Caustic Injury of Esophagus

CAUSTIC INJURY OF THE
ESOPHAGUS

Alkaline
● Liquefaction necrosis and results in a
deep burn
● Esophageal injury more severe
● More frequently swallowed accidentally
than acid due to less burning pain

Acid
● Coagulative necrosis and results in
forming an eschar that limits tissue
penetration
● Gastric injury more severe due to pyloric
spasm

PATHOLOGICAL PHASE
1. Acute necrotic or initial phase
: 1-4 days post injury
: inflammatory reaction & tissue necrosis
: pain in the mouth & substernum

PATHOLOGICAL PHASE
2. Ulceration & granulation phase
: subacute or latent phase
: 3-5 days post injury & last 10-12 days
: tissue necrosis & tissue sloughs result in
mucosal defect, inflamed base and filling
granulation tissue
: weakest esophagus

PATHOLOGICAL PHASE
3. Cicatrization & scarring phase
: begins the third week following injury
: contracting connective tissue &
narrowing esophagus
: stricture formation

CLINICAL MANIFESTATIONS
● Initial complaints consist of pain in the mouth
and substernal region & pain on swallowing
● Hypersalivation, fever, bleeding vomitus
● Initial complaints disappear during latent phase
● Dysphagia reappears during scarring phase,
60% within 1 month and 80% within 2 months
● If no dysphagia within 8 months, no stricture will
occur

CLINICAL MANIFESTATIONS
● Serious systemic reaction such as
hypovolumia and acidosis
● Renal damage caused by strong acids
● Respiratory complication such as
laryngospasm or edema or aspirated
pneumonia

CLINICAL MANIFESTATIONS
● Oropharyngeal examination
● Esophageal burns can be present without
symptoms or evidence of oropharyngeal
burns
● Early esophagoscopy is recommended
12-24 hours post injury & the scope should
not be introduced beyond the proximal
esophageal lesion to assess severity for
treatment plan

CONTRAINDICATION FOR EARLY
ESOPHAGOSCOPY
● Perforation or peritonitis
● Airway obstruction
● >48 hours post injury

ENDOSCOPIC GRADING OF
CAUSTIC INJURY
● Grade 1 : superficial mucosal hyperemia
● Grade 2A : superficial ulcer
● Grade 2B : deep ulcer or circumferential
ulcer
● Grade 3A : focal necrosis & eschar
● Grade 3B : extensive necrosis & eschar

RADIOGRAPHIC EXAMINATION
● Not reliable means for early injury
● Early : water soluble contrast for suspicious
perforation
● Late : barium swallow in later follow up to
identify strictures

ACUTE PHASE TREATMENT
● Grade 1, 2A : observe 24-48 hr
: without painful swallowing,
starting oral diet and
discharge with antacid
● Grade 2B, 3A : ICU care ~ 1wk
: NPO, IV, ATB,PPI

ACUTE PHASE TREATMENT
● Neutralizing agent may be effective within the
first hour
● Contraindication : NG tube, lavage, induction of
emesis, esophagoscopy after
48 hr.
● Without strong evidence support for stricture prevention

: steroid, intraluminal stent, early
dilatation, antifibrotic agent
(penicillamine)

ACUTE PHASE TREATMENT
● Hoarseness, stridor, dyspnea suggest
laryngeal edema or epiglottic injury
● Prompting airway evaluation with
bronchoscopy or laryngoscopy and possible
intubation or tracheostomy to maintain airway
patency

INDICATION FOR EARLY SURGERY
● Presence of symptoms & signs of perforation
such as shock, acidosis, sepsis, mediastinitis,
peritonitis
● Transhiatal esophagectomy, cervical
esophagostomy, feeding jejunostomy
● Gastric resection for gastric necrosis
● Delayed reconstruction after 6 months

MANAGEMENT OF STRICTURES
● Optimal time for dilation is 3- 4 weeks post injury
● Pre-dilation esophagogram
● Antegrade dilation
● Tucker retrograde dilation
● Goal : up to 42- 44F but accept 36-38F
● Frequency: severe q 2 wk
mild to moderate q 3- 4 wk
● Duration: 6-12 months

INDICATION FOR SURGERY FOR
STRICTURE
●perforation, fistula
●Failure dilation
●Patient preference
●Malignancy

SUMMARY MANAGEMENT OF
ACUTE
CAUSTIC INJURY

● History and physical examination
● Severe : ABC’s , upright chest x-ray,
abdominal films
: early intubation or tracheostomy
if airway obstruction is suspected
● Perforation : emergency resection
● No perforation : esophagoscopy ±
brochoscopy

SUMMARY MANAGEMENT OF
ACUTE
● Grade 1 ,2ACAUSTIC INJURY
: 48 hr observation
: NPO, advance diet as tolerated
: worsening symptom → treat as 2B,3
● Grade 2B ,3A
: NPO, antibiotics, PPI, ICU observation
: deterioration →emergency resection