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Caustic esophageal lesions in childhood: Prevention of stricture formation
Caustic Esophageal Lesions in Childhood: Prevention of Stricture Formation B y F.A. Wijburg, H.S.A. Heymans, a n d N . A . M . Urbanus
A m s t e r d a m , The Netherlands 9 Accidental caustic ingestion, a problem of childhood, can lead to esophageal stricture formation. W e studied 132 children < 1 9 years of age who w e r e admitted to our hospital for suspected caustic ingestion. Forty-nine had burns in the esophagus, 11 of w h o m had deep and circular burns and were therefore prone to developing esophageal strictures. Only these 11 children w e r e treated for prevention of stricture formation with a special nasogastric tube, functioning as intraluminal stent, this was their sole treatment. No corticosteroids w e r e used. Only one of the 11 developed mild stenosis. In none of the other untreated children was stricture formation observed. Therefore, w e believe that this approach spares many children unnecessary treatment and hospitalization, that our nasogastric tube effectively prevents stricture formation, and that there is no need for the use of corticosteroids in the t r e a t m e n t of caustic esophageal lesions in childhood. 9 1989 by Grune & Stratton, Inc. I N D E X W O R D S : Caustic ingestion; esophageal stenosis; esophageal stenting.
C C I D E N T A L I N G E S T I O N of caustic agents, potentially capable of burning the esophagus, is generally a problem of childhood. Young toddlers especially, who are investigating their surroundings and are unaware of many dangers, are prone to this kind of accident. Severe burning of the esophagus may lead to esophageal stricture formation that can have a terrible effect on the lives of the child and the parents. How stricture formation can be best prevented is still a subject of debate, and there is also no agreement on which children need treatment. Many physicians administer corticosteroids and antibiotics to all children with established esophageal burns and claim good results. ~3 However, there is evidence that this form of treatment is not capable of decreasing the incidence of stricture formation when severe burning is present. 3'4 We, on the other hand, do not use corticosteroids in the treatment of esophageal burns. As mild burns in the esophagus will not result in stricture formation, and therefore do not need therapy, we believe that treatment is necessary only when deep and circular burns are present. We then insert a specially made nasogastric tube that functions as an intraluminal esophageal stent, thereby preventing stricture formation. By excluding most children with burns from intensive therapy and only treating the few with severe (deep and circular) burns, we hope to save many children from unnecessary hospitalization and even potentially dangerous treatment. To evaluate our treatment protocol, we studied the Journal of PediatricSurgery, Vol 24, No 2 (February), 1989: pp 171 - 173
records of all children with suspected caustic ingestion admitted to our hospital between January 1971 and May 1985. MATERIALS AND METHODS
From January 1971 to May 1985, 132 children <19 years of age were admitted to our hospital for suspected caustic ingestion. After examination of the mouth, pharynx, and larynx, an esophagoscopy was performed in all patients within 24 hours after ingestion (except for one patient). If only relatively mild burns were observed, ie, erythema, edema, small erosions, the patient was discharged with a liquid diet for the first few days, but had to report to the clinic immediately when new complaints developed. Patients with more severe burns, ie, extensive noncircular lesions, were admitted for observation for several days and were also put on a liquid diet. When the esophageal burns were classified as circular and deep (burns were considered deep if the surface of the mucosal lining was indented or the mucosa was becoming detached), a siliconized silicone rubber nasogastric tube was immediately inserted (Fig 1). Different tubes were used for different age groups and sexes (Table 1). When accidental removal of the tube occurred, the tube was rinsed, siliconized again, and reinserted. No child had to be excluded from this study for not tolerating the tube. Nothing was given by mouth for 24 hours, after which clear liquid food could be taken, first through the tube and later by mouth, followed by soft solid food within 1 week. The tube remained in situ for 5 to 6 weeks. After removal of the tube, a control esophagoscopy was performed and/or a barium swallow examination was done. Until 1982, all children with deep circular lesions received broad spectrum antibiotics for ten days; later, this was discontinued. None of the patients received corticosteroids. All 132 children were seen at least once in the outpatient clinic for follow-up.
RESULTS
T h e r e c o r d s o f 13 2 c h i l d r e n (71 boys, 61 girls) < 19 y e a r s o f a g e ( m e a n age, 2 y e a r s ) w e r e i n c l u d e d in this s t u d y ( F i g 2). F i v e p a t i e n t s d r a n k a c a u s t i c a g e n t in an a t t e m p t e d suicide ( a g e d 1 1, 14, 16, 17, a n d 18 y e a r s ) ; all o t h e r ingestions w e r e a c c i d e n t a l . In 4 6 cases, t h e i n g e s t e d a g e n t was a h o u s e h o l d bleach. S i x t e e n child r e n d r a n k a m m o n i a , 13 lye, a n d e i g h t acid. T h e r e m a i n i n g 49 c h i l d r e n d r a n k a v a r i e t y o f a g e n t s , in m a n y c a s e s h o u s e h o l d cleansers.
From the Departments of Pediatrics and Otolaryngology, University Hospital of Amsterdam (AMC), Amsterdam, The Netherlands. Address reprint requests to F.A. Wijburg, MD, Department of Pediatrics, University Hospital of Amsterdam (AMC), Meibergdreef 9. 1105 AZ Amsterdam, The Netherlands. 9 1989 by Grune & Stratton, Inc. 0022-3468/89/2402-0007503.00/0 171
172
WIJBURG, HEYMANS, AND URBANUS
60
5 0 84
IZ
40.
Ul
n
30'
I,U
0
6
20.
Z 10-
olD
1
2
3 4
5
6
7 8
9 10 11 12 13 14 15 16 17 18
AGE (yrs.) Fig 1. Special nasogastric tube used to prevent stricture formation (see Table 1 ).
Fig 2.
During endoscopy, lesions in the esophagus were seen in 49 children. In 28 of them, only slight changes (erythema, mild edema, small erosions) were present; whereas in ten patients, the lesions were more severe. The deep and circular lesions, seen in the remaining 11 children, were due to ingestion of household bleach (four patients), acid (two patients), lye (two patients), ammonia, Lysol (cresol), and Savlon (chlorhexidinegluconate and cetrimide). One of these children (aged 18) attempted suicide by drinking an acid. All 11 patients with deep circular lesions received a nasogastric tube. The tube was inserted immediately after the initial esophagoscopy, within 24 hours of ingestion, in ten children. In one child, a 5-year-old girl who had ingested acetic acid and had first been treated elsewhere, the tube was inserted six days after ingestion. In this child, stricture formation was observed during a control esophagoscopy 2 weeks after ingestion. The stricture could be dilated without complications. No stricture formation was observed in the other ten patients, nor in the group of 38 patients with established esophageal lesions that were not treated. Of the 49 children with esophageal burns, only nine of
Number of patients per age group.
the 11 with deep and circular burns received antibiotics during the first ten days following ingestion. Laryngeal edema was observed in two children (both having ingested lye). One patient who had ingested Lysol developed reversible liver function disturbances. In this relatively large series of patients, no infectious complications were noted. DISCUSSION
Although esophageal lesions are found in only a minority of children who are suspected of having ingested a caustic agent (39% of the children in our study), there is almost a general consent that esophagoscopy needs to be performed in all cases. This is necessary because neither the presence of oropharyngeal burns 4 nor the presence of signs or symptoms 5 can accurately predict the presence or absence of esophageal burns. Unfortunately, there is less agreement on what to do when esophageal burns are seen during esophagoscopy. There are conflicting opinions on who needs preventive treatment for stricture formation as well as on the best ways to do this. Since the work of Spain et al, 6 who
Table 1. Different Lengths and External Diameters of Esophageal Stents Part A
Part B
Part C
Part D
Age (yr)
Length ( c m )
Diameter (ram)
Length( c m )
Diameter (mm)
Length ( c m )
Diameter (ram)
Length( c m )
Diameter (mm)
0to2 3 to 5 6 to 12 > 12 (females) > 12 (males)
15 20 22 35 40
5 5 7 10 10
10 10 12 20 20
5 5 5 7 7
8 8 8 20 20
5 5 5 7 7
5 5 5 5 5
7 7 7 10 10
NOTE. Three different silicone rubber tubes are glued together. The most distal portion of part D is perforated for feeding and suction, and a metal ball has been cemented in the blind end. Parts A and D are lubricated with silicone oil (see Fig 1 ).
CAUSTIC ESOPHAGEAL LESIONS
173
showed that the early administration of cortisone had an anti-inflammatory effect and inhibited fibroplasia in wounds, much attention has been paid to the successful treatment of caustic esophageal lesions by using corticosteroids in both experimental 7 and clinical settings. 13 Antibiotics are given in addition to steroids in view of the risk of mediastinitis and pulmonary infections due to aspiration, increased by the use of corticosteroids. Some physicians are more reserved in the use of steroids. They presume that steroids may only be capable of preventing stricture formation in moderately severe burns. 3'4 Some studies even conclude that there is no use at all for steroids in the prevention of esophageal strictures. 8"9We believe that it is inadvisable to treat esophageal burns with corticosteroids. There is danger of bacterial infections in corticosteroid immunesuppressed children] ~ Varicella infection may take a much more serious course in these children, ll Also, it has been shown that even short-term corticosteroid therapy can suppress hypothalamic-pituitary function, which may remain subnormal for months. ~2 In view of these dangers of corticosteroid therapy in childhood, and since in our study only one child of the 49 with lesions in the esophagus developed a mild stricture (while we did not use corticosteroids), we believe that there is no place for steroids in the routine treatment of esophageal burns. We, as well as others, ~315 believe that an indwelling
nasogastric tube can prevent stricture formation in a severely burned esophagus. It causes the lumen to be kept open as the wide esophageal part of the tube functions as an esophageal splint. O f the 11 children with severe burns, ie, deep and circular, who were treated with the nasogastric tube, only one developed a mild stricture. This was the only child in whom the tube was inserted six days after ingestion instead of within 24 hours. Most physicians treat all children with caustic esophageal burns, regardless of degree and extension, to prevent esophageal strictures. 1'2'4'15Because none of the children in this study who had established esophageal burns that were not deep and circular (and therefore not treated for prevention of stricture formation [38 cases]) developed an esophageal stricture, we are convinced that only those children with deep and circular lesions need special treatment. In this manner, many children can be spared from unnecessary therapy and hospitalization. Finally, we want to stress that the prevention of pediatric caustic ingestion by health education and the use of child-safe covers and capsules, if possible dictated by law, is of the greatest importance. ACKNOWLEDGMENT
We are grateful to M.M.J.M. Beukers, MD and R.N.P. Berkovits, MD, PhD, for their help during this study.
REFERENCES
1. Adam JS, Birck HG: Pediatric caustic ingestion. Ann Otol Rhinol Laryngol 91:656-658, 1982 2. Hailer JA, Andrews HG, White J J, et al: Pathophysiology and management of acute corrosive burns of the esophagus. J Pediatr Surg 6:578-584, 1971 3. Hawkins DB, Demeter M J, Barnett TE: Caustic ingestion: Controversies in management. A review of 214 cases. Laryngoscope 90:98-109, 1980 4. Webb WR, Koutras P, Ecker RR, et al: An evaluation of steroids and antibiotics in caustic burns of the esophagus. Ann Thorac Surg 9:95-102, 1970 5. Gaudreault P, Parent M, McGuigan M, et al: Predictability of esophageal injury from signs and symptoms: A study of caustic ingestion in 378 children. Pediatrics 71:767-770, 1983 6. Spain DM, Molomut N, Haber A: The effect of cortisone on the formation of granulation tissue in mice. Am J Patho126:710-711, 1950 7. Hailer JA, Bachman K: The comparative effect of current therapy on experimental caustic burns of the esophagus. Pediatrics 34:236-245, 1964 8. DiConstanzo J, Noirdec M, Jouglard J, et al: New therapeutic
approach to corrosive burns of the upper gastrointestinal tract. Gut 21:370-375, 1980 9. Van Zeben W: Slokdarmverbrandingen bij kinderen. Tijdschr Kindergeneeskd 44:69-80, 1976 10. Haynes RC, Murad F: Adrenocortical steroids, in Goodman A, Gilman LS, Rail TW, et al (eds): The Pharmacological Basis of Therapeutics (ed 7). New York, Macmillan, 1985, pp 168-189 11. Zaia JA: Clinical spectrum of varicella-zoster virus infections, in Nahmias A J, Dowdle WR, Schinazi RE (eds): The Human Herpes-Viruses: An Interdisciplinary Perspective. New York, Elsevier, 1981, pp 10-19 12. Wilson KS, Parker AC: Adrenal suppression after short-term corticosteroid therapy. Lancet 1: 1030, 1979 (letter) 13. Hill JL, Norberg HP, Smith MD, et al: Clinical technique and success of the esophageal stent to prevent corrosive strictures. J Pediatr Surg 11:443-50, 1976 14. Mills L J, Estrera AS, Platt MR: Avoidance of esophageal stricture following severe caustic burns by the use of an intraluminal stent. Ann Thorac Surg 28:60-65, 1979 15. Citron BP, Pincus I J, Geokas MC, et al: Chemical trauma of the esophagus and stomach. Surg Clin North Am 48:1303-1311, 1968
A m s t e r d a m , The Netherlands 9 Accidental caustic ingestion, a problem of childhood, can lead to esophageal stricture formation. W e studied 132 children < 1 9 years of age who w e r e admitted to our hospital for suspected caustic ingestion. Forty-nine had burns in the esophagus, 11 of w h o m had deep and circular burns and were therefore prone to developing esophageal strictures. Only these 11 children w e r e treated for prevention of stricture formation with a special nasogastric tube, functioning as intraluminal stent, this was their sole treatment. No corticosteroids w e r e used. Only one of the 11 developed mild stenosis. In none of the other untreated children was stricture formation observed. Therefore, w e believe that this approach spares many children unnecessary treatment and hospitalization, that our nasogastric tube effectively prevents stricture formation, and that there is no need for the use of corticosteroids in the t r e a t m e n t of caustic esophageal lesions in childhood. 9 1989 by Grune & Stratton, Inc. I N D E X W O R D S : Caustic ingestion; esophageal stenosis; esophageal stenting.
C C I D E N T A L I N G E S T I O N of caustic agents, potentially capable of burning the esophagus, is generally a problem of childhood. Young toddlers especially, who are investigating their surroundings and are unaware of many dangers, are prone to this kind of accident. Severe burning of the esophagus may lead to esophageal stricture formation that can have a terrible effect on the lives of the child and the parents. How stricture formation can be best prevented is still a subject of debate, and there is also no agreement on which children need treatment. Many physicians administer corticosteroids and antibiotics to all children with established esophageal burns and claim good results. ~3 However, there is evidence that this form of treatment is not capable of decreasing the incidence of stricture formation when severe burning is present. 3'4 We, on the other hand, do not use corticosteroids in the treatment of esophageal burns. As mild burns in the esophagus will not result in stricture formation, and therefore do not need therapy, we believe that treatment is necessary only when deep and circular burns are present. We then insert a specially made nasogastric tube that functions as an intraluminal esophageal stent, thereby preventing stricture formation. By excluding most children with burns from intensive therapy and only treating the few with severe (deep and circular) burns, we hope to save many children from unnecessary hospitalization and even potentially dangerous treatment. To evaluate our treatment protocol, we studied the Journal of PediatricSurgery, Vol 24, No 2 (February), 1989: pp 171 - 173
records of all children with suspected caustic ingestion admitted to our hospital between January 1971 and May 1985. MATERIALS AND METHODS
From January 1971 to May 1985, 132 children <19 years of age were admitted to our hospital for suspected caustic ingestion. After examination of the mouth, pharynx, and larynx, an esophagoscopy was performed in all patients within 24 hours after ingestion (except for one patient). If only relatively mild burns were observed, ie, erythema, edema, small erosions, the patient was discharged with a liquid diet for the first few days, but had to report to the clinic immediately when new complaints developed. Patients with more severe burns, ie, extensive noncircular lesions, were admitted for observation for several days and were also put on a liquid diet. When the esophageal burns were classified as circular and deep (burns were considered deep if the surface of the mucosal lining was indented or the mucosa was becoming detached), a siliconized silicone rubber nasogastric tube was immediately inserted (Fig 1). Different tubes were used for different age groups and sexes (Table 1). When accidental removal of the tube occurred, the tube was rinsed, siliconized again, and reinserted. No child had to be excluded from this study for not tolerating the tube. Nothing was given by mouth for 24 hours, after which clear liquid food could be taken, first through the tube and later by mouth, followed by soft solid food within 1 week. The tube remained in situ for 5 to 6 weeks. After removal of the tube, a control esophagoscopy was performed and/or a barium swallow examination was done. Until 1982, all children with deep circular lesions received broad spectrum antibiotics for ten days; later, this was discontinued. None of the patients received corticosteroids. All 132 children were seen at least once in the outpatient clinic for follow-up.
RESULTS
T h e r e c o r d s o f 13 2 c h i l d r e n (71 boys, 61 girls) < 19 y e a r s o f a g e ( m e a n age, 2 y e a r s ) w e r e i n c l u d e d in this s t u d y ( F i g 2). F i v e p a t i e n t s d r a n k a c a u s t i c a g e n t in an a t t e m p t e d suicide ( a g e d 1 1, 14, 16, 17, a n d 18 y e a r s ) ; all o t h e r ingestions w e r e a c c i d e n t a l . In 4 6 cases, t h e i n g e s t e d a g e n t was a h o u s e h o l d bleach. S i x t e e n child r e n d r a n k a m m o n i a , 13 lye, a n d e i g h t acid. T h e r e m a i n i n g 49 c h i l d r e n d r a n k a v a r i e t y o f a g e n t s , in m a n y c a s e s h o u s e h o l d cleansers.
From the Departments of Pediatrics and Otolaryngology, University Hospital of Amsterdam (AMC), Amsterdam, The Netherlands. Address reprint requests to F.A. Wijburg, MD, Department of Pediatrics, University Hospital of Amsterdam (AMC), Meibergdreef 9. 1105 AZ Amsterdam, The Netherlands. 9 1989 by Grune & Stratton, Inc. 0022-3468/89/2402-0007503.00/0 171
172
WIJBURG, HEYMANS, AND URBANUS
60
5 0 84
IZ
40.
Ul
n
30'
I,U
0
6
20.
Z 10-
olD
1
2
3 4
5
6
7 8
9 10 11 12 13 14 15 16 17 18
AGE (yrs.) Fig 1. Special nasogastric tube used to prevent stricture formation (see Table 1 ).
Fig 2.
During endoscopy, lesions in the esophagus were seen in 49 children. In 28 of them, only slight changes (erythema, mild edema, small erosions) were present; whereas in ten patients, the lesions were more severe. The deep and circular lesions, seen in the remaining 11 children, were due to ingestion of household bleach (four patients), acid (two patients), lye (two patients), ammonia, Lysol (cresol), and Savlon (chlorhexidinegluconate and cetrimide). One of these children (aged 18) attempted suicide by drinking an acid. All 11 patients with deep circular lesions received a nasogastric tube. The tube was inserted immediately after the initial esophagoscopy, within 24 hours of ingestion, in ten children. In one child, a 5-year-old girl who had ingested acetic acid and had first been treated elsewhere, the tube was inserted six days after ingestion. In this child, stricture formation was observed during a control esophagoscopy 2 weeks after ingestion. The stricture could be dilated without complications. No stricture formation was observed in the other ten patients, nor in the group of 38 patients with established esophageal lesions that were not treated. Of the 49 children with esophageal burns, only nine of
Number of patients per age group.
the 11 with deep and circular burns received antibiotics during the first ten days following ingestion. Laryngeal edema was observed in two children (both having ingested lye). One patient who had ingested Lysol developed reversible liver function disturbances. In this relatively large series of patients, no infectious complications were noted. DISCUSSION
Although esophageal lesions are found in only a minority of children who are suspected of having ingested a caustic agent (39% of the children in our study), there is almost a general consent that esophagoscopy needs to be performed in all cases. This is necessary because neither the presence of oropharyngeal burns 4 nor the presence of signs or symptoms 5 can accurately predict the presence or absence of esophageal burns. Unfortunately, there is less agreement on what to do when esophageal burns are seen during esophagoscopy. There are conflicting opinions on who needs preventive treatment for stricture formation as well as on the best ways to do this. Since the work of Spain et al, 6 who
Table 1. Different Lengths and External Diameters of Esophageal Stents Part A
Part B
Part C
Part D
Age (yr)
Length ( c m )
Diameter (ram)
Length( c m )
Diameter (mm)
Length ( c m )
Diameter (ram)
Length( c m )
Diameter (mm)
0to2 3 to 5 6 to 12 > 12 (females) > 12 (males)
15 20 22 35 40
5 5 7 10 10
10 10 12 20 20
5 5 5 7 7
8 8 8 20 20
5 5 5 7 7
5 5 5 5 5
7 7 7 10 10
NOTE. Three different silicone rubber tubes are glued together. The most distal portion of part D is perforated for feeding and suction, and a metal ball has been cemented in the blind end. Parts A and D are lubricated with silicone oil (see Fig 1 ).
CAUSTIC ESOPHAGEAL LESIONS
173
showed that the early administration of cortisone had an anti-inflammatory effect and inhibited fibroplasia in wounds, much attention has been paid to the successful treatment of caustic esophageal lesions by using corticosteroids in both experimental 7 and clinical settings. 13 Antibiotics are given in addition to steroids in view of the risk of mediastinitis and pulmonary infections due to aspiration, increased by the use of corticosteroids. Some physicians are more reserved in the use of steroids. They presume that steroids may only be capable of preventing stricture formation in moderately severe burns. 3'4 Some studies even conclude that there is no use at all for steroids in the prevention of esophageal strictures. 8"9We believe that it is inadvisable to treat esophageal burns with corticosteroids. There is danger of bacterial infections in corticosteroid immunesuppressed children] ~ Varicella infection may take a much more serious course in these children, ll Also, it has been shown that even short-term corticosteroid therapy can suppress hypothalamic-pituitary function, which may remain subnormal for months. ~2 In view of these dangers of corticosteroid therapy in childhood, and since in our study only one child of the 49 with lesions in the esophagus developed a mild stricture (while we did not use corticosteroids), we believe that there is no place for steroids in the routine treatment of esophageal burns. We, as well as others, ~315 believe that an indwelling
nasogastric tube can prevent stricture formation in a severely burned esophagus. It causes the lumen to be kept open as the wide esophageal part of the tube functions as an esophageal splint. O f the 11 children with severe burns, ie, deep and circular, who were treated with the nasogastric tube, only one developed a mild stricture. This was the only child in whom the tube was inserted six days after ingestion instead of within 24 hours. Most physicians treat all children with caustic esophageal burns, regardless of degree and extension, to prevent esophageal strictures. 1'2'4'15Because none of the children in this study who had established esophageal burns that were not deep and circular (and therefore not treated for prevention of stricture formation [38 cases]) developed an esophageal stricture, we are convinced that only those children with deep and circular lesions need special treatment. In this manner, many children can be spared from unnecessary therapy and hospitalization. Finally, we want to stress that the prevention of pediatric caustic ingestion by health education and the use of child-safe covers and capsules, if possible dictated by law, is of the greatest importance. ACKNOWLEDGMENT
We are grateful to M.M.J.M. Beukers, MD and R.N.P. Berkovits, MD, PhD, for their help during this study.
REFERENCES
1. Adam JS, Birck HG: Pediatric caustic ingestion. Ann Otol Rhinol Laryngol 91:656-658, 1982 2. Hailer JA, Andrews HG, White J J, et al: Pathophysiology and management of acute corrosive burns of the esophagus. J Pediatr Surg 6:578-584, 1971 3. Hawkins DB, Demeter M J, Barnett TE: Caustic ingestion: Controversies in management. A review of 214 cases. Laryngoscope 90:98-109, 1980 4. Webb WR, Koutras P, Ecker RR, et al: An evaluation of steroids and antibiotics in caustic burns of the esophagus. Ann Thorac Surg 9:95-102, 1970 5. Gaudreault P, Parent M, McGuigan M, et al: Predictability of esophageal injury from signs and symptoms: A study of caustic ingestion in 378 children. Pediatrics 71:767-770, 1983 6. Spain DM, Molomut N, Haber A: The effect of cortisone on the formation of granulation tissue in mice. Am J Patho126:710-711, 1950 7. Hailer JA, Bachman K: The comparative effect of current therapy on experimental caustic burns of the esophagus. Pediatrics 34:236-245, 1964 8. DiConstanzo J, Noirdec M, Jouglard J, et al: New therapeutic
approach to corrosive burns of the upper gastrointestinal tract. Gut 21:370-375, 1980 9. Van Zeben W: Slokdarmverbrandingen bij kinderen. Tijdschr Kindergeneeskd 44:69-80, 1976 10. Haynes RC, Murad F: Adrenocortical steroids, in Goodman A, Gilman LS, Rail TW, et al (eds): The Pharmacological Basis of Therapeutics (ed 7). New York, Macmillan, 1985, pp 168-189 11. Zaia JA: Clinical spectrum of varicella-zoster virus infections, in Nahmias A J, Dowdle WR, Schinazi RE (eds): The Human Herpes-Viruses: An Interdisciplinary Perspective. New York, Elsevier, 1981, pp 10-19 12. Wilson KS, Parker AC: Adrenal suppression after short-term corticosteroid therapy. Lancet 1: 1030, 1979 (letter) 13. Hill JL, Norberg HP, Smith MD, et al: Clinical technique and success of the esophageal stent to prevent corrosive strictures. J Pediatr Surg 11:443-50, 1976 14. Mills L J, Estrera AS, Platt MR: Avoidance of esophageal stricture following severe caustic burns by the use of an intraluminal stent. Ann Thorac Surg 28:60-65, 1979 15. Citron BP, Pincus I J, Geokas MC, et al: Chemical trauma of the esophagus and stomach. Surg Clin North Am 48:1303-1311, 1968