in the absence of early treatment or irregular conduct. In most of these cases, cicatricial esophageal stenosis occurs. In these patients, bougies are carried out later.

Later bougie of the esophagus is carried out after a thorough general clinical examination of the patient, radiographic and esophagoscopic studies. Buzhirovanie begin with buzha № 8-10, gradually passing to the bougiers of a larger diameter. The procedure is carried out daily or every other day, and upon reaching a sufficient effect 1-2 times a week for 3-4 months, and sometimes up to six months or more. It should be noted, however, that due to the density of scar tissue and the obstinacy of stricture, it is not always possible to bring bougies to the latest numbers and we have to stop at mid-size boogers, at which liquefied and shredded dense food products pass, and in control X-ray studies - a thick mass barium sulfate. It should also be noted that breaks in treatment by the method of bougie are detrimental to the result, and the stricture of the esophagus again narrows. Even with a good and relatively stable result achieved with bougie, stricture tends to narrow, so patients who have suffered chemical burns of the esophagus and treatment with bougie should be under control and, if necessary, undergo repeated courses of treatment.

With sharp and sinuous cicatricial narrowing of the esophagus, adequate supply of patients through the mouth is impossible, as it is impossible and effective bougie in the usual way. In these cases, to establish proper nutrition, a gastrostomy is applied, which can also be used simultaneously for bougie by the "without end" method. Its essence lies in the fact that the patient swallows a strong nylon thread through the mouth, which is removed into the gastrostomy, the bougie is tied to her, and to the other end - the end of the thread emerging from the mouth. The bouge is inserted into the esophagus for the lower end of the thread, then it is taken out through its stricture and gastrostomy; the cycle is repeated several times many days in a row, until it becomes possible to bougie in the usual way.

The same method is also applicable to a number of sick children in late bougie who do not manage to expand the stricture to an acceptable diameter, which ensures satisfactory nutrition even in liquid food. In this case, to save the child, impose a gastrostomy, through which the feeding is carried out. After improving the child's condition, he is allowed to swallow silk thread No. 50 with a length of 1 m with water; then open the gastrostomy, and the thread is released together with water. A thin thread is replaced by a thick one. The upper end is drawn through the nasal passage (to prevent snacking of the thread) and is connected to the lower one. The bougie is tied to the thread and stretched from the side of the mouth or retrograde from the fistula. Buzhirovanie "for a string" ("infinite" bougie) perform 1-2 times a week for 2-3 months. By establishing a stable patency of the esophagus, the filament is removed and the bougie is continued through the mouth on an outpatient basis for 1 year. Given the possibility of recurrence of stricture, the gastrostomy is closed 3-4 months after removal of the thread with a stable patency of the esophagus.

Surgical treatment of after-burn strictures of the esophagus is divided into palliative and pathogenetic, i.e., elimination of stenosis by the methods of plastic surgery. Palliative methods include gastrostomy, which is produced in those cases when bougienage does not bring the desired result. In Russia for the first time imposed a gastrostomy in animals VA Bassov in 1842. French surgeon I. Sedio in 1849 for the first time imposed gastrostomy in humans. With the help of this surgical intervention, a gastrostomy is created, which is a fistula of the stomach for artificial feeding of patients with obstruction of the esophagus. Gastrostomy is used with congenital atresia of the esophagus, its scar scarring, foreign bodies, tumorous diseases, fresh burns and wounds of the masticatory apparatus and esophagus, with surgical interventions on the esophagus for the plastic elimination of its obstruction and bougie "without end". The gastrostoma intended for feeding must satisfy the following requirements: the fistula should fit tightly into the stomach of a rubber or polyvinylchloride tube and do not leak with a filled stomach, should pass a sufficiently thick tube, so that the patient can not only eat liquid, but also thick food, should not skip food from the stomach if the tube is temporarily removed or drops out itself. There are a variety of gastrostomy methods that meet these requirements. For clarity, we give a scheme of gastrostomy according to LV Serebrennikov.

[1], [2], [3], [4]