今日の臨床サポート

腐食性食道炎、潰瘍

著者: 八島一夫 鳥取大学 消化器・腎臓内科学分野

監修: 木下芳一 兵庫県立はりま姫路総合医療センター

著者校正/監修レビュー済:2022/07/06
患者向け説明資料

概要・推奨   

  1. 腐食性食道炎、潰瘍の経過は、腐食性物質の種類、濃度、量、pH、粘性、接触時間などにより決まるため、受傷時の状況把握を行うことは重要である(推奨度1)
  1. 急性期の病状把握のためCT、上部消化管内視鏡検査は必要である(推奨度2)
  1. 受傷数日後から2週間程度は内視鏡検査を避けるべきである(推奨度2)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
八島一夫 : 特に申告事項無し[2022年]
監修:木下芳一 : 講演料(武田薬品工業,大塚製薬,アストラゼネカ,第一三共,ヴィアトリス,EAファーマ,アステラス製薬),奨学(奨励)寄付など(EAファーマ)[2022年]

改訂のポイント:
  1. 定期レビューを行い、診断・治療方針について加筆修正を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 腐食性食道炎とは、組織傷害性の強い化学物質の飲用によって起こる食道壁の損傷である。
  1. 原因としては、小児は洗剤などの誤飲の場合が多く、成人では自殺目的の服用が大部分を占める。欧米では小児の誤飲が原因の約80%を占め、死亡率は13.6%とされている[1][2][3][4]。一般的な腐食性物質として、酸ではトイレ用洗剤などに含まれる塩酸、硫酸など、アルカリでは配水管洗剤、漂白剤などに含まれる水酸化ナトリウム(苛性ソーダ)、次亜塩素酸ナトリウムなどがある。その他、重金属、農薬、フェノール、ホルムアルデヒドなどの飲用によるものもある。
  1. 食道壁の損傷の程度は、腐食性物質の種類、濃度、量、pH、粘性、接触時間に左右される。
  1. 酸は粘膜傷害が比較的表面にとどまることが多いが、アルカリは強い吸湿性および鹸化・蛋白融解作用のため病変が深部まで及び、瘢痕狭窄を来しやすい。
  1. 臨床経過は受傷後の時期により3期に分類される。(表<図表>
  1. 受傷後3週以降に組織の線維化と拘縮が始まり食道狭窄が徐々に進行する。受傷8カ月以内に狭窄が完成するといわれている。
 
  1. 腐食性食道炎、潰瘍の経過は、腐食性物質の種類、濃度、量、pH、粘性、接触時間などにより決まるため、受傷時の状況把握を行うことは重要である(推奨度1)
  1. 酸は口腔内ですぐに傷害が起きるため摂取困難であることが多く、また表面組織に凝固壊死を起こすため深部への浸透は少ない。アルカリは融解壊死を起こすため傷害が深部へ及びやすい。
問診・診察のポイント  
  1. 腐食性物質の種類、濃度、量、pH、粘性、接触時間などの受傷時の状況を把握する。

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文献 

S A Zargar, R Kochhar, B Nagi, S Mehta, S K Mehta
Ingestion of corrosive acids. Spectrum of injury to upper gastrointestinal tract and natural history.
Gastroenterology. 1989 Sep;97(3):702-7.
Abstract/Text We have prospectively evaluated 41 patients who ingested acid for location, extent, severity, and outcome of the injury to the upper gastrointestinal tract. The injury was assessed within 36 h of acid intake by endoscopy or surgery, or at autopsy. Symptoms and signs were unreliable in predicting the extent and severity of injury. The degree of burns was classified as follows: grade 0 in 2 patients, grade 1 in 3, grade 2 in 16, and grade 3 in 20. Esophageal injury was seen in 87.8% of the patients, gastric injury in 85.4%, and duodenal injury in 34.1%. All patients with grade 0, 1, and 2a injury recovered without sequelae. Acute complications occurred in 39.1% of the cases, and death in 12.2%. It is significant that all such patients had grade 3 burns. Five of the 8 patients with grade 2b injury and all survivors of grade 3 injury developed esophageal or gastric cicatrization, or both, which subsequently needed endoscopic or surgical treatment. We find that endoscopy is not only the tool of choice for diagnosis in such cases but also aids in deciding upon treatment and prognosis. We conclude that acid injury of the upper gastrointestinal tract is a very serious condition that affects the esophagus and stomach equally and results in high morbidity and mortality.

PMID 2753330
S A Zargar, R Kochhar, B Nagi, S Mehta, S K Mehta
Ingestion of strong corrosive alkalis: spectrum of injury to upper gastrointestinal tract and natural history.
Am J Gastroenterol. 1992 Mar;87(3):337-41.
Abstract/Text We have prospectively studied 31 patients who ingested strong alkalis for location, extent, severity, and outcome of the injury to the upper gastrointestinal tract. Alkalis ingested were sodium hydroxide (n = 28) and potassium hydroxide (n = 3). The injury was assessed within 36 h of alkali intake by endoscopy or surgery, or at autopsy. Symptoms and signs did not give a reliable forecast of the extent and severity of injury. The corrosive burns were classified as grade 2a in six patients, grade 2b in eight, and grade 3 in 17. The esophagus was injured in all patients, the stomach in 93.5%, and the duodenum in 29.6%. Acute complications occurred in 32.3% of the patients and death in 12.9%; all but one of such patients had grade 3 burns. All patients with 2a injury recovered without sequelae. Four of the eight patients with grade 2b injury and all survivors of grade 3 injury developed esophageal or gastric cicatrization, or both, which needed endoscopic or surgical treatment. We find endoscopy is not only a safe and reliable tool for diagnosis in such patients, but also is of importance in treatment and prognosis. We conclude that ingestion of strong alkalis is a very serious condition that inflicts severe contiguous injury to the esophagus and stomach and results in high morbidity and mortality.

PMID 1539568
Mircea Chirica, Luigi Bonavina, Michael D Kelly, Emile Sarfati, Pierre Cattan
Caustic ingestion.
Lancet. 2017 May 20;389(10083):2041-2052. doi: 10.1016/S0140-6736(16)30313-0. Epub 2016 Oct 26.
Abstract/Text Corrosive ingestion is a rare but potentially devastating event and, despite the availability of effective preventive public health strategies, injuries continue to occur. Most clinicians have limited personal experience and rely on guidelines; however, uncertainty persists about best clinical practice. Ingestions range from mild cases with no injury to severe cases with full thickness necrosis of the oesophagus and stomach. CT scan is superior to traditional endoscopy for stratification of patients to emergency resection or observation. Oesophageal stricture is a common consequence of ingestion and newer stents show some promise; however, the place of endoscopic stenting for corrosive strictures is yet to be defined. We summarise the evidence to provide a plan for managing these potentially life-threatening injuries and discuss the areas where further research is required to improve outcomes.

Copyright © 2017 Elsevier Ltd. All rights reserved.
PMID 28045663
Hyun Ho Ryu, Kyung Woon Jeung, Byung Kook Lee, Jun Hwan Uhm, Young Hun Park, Min Ho Shin, Hyun Lee Kim, Tag Heo, Yong Il Min
Caustic injury: can CT grading system enable prediction of esophageal stricture?
Clin Toxicol (Phila). 2010 Feb;48(2):137-42. doi: 10.3109/15563650903585929.
Abstract/Text BACKGROUND: The aim of this study was to test the utility of our computed tomography (CT) grading system, compared with endoscopy, for association with the development of esophageal stricture in patients with caustic ingestion.
METHODS: This retrospective case series involved 49 patients with caustic ingestion from 1998 to 2009. The degree of esophageal damage was graded using a scoring system based on the extent of esophageal wall edema and the damage in adjacent tissue as seen on thoracoabdominal CT scans. The presence of esophageal stricture was established by esophagography. Diagnostic performance was compared using receiver operating characteristic (ROC) analysis. Sensitivity and specificity were calculated for the grading system.
RESULTS: The CT grading score results showed that grade III was the most common injury (20 cases, 40.8%), followed by grade IV (14 cases, 28.6%), grade II (9 cases, 18.4%), and grade I (6 cases, 12.2%). In addition, damage to the esophagus was significantly correlated with esophageal stricture when the extent of damage approached grades III and IV (p < 0.001). The CT grading system for esophageal stricture resulted in a slightly larger area under the receiver operating characteristic curve (0.90) compared with endoscopic grading system (0.79). The sensitivity and specificity of CT grading system were moderately higher than those of endoscopic grading system.
CONCLUSION: Assessment of the degree of esophageal damage using CT, a noninvasive modality, in patients who visit the emergency department following caustic ingestion should be useful in estimating the occurrence of complications including esophageal stricture.

PMID 20199130
Prasit Mahawongkajit, Prakitpunthu Tomtitchong, Nuttorn Boochangkool, Chatchai Mingmalairak, Surajit Awsakulsutthi, Chittinad Havanond
A prospective randomized controlled trial of omeprazole for preventing esophageal stricture in grade 2b and 3a corrosive esophageal injuries.
Surg Endosc. 2021 Jun;35(6):2759-2764. doi: 10.1007/s00464-020-07707-0. Epub 2020 Jun 15.
Abstract/Text OBJECTIVES: Esophageal stricture is a significant complication of grade 2b and 3a esophageal injuries and causes much patient suffering. Preventing strictures would be beneficial to patients but there are currently no proven effective drugs. This study aimed to evaluate the effect of omeprazole for preventing esophageal stricture in adults with grade 2b and 3a corrosive esophageal injuries.
METHODS: This study was an open single-center prospective randomized controlled trial that took place from April 2018 to January 2020. Patients were randomized to standard treatment or 80 mg/day intravenously × 3 days followed by 40 mg/day orally for 4 weeks. They were endoscoped at baseline and 4 weeks post discharge. Strictures were confirmed radiologically.
RESULTS: 20 patients were enrolled: 15 with grade 2b and five with grade 3a injuries. Standard care and omeprazole groups numbered 10 each. At 1 month, seven and two patients developed strictures in the standard and omeprazole groups, respectively, p = 0.024, for a risk reduction of 71.4%.
CONCLUSIONS: Omeprazole reduced the risk of short-term developing esophageal strictures following grade 2b and 3a corrosive esophageal injuries. Larger studies are needed to reconfirm this finding. Thai Clinical Trials Registry (TCTR) number TCTR20190504001.

PMID 32556768
J M Howell, W C Dalsey, F W Hartsell, C A Butzin
Steroids for the treatment of corrosive esophageal injury: a statistical analysis of past studies.
Am J Emerg Med. 1992 Sep;10(5):421-5.
Abstract/Text Caustic esophageal injury causes substantial morbidity and mortality. However, the use of corticosteroids to treat this problem has been evaluated in a limited number of studies because adequate sample size is difficult to obtain. We analyzed 361 subjects with corrosive esophageal injury derived from 10 retrospective and three prospective publications. We divided cases into those treated with corticosteroids and antibiotics (T) and those that received neither modality (NT) based on inclusion and exclusion criteria. Forty-one percent of NT cases developed esophageal stricture and 19% of T cases developed this complication (P less than .01). There were no reported strictures among 72 first-degree esophageal burns (combined T and NT cases). The T group contained 54 strictures among 228 patients (24%) with either second- or third-degree burns. The NT group of 25 patients with the same burn severity suffered 13 strictures (52%) (P less than .01). Reports of death and gastrointestinal hemorrhage did not increase among steroid-treated patients. We do not recommend corticosteroid therapy for first-degree esophageal injuries. However, this therapy may be useful in preventing strictures among patients with second- or third-degree corrosive esophageal burns.

PMID 1642705
Asada Methasate, Varut Lohsiriwat
Role of endoscopy in caustic injury of the esophagus.
World J Gastrointest Endosc. 2018 Oct 16;10(10):274-282. doi: 10.4253/wjge.v10.i10.274.
Abstract/Text Caustic injury of the esophagus is a problematic condition challenging endoscopists worldwide. Although the caustic agents and motives are different among countries and age groups, endoscopy still plays an invaluable role in diagnosis and treatment. Endoscopy can determine the severity of caustic ingestion which is of great importance in choosing appropriate treatment. However, some aspects of endoscopy in diagnosis of caustic injury remain controversial. Whether or not all patients need endoscopy, when to perform endoscopy and how to assess the severity are just some examples of these controversies. Due to lack of randomized controlled trials, many findings and suggestions are inconclusive. Computerized tomography scan of the chest and abdomen gains popularity in assessing the severity of caustic injury and avoiding unnecessary surgery. If esophageal stricture eventually develops, endoscopic dilatation is a mainstay. Maneuvers such as steroid injection and esophageal stent may be used in a refractory stricture. Nevertheless, some patients have to undergo surgery in spite of vigorous attempts with esophageal dilatation. To date, caustic injury remains a difficult situation. This article reviews all aspects of caustic injury of the esophagus focusing on endoscopic role. Pre-endoscopic management, endoscopy and its technique in acute and late phase of caustic injury including the endoscopic management of refractory stricture, and the treatment outcomes following each endoscopic intervention are thoroughly discussed. Finally, the role of endoscopy in the long term follow-up of patients with esophageal caustic injury is addressed.

PMID 30364838

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