Research code: 0
Ethics code: IR.IUMS.REC.1403.227
Clinical trials code: 0
school of Medicine, Aliasghar Children's Hospital, Iran University of Medical Sciences, Tehran, Iran. , ali_phd203@yahoo.com
Abstract: (43 Views)
Dear Editor,
I would like to highlight findings from a recent study at Ali Asghar Children's Hospital exploring the necessity of simultaneous bronchoscopy and endoscopy in patients under 18 years old following caustic substance ingestion. While endoscopy remains the gold standard for evaluating gastrointestinal injury after caustic ingestion, respiratory tract assessment via bronchoscopy is typically reserved for cases with overt respiratory symptoms. Given that bronchoscopy is invasive and carries risks — particularly in children — its routine use alongside endoscopy remains controversial and protocols are inconsistent. This study aimed to evaluate the clinical value of performing both procedures concurrently to inform evidence-based management.
We prospectively analyzed 21 patients aged 6 months to 8 years, mostly boys (71.4%), predominantly exposed to alkaline agents such as bleach (52.4%) and pipe openers (38.1%). Presenting symptoms ranged from mild signs like drooling and agitation to severe manifestations including hematemesis and altered consciousness. Patients who ingested bleach or descalers generally had normal or mild esophageal, laryngeal, and tracheal injuries on endoscopy and bronchoscopy, with no symptoms or complications after one month. Conversely, pipe opener ingestion resulted in more severe tissue damage (usually grade 2B or higher) evident throughout the esophagus and airway, with symptomatic complications such as dysphagia and esophageal strictures during follow-up.
Importantly, a significant correlation emerged between bronchoscopic and endoscopic findings. Patients with normal bronchoscopy typically had normal or minimal esophageal injury, while those with localized airway damage had limited esophageal involvement (grade 2B). Severe airway deformities, such as epiglottic and pharyngeal abnormalities, corresponded with extensive erythema and mucosal injury across the esophagus and stomach (grades 2B–3A). This indicates that airway injuries may parallel or predict gastrointestinal severity — crucial information for airway management and nutritional planning.
Although initial symptoms were not always statistically predictive of clinical outcomes, a meaningful association was observed between early clinical signs and subsequent complications. Only patients asymptomatic at presentation remained complication-free at one month. Those with mild symptoms (e.g., nausea, tongue or lip edema, abdominal pain) often remained asymptomatic later but were not necessarily free of complications.
These findings support the clinical value of simultaneous bronchoscopy and endoscopy, especially when respiratory symptoms or upper airway involvement are suspected. Assessing both airway and gastrointestinal tracts comprehensively allows better classification of injury severity, guides management, and justifies repeat evaluations in patients with initial injury grade ≥ 2B or persistent symptoms to monitor late complications like strictures. This approach aligns with current guidelines emphasizing surveillance of moderate to severe injuries.
In summary, it is recommended that bronchoscopy be performed based on endoscopic findings and Zarger grading criteria. According to our results, simultaneous endoscopy and bronchoscopy are advised for grade 2b and above, as bronchoscopy findings often correspond with the severity of endoscopic injury and aid in prognosis and management.
I would like to highlight findings from a recent study at Ali Asghar Children's Hospital exploring the necessity of simultaneous bronchoscopy and endoscopy in patients under 18 years old following caustic substance ingestion. While endoscopy remains the gold standard for evaluating gastrointestinal injury after caustic ingestion, respiratory tract assessment via bronchoscopy is typically reserved for cases with overt respiratory symptoms. Given that bronchoscopy is invasive and carries risks — particularly in children — its routine use alongside endoscopy remains controversial and protocols are inconsistent. This study aimed to evaluate the clinical value of performing both procedures concurrently to inform evidence-based management.
We prospectively analyzed 21 patients aged 6 months to 8 years, mostly boys (71.4%), predominantly exposed to alkaline agents such as bleach (52.4%) and pipe openers (38.1%). Presenting symptoms ranged from mild signs like drooling and agitation to severe manifestations including hematemesis and altered consciousness. Patients who ingested bleach or descalers generally had normal or mild esophageal, laryngeal, and tracheal injuries on endoscopy and bronchoscopy, with no symptoms or complications after one month. Conversely, pipe opener ingestion resulted in more severe tissue damage (usually grade 2B or higher) evident throughout the esophagus and airway, with symptomatic complications such as dysphagia and esophageal strictures during follow-up.
Importantly, a significant correlation emerged between bronchoscopic and endoscopic findings. Patients with normal bronchoscopy typically had normal or minimal esophageal injury, while those with localized airway damage had limited esophageal involvement (grade 2B). Severe airway deformities, such as epiglottic and pharyngeal abnormalities, corresponded with extensive erythema and mucosal injury across the esophagus and stomach (grades 2B–3A). This indicates that airway injuries may parallel or predict gastrointestinal severity — crucial information for airway management and nutritional planning.
Although initial symptoms were not always statistically predictive of clinical outcomes, a meaningful association was observed between early clinical signs and subsequent complications. Only patients asymptomatic at presentation remained complication-free at one month. Those with mild symptoms (e.g., nausea, tongue or lip edema, abdominal pain) often remained asymptomatic later but were not necessarily free of complications.
These findings support the clinical value of simultaneous bronchoscopy and endoscopy, especially when respiratory symptoms or upper airway involvement are suspected. Assessing both airway and gastrointestinal tracts comprehensively allows better classification of injury severity, guides management, and justifies repeat evaluations in patients with initial injury grade ≥ 2B or persistent symptoms to monitor late complications like strictures. This approach aligns with current guidelines emphasizing surveillance of moderate to severe injuries.
In summary, it is recommended that bronchoscopy be performed based on endoscopic findings and Zarger grading criteria. According to our results, simultaneous endoscopy and bronchoscopy are advised for grade 2b and above, as bronchoscopy findings often correspond with the severity of endoscopic injury and aid in prognosis and management.
Type of Study: Letter to the editor |
Subject:
Pediatric Gastroentrology
Send email to the article author
