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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Management of Corrosive Injuries of the Upper Gastrointestinal Tract
Correspondence Address :
Chhaya Joshi,
Assistant Professor, Dept. of Anaesthesiology,
SN Medical College and HSK Hospital,
Bagalkot, Karnataka, India-587101,
Phone: 9743320105.
E-mail: chhaya_joshi@yahoo.com
Introduction: A corrosive injury to the upper gastrointestinal tract is a common problem and has a wide spectrum of presentations. We have prospectively evaluated 16 patients who ingested corrosive substances for the location, extent and the severity of injury and its outcome. The best time to assess the injury is by 12-48 hours of ingestion of the corrosive substances. Upper gastrointestinal (GI) endoscopy is the single most important investigation which helps to grade the injury and to plan the further management.
Materials and Methods: All the patients who presented to the Casualty and to the Out patients Department of the H S K hospital, Bagalkot, during August 2009 to July 2010, with a history of corrosive agent ingestion were admitted and resuscitated. In the indicated cases, upper GI endoscopy was done to assess the severity of the injury. The following grading system was used. Grade 0- Normal mucosa, Grade1(superficial)- Superficial hyperaemia and oedema, Grade2A (Transmucosal)- Haemorrhage, exudates, linear erosions, blisters, shallow ulcers involving the mucosa and the submucosa, Grade2B- Circumferential burn present, Grade3-Deep ulceration, eschar formation with necrosis, full thickness injury with and without perforation.
Results: Out of the 16 patients, 10 were females and most were of the age group of 10-30 years.10 had consumed acid and 3 alkalis and in another 3 cases, the substance which was ingested was not elicitable. 15 patients had consumed the substances with suicidal intentions and in only one patient it was accidental. The predominant symptom was pain and most had oesophageal injuries. The grade 2 injury was the most common type of injury. 13 patients were managed conservatively and 3 required surgery. The most common complication was a stricture in the oesophagus.
Conclusion: The corrosive injury is more common in females. Most of the patients were of younger ages. Acid ingestion was more common than alkali ingestion, and most had suicidal intentions. Early upper G.I. endoscopy has a definite role in diagnosing the severity of the injury and in planning the management. Most of the patients with corrosive injuries can be managed conservatively with follow up for the stricture, which is the most common complication that is often treated by dilatation.
Acid, alkali, endoscopy, corrosive substances
Introduction
Corrosive injuries to the upper gastrointestinal tract are still a major concern in developing countries like India, where the corrosive substances are easily accessible to common people including children. These substances are used commonly in the form of toilet cleaning agents, soaps, bleaches, disc batteries, etc.
The ingestion of corrosive substances has devastating effects on the upper gastrointestinal tract and present major problems in their management (1). The severity of the resulting damage depends largely on the corrosive properties and the concentration of the ingested agent. These injuries occur as a result of accidental ingestion as in children or because of suicidal or homicidal intentions and under the influence of alcohol or drugs in case of adults (2). Hence, a lot of medico legal issues are also associated in the management of such injuries.
Acids and alkalis in various forms cause different patterns of injuries depending upon the quantity which has been ingested and the concentration. The management of such injuries is multidisciplinary, which involves reducing the morbidity and mortality by accurate early diagnosis, aggressive treatment of the life threatening complications and an attentive, long term follow up (3).
Caustic ingestion can cause severe injury to the oesophagus and the stomach. The severity and the extent of the oesophageal andthe gastric damage which results from a caustic ingestion depends upon the following factors (4) • Corrosive properties of the ingested substance • Amount, concentration, and physical form (solid or liquid) of the agent • Duration of contact with the mucosa.
More than 5000 caustic ingestions are reported annually in the United States; these ingestions are the leading cause of oesophageal strictures in children (5).
All the patients who presented to the Emergency Department or the Out Patients Department of the H S K hospital during August 2008 to July 2010, with a history of corrosive agent ingestion, were included in the study. The patients who had consumed other poisons were excluded. All the indicated cases underwent video endoscopy during the same period.
All the patients were admitted and adequate resuscitation was given. The medico legal aspects were taken due care of. The history was elicited to know as to what corrosive agent was ingested and the quantity and the concentration of the same. After resuscitation, upper gastrointestinal (GI) endoscopy was performed in the indicated cases, usually after 12-48 hours of ingestion oras suitable for the case. The grades of the injury were assessed endoscopicaly and the management was planned suitably. The following grading system was used.
The grade1 and 2 injuries were managed conservatively and the patients were advised follow up. The grade 3 and 4 injuries required surgery and follow up.
Observati ons and results
A total number of 16 patients were included for the study. The age of the patients ranged from 14 yrs to 67yrs. Most of the patients were of younger ages of 10 to 30 years (62.5%)(Table/Fig 1).
10 patients out of the 16 consumed acids (62.5%), 3 patients consumed alkalis (18.75%) and 3 patients consumed substances which were difficult to find out (18.75%)(Table/Fig 2).
In 15 patients, the corrosive ingestion was suicidal (93.75%) and in one patient it was accidental (6.25%). However, no cases of homicidal injuries were seen(Table/Fig 3).
The predominant symptoms in the early cases were pain, haemetemesis and retching. In the late cases, the symptom was difficulty in swallowing(Table/Fig 4).
Other symptoms were the drooling of saliva, anxiety, cough and hoarseness of the voice(Table/Fig 5).
Upper GI endoscopy was the most important investigation in both the early and the late cases. Most of the cases had oesophageal injury, whether the case was an early or late one or whether it was caused by acid or alkali. The duodenum was involved in 2 cases. Barium studies were done in 4 cases to delineate the strictures(Table/Fig 6).
The most common injury endoscopically was the grade 2 injury which involved the oesophagus and the stomach together. 5 grade 2a and 2b injuries were seen (31.25%). In 2 cases, the duodenum was also injured. No cases of perforations were seen in our series(Table/Fig 7).
The initial management was conservative in 13 cases (81.25%)(Table/Fig 8).
Three cases underwent surgery for the initial management. One case underwent antrectomy and Billroth 1 gastro-duodenostomy. One more patient needed antrectomy with anterior gastrojejunostomy. Another patient underwent feeding jejunostomy and oesophageal dilatation. The same patient developed tracheo-oesophageal fistula on follow up and needed definitive surgery)(Table/Fig 9).
The most common complication was stricture in the oesophagus (62.5%), two cases developed an antral stricture and chest complications were seen in one case. No patient developed hiatus hernia or malignancy during this study period, but however, further follow up was necessary(Table/Fig 10).
Corrosive injuries to the upper gastrointestinal tract are a complex clinical challenge. The signs and symptoms alone are an unreliable guide to the injury. Early endoscopy has a crucial role in both diagnosing and managing the cases of corrosive injuries. Most of the patients can be managed conservatively with follow up for the late complications. High grade injuries require operative management.
The ingestion of caustic substances can cause devastating injuries to the oesophagus and the stomach. The involvement of the duodenum and the perforation of the viscera which causes peritonitis, suggests the severity of the injury. The morbidity and the mortality in the cases of corrosive injuries is due to the immediate effect of the severe burns to the upper gastrointestinal tract or due to the late complications.
It has been said that strong alkalis “bite the oesophagus and lick the stomach” while strong acids “lick the oesophagus and bite the stomach” (6). Typically, alkali ingestions do result in more oesophageal than gastric damage, while strong acids cause more severe injury to the stomach than to the oesophagus. However, the ingestion of either type of corrosive agents can inflict a serious injury on the oesophagus, stomach and even the duodenum. The Toxic Exposure Surveillance System (TESS) compiles data annually from a population of approximately 290 million people who are served by the American Association of Poison Control Centres (7). In 2002, more than 1.5 million toxic exposures in children occurred, accounting for 66 percent of all the toxic exposures. The severity and the site of the injury depends on the substance which is ingested, its quantity, the residual food in the stomach and the duration of the tissue contact.
The goals for the management of such injuries are to limit and treat the immediate life threatening consequences of the corrosive ingestion and to control the subsequent stricture formation.
Plain radiographs of the chest and abdomen are taken to rule out pneumomediastinum or pneumoperitoneum. Upper GI endoscopy is the single most important investigation which helps to grade the injury and to plan the further management. Endoscopy should be performed within 12-24 hours of the corrosive ingestion. But its requirement in every case is controversial, due to its invasive nature. A case report by Sunil H V et al illustrates the importance of pertechnetate SPECT-CT as a non invasive, physiological investigation to delineate the integrity and viability of the mucosa in cases of corrosive gastric injuries (8). Barium studies have an important role in the late follow up to delineate the strictures. CT scan helps to differentiate the necrosis and to assess the stricture.
The acute phase management focuses on assessing and treating the dyspnoea, strider, dysphagia, bleeding, ulceration, necrosis and the perforation. Surgery in the acute phase depends on the site and the extent of the injury. Oesophago gastrectomy with cervical oesophagostomy and delayed reconstruction, distal gastrectomy, total gastrectomy and enteral access are the surgeries of choice. Oesophagectomy with colonic interposition may be required for patients with severe strictures. Minimally invasive oesophagectomythrough a combined thoracoscopic and laparoscopic approach is preferred because it is associated with a decreased hospital stay and a more rapid return to the normal activities as compared to standard oesophagectomy. The most important factors which guarantee a successful outcome for the surgery are a good vascular supply and the absence of tension at the anastomosis (9). Gastric transposition may be an acceptable alternative in the paediatric population, but one report showed a 5 percent mortality rate and a 12 percent leak rate, while 20 percent required dialation for the stricture formation (10).
Chronic phase management is done to limit and treat the stricture, gastric outlet obstruction, hiatus hernia, gastro oesophageal reflux disease, tracheo-oesophageal fistula, and the carcinoma. The chances for the development of the stricture is about 10-30% in the grade 2 injury and about 40-70% in the grade 3 injury. Its evaluation is done by barium swallow studies, upper GI endoscopy and CT scan.
Oesophageal dilatation is the primary treatment. The dilatation produced will be 4mm (or) 8 mm less than the dilating bougie. Most of the patients swallow when the oesophageal diameter is 12 mm. An attempt to dilate the stricture stagewise to a maximumdiameter of 17 to 20 mm without excessive force is advisable. Fluoroscopically guided oesophageal balloon dilatation is generally considered as a safe, easy, and effective means of treating a variety of oesophageal strictures in children (11).
Our study also confirmed these findings. According to the studies of Spiegel J et al (12), the signs and symptoms of the corrosive injuries do not reliably indicate the severity of the injury to the oesophagus and the stomach. In our study, two patients had minimal symptoms and signs, but they had endoscopicaly grade 2 injuries.
Sex incidences were variable in various studies, but in our study, the corrosive injury was more common in females than in males, which can be accounted to the more suicidal tendencies in females due to social atrocities.
The incidence of acid and lye ingestion in our study was found to be similar to that in the study of Youn et al (11). In our study, the substance which was ingested was not known in 3 patients.
Early, diagnostic, upper GI endoscopy is the critical component of the initial evaluation, based on which the clinical decisions can be made. In our study, endoscopy helped in the diagnosis and the management of both the early and the late cases. Howkins et al (13) and Zergar et al (14) had similar conclusions.
Most of patients with the grade 1 and 2 injuries can be managed conservatively with a late follow up. Grade 3 injuries also can be managed conservatively unless there is clinical deterioration.
No patient in our study had corrosive perforation. The commonest late sequel of the corrosive ingestion in our study was stricture of the oesophagus and the next common one was pyloric stenosis.
All the patients with corrosive strictures were managed by graduated, serial oesophageal dilatations by using Savary-Gillard dilators. Two patients required surgery for pyloric stenosis.
No mortality was observed during our study period. The study period may be insufficient to completely assess the validity of the various surgical modalities for the treatment and their complications. A long term study with a follow-up is however needed.
In our study, the corrosive injury was more common in females than in males. Most of the patients were of younger ages. Social factors may have been the reason for the ingestion of the corrosive substances. Acid ingestion was more common than alkali ingestion, and most of the patients had suicidal intentions. Early upper G.I. endoscopy has a definite role in diagnosing the severity of the injury and in planning the management. Most of the patients with corrosive injuries can be managed conservatively with follow up for the stricture, which is the most common complication that is often treated by dilatation. Patients who developed the oesophageal stricture underwent multiple dilatations.
1] Hughs TB, Kelly MD. Corrosive ingestion and the surgeon. J Am Coll Surg 1999; 50: 5-22.
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