Caustic Esophageal Stenosis: Epidemiological, Clinical, Endoscopic and Therapeutic Aspects at the Gabriel Touré University Hospital in Bamako

Voluntary or accidental ingestion of a caustic product is increasingly encountered in our country. Caustic esophageal stenosis is the most common sequel. Its treatment involves instrumental dilation and/or surgery which is particularly heavy. The aim of this study was to study the epidemiological, clinical and therapeutic aspects of caustic esophageal strictures in our context. The retrospective study took place from December 2013 to December 2017 in the Hepato-Gastroenterology department of the Gabriel Touré university hospital in Bamako. We included patients with caustic esophageal stenosis referred to the gastrointestinal endoscopy unit for dilation. 67 patients admitted for caustic stenosis were included. The mean age of our patients was 20.76 ± 19.9 years with extremes of 1 and 70 years and a sex ratio of 1.9. In 50.7% of cases, the product ingested was basic in nature. The clinical symptomatology was dominated by dysphagia (100%), vomiting (100%), the emaciated (60%) and cough (40%). In 59 (88%) patients, the stenosis was unique and multiple in 8 (12%). The KILLIAN mouth as the sole site of the stenosis was found in 40.3% of patients. The number of sessions was ≤ 3 in 16.4% and >3 in 83.6% with a mean of 4.59 ± 1.57 sessions. The evolution was favorable in 95.5% of our patients. However, we recorded three (3) cases of death all following a perforation. Conclusion: Caustic esophageal stenosis, a consequence of ingestion of caustics, is increasingly observed in our context. Endoscopic dilation occupies an important place in its management.


Introduction
The voluntary or accidental ingestion of caustic is increasingly encountered in our country and is a real public health problem today. The resulting complications can be serious and deadly, involving the vital prognosis or causing disabling sequelae. Caustic esophageal stenosis (SCO), the most frequent sequel to these burns, can be severe, leading to dysphagia or even aphagia with a deficit in weight and a significant deterioration in the patient's quality of life [1]. Its treatment involves instrumental dilation and/or surgery, which is particularly heavy [2] [3].
The incidence of caustic accidents varies from region to region. While this incidence is clearly decreasing in developed countries thanks to legislation and information campaigns carried out among parents and industry. However, it remains high in developing countries in the absence of adequate measures. In Africa, Oumnia et al. collected 132 cases of caustic esophageal stenosis in four years [1] while Yéna et al. collected 67 cases in seven years [4]. Formerly mainly surgical, the treatment of caustic esophageal stenosis has become accessible to endoscopic dilation as a first-line. Surgery now seems to be reserved for dilation failures and can even, in some cases, be coupled to it [5]. Caustic burns are relatively frequent in our department and their management is difficult because of the insufficient technical platform and the delay in the consultation. We initiated this work with the aim of studying its epidemiological, clinical and therapeutic aspects. For the endoscopic dilation, we used a metal guide wire fitted at its end with a very flexible tip or a hydrophilic guide wire, a set of candles semi-transparent GUILLARD (diameter from 5 to 18 mm) and/or a pneumatic dilator (through the scope TTS balloon). After each dilation, an endoscopic check is made to assess the mucosa. Once the last candle has passed, the guidewire is completely removed after endoscopic control. The patient is then put placed on a Proton Pump Inhibitor (PPI) and paracetamol in case of pain, and allowed to eat 3 hours after the session for children and 6 hours for adults.

Patients and Method
Data entry and data analysis were performed on SPSS 12.0 software for Windows. We simply entered texts and tables on the World and Excel software. The confidentiality of the data collected was guaranteed. The Chi-square statistical test was used to compare our results which were significant for a probability p < 0.05.

Results
In this study 67 patients admitted for caustic stenosis were included. On the socio-demographic level (Table 1): the mean age of the patients was 20.76 ± 19.9 years with extremes of 1 and 70 years and a sex ratio of 1.9. In 49.3% our patients had no professional activity. In 50.7% of cases, the product ingested was a base and in 49.3% an acid. The clinical symptomatology was dominated by dysphagia (100%), vomiting (100%), the emaciated and cough (40%). In 88% of patients the stenosis was single and multiple in 12% (six cases of double stenosis and six cases of triple stenosis) ( Table 2). For single stenosis, Killian's mouth was the site in 40.3% of cases, the middle 1/3 of the esophagus in 10.4%, and the lower 1/3 in 34.3%. For double stenosis, 3% were located at the level of the middle 1/3 and lower 1/3, 7.5% at the level of Killian's mouth and of the middle 1/3 and 4.5% at the level of the mouth of Killian and the lower 1/3 of the esophagus.
( Table 3). The number of sessions was ≤3 in 16.4% and >3 in 83.6% with an Open Journal of Gastroenterology

Discussion
We collected 67 patients who underwent endoscopic dilation. Our sample was limited by the difficulties in achieving dilation in some patients for financial reasons. The sex-ratio was 1.9. This male predominance has also been reported by Rakesh et al. [6] and Togo et al. [7]. The mean age of our patients was 20.76 ± 19.9 years. Rheman et al. [8] found in their study an average age of 19.25 years while Rakesh et al. [6] found an average age of 35.5 years. Although this incident affects all age groups, it occurs more frequently in adolescents and young adults.
This is often an impulsive act, as this period is characterized by the onset of psycho-affective disorders in a context of emotional immaturity or isolation, which may explain this high percentage. In our study, in 50.7% of cases the product ingested was a baseline against 85.1% in that of Sanchez et al. [9] and 89.2% in the series of Rakesh et al. [6]. It has been reported that alkaline substances account for most cases of caustic ingestion in developed countries while acid ingestion is more common in developing ones [10]. The clinical symptomatology was dominated by dysphagia (100%), vomiting (100%), the emaciated and cough (40%). Ahmed et al. [11] reported 76.7% dysphagia, 69.8% vomiting and 4.2% epigastric pain. In 59 patients (88%) the stenosis was unique and multiple in 8 patients (12%). The strictures were preferentially located at the level of the Killian mouth and in the lower 1/3 of the esophagus. Mekki et al. [12] demonstrated the stricture at the upper 1/3 level in 40% of patients, 2/3 higher in 40%, 1/3 mean in 10% and 1/3 lower in 10%. The number of sessions was ≤ 3 in 16.4% and >3 in 83.6% with an average of 4.59 ± 1.57. Youn et al. [13] and Ahmed et al. [11] respectively reported an average number of sessions of 4 and 3. The evolution was favorable with resumption of feeding in 95.5% of our patients. Our success rate is higher than that of Geng et al. [14] who found a favorable outcome in 60.5% of cases and significantly higher than that of Tadmori et al. [15] who found 30% success. Three cases of perforation complicated the procedure.

Conclusion
Caustic esophageal stenosis is the main long-term complication of caustic ingestion. It is more and more common in our country. Endoscopic dilation is a simple, effective and accessible therapeutic means in our context. However, prevention remains the best treatment for caustic burns.