This document discusses the evaluation and management of caustic ingestion injuries of the esophagus. It describes grading the severity of injuries based on endoscopic and CT findings. For low grade injuries, supportive care is recommended, while high grade injuries require inpatient monitoring. Endoscopic dilation may be attempted for strictures after 3-6 weeks, while surgical reconstruction is considered for multiple dilation failures or severe injuries. Long term risks include stricture formation, fistula, bleeding and cancer development.

1. Dr Hafiz Muhammad Wasif Khan
Fellow in Gastroenterology
Pakistan Kidney and Liver Institute

2. Etiology
 Gastroesophageal Reflux Disease(GERD)
 Corrosive Intake
 Treatment of esophageal varices
 Eosinophilic esophagitis
 Extended use of a nasogastric tube
 Dermatologic disease(Lichen planus, Systemic sclerosis)
 Radiation therapy

3. Classification
 Simple, Complex and Refractory
 Based on appearance, endoscopic findings, and
response to dilation

4. Classification
Simple Complex
 Smooth-surfaced
 Short (<2 cm in length)
 Concentric
 Diameter of stricture lumen
>10 mm
 Irregular surface
 length ≥2 cm
 Tortous
 Severely narrowed (diameter
≤10 mm), or.

5. Refractory Strictures
 Not successfully dilated to a diameter of 14 mm over
five endoscopic sessions at two-week intervals.

6. Management
 Medical Management i.e PPI
 Endoscopic Dilatation
 Surgical Resection

7. CONTRAINDICATIONS
 Acute or incompletely healed esophageal perforation.
 Patients with disorders of hemostasis including platelet count
(<50,000/microL or international normalized ratio >1.5).
 Patients who are hemodynamically unstable.
 Patients with erosive esophagitis
 Eosinophilic esophagitis is suspected but has not been
confirmed and/or have not been treated with medical therapy.

8. Risk increased ,not absolutely
contraindicated
 Recent gastroesophageal surgery – should be
postponed till one month preferably
 Large thoracic aortic aneurysm – For patients with a
large thoracic aortic aneurysm (aortic diameter >5.5
cm) who require esophageal dilation,Use through-the-
scope (TTS) balloon dilators rather than push dilators,

9. ENDOSCOPIC DILATION
 Goal is relief of dysphagia
 Lumen diameter ≥18 mm – allows intake of a regular-
consistency diet (eg, solid foods).
 Lumen diameter 15 to 17 mm – allows intake of a soft diet,
while dysphagia for regular solid food may persist.
 Lumen diameter 13 to 14 mm – allows intake of thick
liquids but dysphagia for solid foods persists.

10. Push (bougie) Dilators
 Push (bougie) dilators
are either wire-guided
dilators or non-wire-
guided dilators
(tungsten-filled,
weighted rubber
bougies).
 Savary-Gilliard dilator
..made from plastic

11. Non-wire-guided Dilators
 Maloney dilator
 passed blindly through
the stricture.

12. Balloon Dilators
 Balloon dilators– TTS
balloon dilators are
passed directly through
the biopsy channel of the
endoscope.
 TTS balloon dilators
typically provide gradual
dilation in 1 to 1.5 cm
increments with three
sizes per balloon

13. Patient preparation
 Anesthesia : Moderate sedation or monitored
anesthesia care.
 Antibiotics
 Antiplatelets/Anticoagulants

14. General principles
 Rule of three
 No >3 push dilators of progressively larger diameter
or, if using balloon dilators, no more than three
incremental balloon inflation sizes during a single
endoscopic session.
 luminal diameter should be increased by no more than
2 mm (6 French) during the session

15. Selecting a dilator
 Maloney dilators should preferably not be used for
complex strictures because data have suggested that non-
wire-guided push dilators have been associated with higher
rates of esophageal perforation.
 In a study including 348 endoscopic sessions for
esophageal dilation, Maloney dilators were associated with
higher rates of esophageal perforation compared with
balloon or wire-guided dilators (4 versus 0 and 0 percent,
respectively). All perforations occurred when Maloney
dilators were passed blindly into complex strictures.

16. Wire-guided push dilators

17. TTS Balloon Dilation

18.  Limited data comparing push dilators with balloon
dilators have not demonstrated a significant difference
in long-term relief of dysphagia

19. REFRACTORY STRICTURES
 Confirm etiology of stricture – obtain additional
biopsies from a refractory stricture to confirm that it is
nonmalignant

20. REFRACTORY STRICTURES
 Glucocorticoid injection into the stricture and
endoscopic dilation during one endoscopic session .
 Place a sclerotherapy needle
 Inject triamcinolone acetonide (10 mg/mL), 1 mL, into
each of four quadrants of the stricture at its narrowest
region
 Remove the sclerotherapy needle is removed.

21.  Glucocorticoid injection of refractory strictures resulted in lower
risk of stricture recurrence and fewer dilation sessions.
 In a meta-analysis of six trials (most of which were nonblinded)
including 176 patients with refractory esophageal
strictures, triamcinolone injection plus endoscopic dilation
resulted in lower risk of stricture recurrence (risk ratio 0.64, 95%
CI 0.51-0.81) .
 In a meta-analysis of three trials including 72 patients with
refractory anastomotic esophageal stricture, patients treated
with intralesional glucocorticoid injection plus dilation had
fewer endoscopic dilation sessions compared with patients
treated with dilation alone (mean difference -1.62; 95% CI -2.72
to -0.50].

22. Subsequent intervention
 Temporary placement of an esophageal stent has been used for treating
refractory nonmalignant stricture.
 Metal stents – six to eight weeks (but not to exceed 12 weeks) before endoscopic
removal.
 Partially covered or uncovered self-expandable metal stents are not used

23.  Plastic stents.
 Biodegradable stents –

24. Interventions of uncertain benefit
 Endoscopic incisional therapy – for treating short
(<1 cm) strictures.
 the fibrotic rim of the stricture is directly incised
in a radial fashion using a needle-knife or snare tip.
 Mitomycin – antibiotic chemotherapeutic agent…
may inhibit fibrosis.

25. CORROSIVE INTAKE
 strong alkali (sodium or potassium hydroxide)
contained in drain cleaners, other household cleaning
products, or disc batteries.
 Highly concentrated acids (hydrochloric, sulfuric, and
phosphoric acid)
 Liquid household bleach

26. CLINICAL PRESENTATION
 oropharyngeal, retrosternal or epigastric pain
 dysphagia/odynophagia.
 Persistent severe retrosternal or back pain may indicate
esophageal perforation with mediastinitis.
 Peritonitis.
 Hoarseness, stridor,
 Dyspnea.

27. Evaluation
 INITIAL EVALUATION: Aim to distinguish between
patients with severe life-threatening injuries who require
emergency surgery from patients with mild injuries who
are eligible for non-operative management.
 The history.
 Physical examination : vitals, SPO2, Signs of
gastrointestinal perforation

28. Laboratory studies
 Baselines
 ABG
 CRP

29. Imaging
 CXR :
 rule out other etiologies (eg, foreign body ingestion or
pneumonia
 pneumomediastinum, mediastinal widening,
subcutaneous emphysema in the neck, pleural
effusions, hydropneumothorax, or subdiaphragmatic
air.

30. CT GRADING
 Grade 1 – Normal appearing organs. This usually corresponds to low
grade 0 to 2a endoscopic burns
 •Grade 2 – Wall edema, with surrounding soft tissue inflammatory
change and increased post-contrast wall enhancement. This
corresponds to more severe endoscopic burns.
 •Grade 3 – Transmural necrosis as shown by the absence of post-
contrast wall enhancement. This usually corresponds with grade 3b
necrosis on endoscopy.

31. EGD
 Should be performed early (3 to 48 hours) and
preferably during the first 24 hours.
 contraindicated in patients who have evidence of
gastrointestinal perforation or respiratory distress.
 In hemodynamically unstable, upper endoscopy
should be postponed until the patient is
hemodynamically stable.

32. Grading endoscopic severity

34. Supportive care
 Respiratory support
 fluid resuscitation
 Pain control
 NPO
 PPI
 Broad spectrum antibiotics are reserved for patients with a suspected
perforation
 No role for emetics, neutralizing agents, or corticosteroids

35. Management
 Patients with low-
grade injuries
Endoscopy grade 1 or 2A
or CT grade 1)
 supportive care with
pain control.
 A liquid diet may be
initiated and the patient
can be advanced to a
regular diet in 24 to 48
hours

36.  Patients with high-grade injuries
 require inpatient monitoring at least a one-week.
 Endoscopic evaluation be considered if new symptoms arise and
at two months to ascertain mucosal restoration to integrity.
 Oral liquids are allowed after the first 48 hours if the patient is
able to swallow saliva.
 If patients are unable to tolerate…. early enteral feeding /TPN

37. Endoscopic management
 Wait three to six weeks after the initial injury before
attempting dilation.

38. Surgical reconstruction
 Multiple failed attempts at endoscopic dilatations.
 Elective esophageal resection with esophagogastric
anastomosis or colonic interposition
 In the absence of significant gastric injury, a gastric
transposition (pull-up) can often be performed
 . Most experts recommend delaying surgical reconstruction
for six months to stabilize the injury.

39. COMPLICATIONS
 Bleeding
 Fistula
 Stricture
 Carcinoma

40. Screening for esophageal cancer
 Every two to three years beginning 10 to 20 years after
the caustic ingestion.

41. PROGNOSIS
 Grades 1 and 2A have an excellent prognosis without
significant acute morbidity or subsequent stricture
formation.
 Patients with grades 2B and 3A develop strictures in 70 to
100 percent of cases.
 Grade 3B injuries are associated with an early mortality rate
of 65 percent, and esophageal resection with colonic or
jejunal interposition is required in most cases.