Alkalis PH > 7 Tasteless, odorless →largeramounts liquefaction necrosis => directextension, deeper injuries Esophageal injury is common In stomach, partial neutralizationby gastric acid may result limitedinjury Duodenal injury is less commonAcid PH < 7 Pungent odor and noxioustaste coagulation necrosis =>formation of a coagulumlayer : limit the depth ofinjury Less esophageal injury More gastric injury As the acid toward thepylorus, pylorospasmimpairs emptying into theduodenum
Corrosive properties of the ingested substance Amount, concentration, and physical form(solid or liquid) of the agent Duration of contact with the mucosa
1. Vary widely Hoarseness, stridor, dyspnea => Airway evaluation Perforation: (During first 2 weeks) Retro-sternal or back pain Localized abdominal tenderness, rebound, rigidity,Psoas sign, obturator sign Massive hematemesis Dysphagia, odynophagia, drooling, nausea, vomiting2. Early signs and symptoms may not correlate with the severityand extent of tissue injury3. Oropharyngeal burns (-) :10-30% esophageal burns(+)Oropharyngeal burns (+) : 70% esophageal burns(-)
Avoid: The use of emetics: re-exposes Neutralizing agents: thermal injury Gastric lavage: may induce retchingand vomiting which can compoundinjury
Primary survey Keep NPO IV fluids administer Gastric acid suppression with intravenous PPI Adequate pain relief with intravenous narcotics Airway evaluation - laryngoscopy R/O perforation - Plain films of chest and abdomen Observation for Clinical signs ofperforation, mediastinitis, or peritonitis Broad spectrum antibiotics - given for patients with Grade3 caustic injury or high suspicion for esophageal perforation. Endoscope
1. Timing: No later than 24 hours Usually avoided from 5-15 days2. Purpose: Grading, manage appropriately3. Risk of perforation: Low, under adequate sedation4. Extent: Advance until a circumferential second or third degree burn isseen To first part of duodenum
1. Patients with mild or no injury○ may be discharged.2. Patients with grade 1 or 2A injury○ require no therapy.○ a liquid diet may be initiated○ advanced to a regular diet in 24 to 48 hours.3. Patients with grade 2B or 3 injuries○ should have nasoenteric tube feeding initiated after 24hours.○ oral liquids are allowed after the first 48 hours if thepatient is able to swallow saliva.○ steroids ???.*Patients with grade 3 injuries should be carefullyobserved for signs of perforation over at least a one-week.Prophylactic esophageal stenting is not recommended.
In animal studies: incidence of stricture formation In human studies: Inconclusive so far NEJM. 1990: Prospective study over an 18-year period No benefit Related only to the severity of the corrosiveinjury Toxicol Rev. 2005: 1991-2004 in theEnglish, German, French, Spanish No benefit
Clinical signs of perforation, mediastinitis, or peritonitis areindications for emergency surgery. Esophagectomy may be required for patients with severestrictures. Minimally invasive esophagectomy approach may be preferredbecause it is associated with a decreased hospital staycompared with standard esophagectomy. The most important factors to guarantee a successful outcomefor surgery are good vascular supply and absence of tension atthe anastomosis. If the stomach is damaged as well as the esophagus, a colonicinterposition can be used to create a new conduit.
The prognosis is variable and depends uponthe grade of esophageal injury and theunderlying medical condition of the patient. Most deaths are due to the sequelae ofperforation and mediastinitis.
1. Stricture formation one-third of patients suffered caustic esophageal injury developesophageal strictures Primarily in those with grade 2B or 3 injury Peak incidence: two months Occur as early as two weeks or as late as years after ingestion Barium swallow examination is useful in the evaluation
1. Endoscopic dilatation The goal: dilate the esophageal lumen to 15 mm Perforation rate: 0.5% Special consideration: Long, eccentric strictures: risk of perforation increased Thick-walled strictures: recur rapidly Multiple sessions: elective esophageal resection2. Intraluminal stent Temporary placement of a self-expanding plastic stent Successful in case reports3. Surgery Esophagectomy with colonic interposition Gastric transposition: high leak rate Perform 6 months later
2. Esophageal carcinoma Incidence: 1000 to 3000-fold increase 3% have history of caustic ingestion Mean latency: 41 years (13-71years) Scar carcinoma: Less distensible => dysphagia presents earlier Lymphatic spread and direct extension Endoscope surveillance Begin 15-20 years after ingestion The time interval : No more than every 1-3 years
Severity depend upon: the amount, concentration, physical formand the duration of contact with the mucosa. The absence of oropharyngeal burns does not preclude thepresence of esophageal or gastric injury. The use of emetics, neutralizing agents, or nasogastric intubation toremove remaining caustic material is contraindicated. Gastrointestinal endoscopy should be performed in first 24 hours. Endoscopy is contraindicated if hemodynamic instability, evidenceof perforation, severe respiratory distress, or severe oropharyngealor glottic edema and necrosis. Clinical signs of perforation, mediastinitis or peritonitis areindications for emergency surgery. Long-term complications include esophageal strictures andesophageal squamous cell carcinoma. Endoscopic surveillance forcancer is recommended at 15-20 years after ingestion.