Corrosive esophagitis and esophageal strictures related to corrosive substance ingestion (CSI) are common and important public health issues, especially in developing or undeveloped countries.
The study aimed to evaluate the total cost of the patients with the CSI whether performed endoscopy or followed inpatient conservatively. In English literature, studies advocate that performing routine endoscopy for CSI patients is a more expensive method than clinical observation [22, 23]. Besides that, Abbas et al., with a large series of 21682 patients with CSI, reported that early endoscopic evaluation decreases the cost of late endoscopic evaluation [22]. This study reports a similar result without evaluating the timing of the endoscopy; endoscopic evaluation increases the total cost of clinical observation for CSI patients (E: ₺474.11±235.45, CO: ₺375.13±160.18; p = 0.045).
It was reported that early endoscopic evaluation in CSI patients with mild or no esophageal burn is mentioned to decrease the nil per oral period [24, 25]. The results of this study are to the literature (E: 21.03±18.77 hours, CO: 29.20±12.66 hours; p < 0.001).
In 2016, with 9888 patients by Rafeey et al. and in 2017 by Abbas et al., early endoscopic evaluation was mentioned to decrease the inpatient duration by exhibiting the presence or absence of the damage so that the clinician could make the appropriate approach earlier [22, 25]. Nevertheless, the “DROOL scoring system” presented by Uygun et al. advocated clinical evaluation and laboratory tests to evaluate the possible esophageal damage with 100% sensitivity and 96.6% specificity without performing esophagoscopy [26]. This study showed that the esophagoscopy diagnosed the esophageal injury earlier, and the patients were fed and discharged earlier.
Data on contact with chemicals worldwide are generally collected in national poison information and follow-up centers of countries. Considering that not all countries report these data regularly, it is not possible to determine the total exposure to corrosive substances worldwide and how many of them are in children. The 2018 report created by the NPDS in the United States was reported under the heading of chemicals most commonly used in household cleaning in childhood [14]. Among the substances most frequently contacted by children in the subjects included in our study, the most common ones were dishwasher polish, sink opener, descaling agent, and degreaser, respectively. Our research observed that the corrosive substance was drunk from its original packaging in 76% of the cases.
The pH value of the corrosive compounds that come into contact can predict the location and degree of damage they may cause. For this reason, it is crucial to learn the chemical properties of the contacted substance in cases presenting due to contact with a chemical substance in determining the path to be chosen in the patient's follow-up. In the reports reported in the literature, the most frequently detected group associated with corrosive activity in the esophagus is the strong alkaline substances group [25, 27]. Studies show that more signs of gastric outlet obstruction are seen with ingesting strongly acidic substances [28–30]. In the cases participating in our research, contact with strong alkaline (pH 11) substances was the highest (46.7%), followed by weak alkaline (pH 8–11) substances, second most frequently (22.7%).
In evaluating the patients at the time of admission to the hospital, there was no difference between the patients with acid or alkali contact in terms of symptoms or physical examination findings. The literature has reported that tissue damage is frequently observed due to strong acids and especially strong alkalis [12, 31, 32]. The absence of a relationship between pH value and symptoms and physical examination findings in this study may be due to the small number of patients or the fact that patients with a history of suspected drinking and patients with a proven record of drinking were not separated when information was collected from the patients. The most frequent symptom was vomiting (30.6%), thought to be the result of forced vomiting by parents.
It has been reported in different studies that substances with a pH value of less than three are associated with lesions that occur primarily at the gastric outlet and substances with a pH value above 11, especially in the esophagus [27, 30, 32]. There are studies on the time until endoscopy and symptoms at the time of application in adults, but the first 24–48-hour period is considered the early period in time intervals [22]. In our study, the latest endoscopy was performed at the 26th hour in patients who underwent endoscopy, so no comparison with the literature could be made. In our study, the relationship between the patients who underwent an endoscopy and the time elapsed between the ingestion of corrosive substances and the endoscopy, the presence of symptoms at the time of admission, or the pH value of the substance consumed by the patient and the damage levels determined as a result of endoscopy were evaluated, but no statistically significant result was reached. To make this evaluation more accurate, a study with a more extensive patient series is thought to be needed.
Temiz et al. [33] argued that the early evaluation of patients with esophagoscopy after ingesting corrosive substances may prevent the patient from taking unnecessary medication. It has been reported that the use of drugs can be reduced with scales that can be used to evaluate possible esophageal damage in patients without endoscopy [26]. Our study showed that the use of antibiotics and antacid treatment in patients with no or very low-grade burns detected by endoscopy was less than clinical observation. This may be due to the initiation of empirical therapy in patients in the clinical observation group.
In current guidelines, it is recommended that clinical observation should be preferred first in patients who present with a history of corrosive substance intake but have no symptoms at the time of admission, no physical examination findings, and no significant findings in the examinations, and it is emphasized that the need for EGD or endoscopy application is reduced [16, 34, 35]. In our study, it was demonstrated in the results of patients who did not have this symptom that the length of stay and the time they spent without oral administration could be reduced by early endoscopy. The use of drugs could be reduced, but the average cost of these patients also increases with the application of endoscopy. In addition, the fact that only one of the 75 patients had stenosis with EGD and only this patient had dilatation supports the endoscopic evaluation and extraction of EGD in selected cases instead of the routine application.
In patients who have findings suggestive of esophageal injury due to corrosive substance and who do not have severe oropharyngeal-glottic edema, hemodynamic instability, and gastrointestinal system perforation findings in terms of endoscopy, by demonstrating whether there is a lesion in the esophagus or stomach by performing endoscopy, the patient can be discharged from the hospital in a shorter time can be provided. However, in patients who do not have symptoms, physical examination findings, and laboratory findings at the time of admission, conservative monitoring without endoscopy, drug administration, and controlled close oral intake can be considered a preferable method.