Computed Tomography Evaluation of Esophagogastric Necrosis After Caustic Ingestion.
Endoscopy is the standard of care for emergency patient evaluation after caustic ingestion. However, the inaccuracy of endoscopy in determining the depth of intramural necrosis may lead to inappropriate decision-making with devastating consequences. Our aim was to evaluate the use of computed tomography (CT) for the emergency diagnostic workup of patients with caustic injuries.



In a prospective study, we used a combined endoscopy-CT decision-making algorithm. The primary outcome was pathology-confirmed digestive necrosis. The respective utility of CT and endoscopy in the decision-making process were compared. Transmural endoscopic necrosis was defined as grade 3b injuries; signs of transmural CT necrosis included absence of postcontrast gastric/ esophageal-wall enhancement, esophageal-wall blurring, and periesophageal-fat blurring.



We included 120 patients (59 men, median age 44 years). Emergency surgery was performed in 24 patients (20%) and digestive resection was completed in 16. Three patients (3%) died and 28 patients (23%) experienced complications. Pathology revealed transmural necrosis in 9/11 esophagectomy and 16/16 gastrectomy specimens. Severe oropharyngeal injuries (P = 0.015), increased levels of blood lactate (P = 0.007), alanine aminotransferase (P = 0.027), bilirubin (P = 0.005), and low platelet counts (P > 0.0001) were predictive of digestive necrosis. Decision-making relying on CT alone or on a combined CT-endoscopy algorithm was similar and would have spared 19 unnecessary esophagectomies and 16 explorative laparotomies compared with an endoscopy-alone algorithm. Endoscopy did never rectify a wrong CT decision.



Emergency decision-making after caustic injuries can rely on CT alone.
*Department of General, Endocrine and Digestive Surgery†Department of Biostatistics and Medical Informatics‡Department of Gastroenterology§Department of Anesthesiology and Surgical Intensive Care¶Department of Radiology||Department of Pathology, Saint-Louis Hospital, Paris, France.
Mircea
M
Chirica
Matthieu
M
Resche-Rigon
Anne Marie
AM
Zagdanski
Matthieu
M
Bruzzi
Damien
D
Bouda
Eric
E
Roland
François
F
Sabatier
Fatiha
F
Bouhidel
Francine
F
Bonnet
Nicolas
N
Munoz-Bongrand
Jean
J
Marc Gornet
Emile
E
Sarfati
Pierre
P
Cattan
D000328:Adult; D002057:Burns, Chemical / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery; D002424:Caustics; D003657:Decision Making; D004435:Eating; D016629:Esophagectomy / Q000379:methods; D004945:Esophagoscopy / Q000379:methods; D004947:Esophagus / Q000000981:diagnostic imaging / Q000473:pathology*; D005260:Female; D005743:Gastrectomy / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D009336:Necrosis / Q000000981:diagnostic imaging; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D013270:Stomach / Q000000981:diagnostic imaging / Q000473:pathology*; D014057:Tomography, X-Ray Computed / Q000379:methods
D002424:Caustics