Episode 18: GI Toxicology

by Bob Stuntz in , ,


Updated 8/5/14: Show note formatting cleaned up.  Also, typo in notes: kids most commonly get objects loved in the esophagus at the level of C6 (cricopharyngeus mm).  Typo incorrectly said T6.  

In Episode 18, we take a look at the ingestions and insertions - both accidental and not - that make their way into the GI tracts of your patients.  This is by no means a comprehensive review of all things toxicology that can affect the GI system.  Rather, we focus on ingestions, foreign bodies, and whether or not GI decontamination actually helps.  

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Check out the podcast below, the show notes that follow, and if you can get credit, the quiz is at the bottom of the page!  

Download the show notes here

Case 1: Caustic ingestion - alkali or acidic ingestion (Images from Reference 3)

  1. Epidemiology
    • Kids: Usually accidental and smaller amounts, more upper injury
    • Adults: Usually intention, more severe
  2. Types
    • Acidic: Coagulation necrosis, usually limited superficial injury, pain limits ingestion
      • Studies suggest acid ingestion may have worse outcome overall
      • Tend to affect stomach more vs esophagus
    • Alkali: Liquefactive necrosis, delayed/continued injury, 
      • Usually more viscous preparations
      • More esophageal injury
    • If you can obtain the material ingested, look at contents or check pH 
  3. Management
    • Airway: Intubate early for signs of airway compromise
    • Skilled intubator
    • Have backups and surgical airway ready
    • Imaging: CXR/AXR to evaluate for pneumomedastinum or pneumoperitoneum
    • Give IV fluids if needed.  If delayed and high suspicion for perforation/mediastinitis, treat as sepsis (fluids, antibiotics)
    • Decontamination: DON’T
      • Never induce emesis
      • NG/OG tubes contraindicated initially
      • charcoal of no benefit, and risk aspiration
    • Steroids: Thought to decrease inflammation and thus stricture formation
      • Stricture formation largely depends on initial injury grading (more on that later)
      • Current research suggests likely no benefit
    • Proton pump inhibitors: Thought to decrease acid damage in stomach
      • Few studies with mixed results
      • Talk to your local GI specialist
    • Antibiotics
      • Yes if patient on steroids or immunocompromised and suspect significant injury/ingestion
      • Yes if suspect high grade injury/significant ingestion
      • Yes if toxic/septic, or evidence of perforation/mediastinitis/pneumoperitoneum/peritonitis
      • Otherwise, no
    • Endoscopy
      • Want done within 24 hours
      • Grading of injury
        • 0, 1, 2A: Good prognosis
        • 2B, 3A and 3B: Bad prognosis
    • Consultation
      • GI for endoscopy
      • May need CT surgery for esophagectomy or more intensive therapy if severe or evidence of perforation
      • May need general surgery is gastric perforation
      • Psychiatry if intentional
      • Consider child abuse/neglect
See reference #3

See reference #3

See reference #3

See reference #3

Case 2: Billy swallowed something

  1. Epidemiology
    • Kids: usually accidental
    • Adults: usually intentional
  2. Management
    • Airway: Look for signs of airway compromise (stridor, drooling, respiratory distress)
    • Imaging
      • AP/Lateral Plain films to start
        • Esophagus: Face on AP
        • Trachea: face on lateral
        • Kids: C6/cricopharyngeus
        • Adults: Lower esophageal sphincter
      • If respiratory concern in kids with a non radioopaque foreign body (hot dog), consider plain films in lateral position, look for hyperinflation (ball valve physiology) - but that’s another episode
      • If negative and concerning or unknown ingestion, consider CT
    • Removal, or let it pass?
      • Most things: Let it pass
      • Indications for urgent removal:
        • Sharp objects or very long objects (> 2 inches/5 cm)
        • Magnets
        • Disc battery in esophagus
        • Inability to swallow or handle secretions
        • Toxic
      • Button batteries
        • Remove if in the esophagus
        • If in the stomach or farther, re-image in the next 3-4 days
The classic appearance of a coin in the esophagus.  A tracheal going would have the opposite appearance on each image. 

The classic appearance of a coin in the esophagus.  A tracheal going would have the opposite appearance on each image. 

Case 3: Packers and stuffers

  1. Stuffers: Running from the police, and they ingest a substance to avoid detection
    • Treat the toxidrome
    • Expected management based on what they ingested
  2. Packers: Intentional and methodical concealment of smuggled substances
    • Most commonly opioids and cocaine
    • Evaluation: Sick or not sick
      • If not sick/asymptomatic, packing likely intact
      • Otherwise, look for toxidrome
    • Imaging
      • XR: initial imaging, especially if concern for perforation
      • CT: If high suspicion or to guide clearance/surgical management/approach
    • Management
      • Treat toxidrome if present
      • Whole bowel irrigation (WBI) with PEG
      • If obstruction/perforation or symptomatic, surgical consult
      • Disposition: admit for WBI

Check out this interesting article regarding suspected body packers and the role of the police in these patients

And what did you eat again, sir?

And what did you eat again, sir?

So what about Decontamination?

  1. Ipecac: NO
  2. Gastric levage: NO
  3. Cathartics: NO
  4. Single dose charcoal
    • Minimal evidence this works at all
    • If you do it, do it within an hour of ingestion
    • No definite evidence of outcome improvement
  5. Multi-dose activated charcoal (MDAC)
    • Consider if life threatening ingestion of carbamazepine, dapsone, phenobarbitol, quinine or theophylline
  6. Whole bowel irrigation:
    • If iron, lead, zinc, or body packing, may help
    • Consider for sustained release or enteric coated drugs
    • Avoid if perforation, obstruction, hemodynamic instability, or otherwise toxic
  7. Sodium polystyrene sulfonate (SPS - kayexalate)
    • Used in Lithium ingestion to prevent absorption and increase excretion
    • Side effects: hypokalemia, GI necrosis
    • No definite clinical outcome improvement

References

  1. Brent, J et. al.  Critical Care Toxicology.  2005.  Elsivier Mosby.  
  2. Up To Date: Caustic Esophageal Injury in Adults, updated 9/11/13.
  3. Lupa, M et. al.  Update on the diagnosis and treatment of caustic ingestion.  Ochsner J. 2009 Summer; 9(2): 54–59. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096249/)
  4. Contini, S. and Scarpignato, C.  Caustic injury of the upper gastrointestinal tract: A comprehensive review.  World J. Gatroenterol.  2013 July 7; 19(25): 3918-3930.  
  5. Abaskharoun, R et. al.  Nonsurgical management of severe esophageal and gastric injury following alkali ingestion.  Can J Gastroeneterol.  2007 November 11; 21(11): 757-760.  
  6. Up To Date: Foreign bodies of the esophagus and gastrointestinal tract in children, updated 12/30/13. 
  7. Albertson, TE et. al.  Gastrointestinal decontamination in the acutely poisoned patient.  Int J of Emergency Medicine.  2011, 4(65).  

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