This document discusses corrosive ingestion, which is a major health hazard especially for young children. Common caustic agents involved include sodium hydroxide and drain cleaners. Ingestion can cause severe and sometimes lifelong damage to the esophagus. Treatment depends on the severity of injury but may include endoscopy, dilation, steroids, or surgery. Prevention through education and safe storage of chemicals is important to reduce risk of this devastating condition.

1. By: Dr. Mahwish Khan

2.  Corrosive Ingestion is a disease of industrial
age.
 A major health hazard in children.
 In rural areas, and in developing countries,
caustic soda is used in home industry for
soap making, fruit drying and container
cleaning on farms.

3.  Most Ingestions occur in children younger
than 3-years ---- entirely preventable.
 Boys are frequently involved.
 In children more than 5-years is suspect.
 Ingestion in adolescents (where girls
predominate) is usually intentional

4.  Mortality is rare, morbidity is devastating,
and can be associated with life long
consequences.
 20% ingestions of caustic substances result in
some degree of esophageal injury.

5.  Physical form of substance ingested and its
pH, play a substantial role in the site and type
of post ingestion esophageal injury.
 pH > 12 or < 1.5 being associated with
severe corrosive injuries.

7.  Crystalline drain cleaners e:g. sodium
hydroxide adhere to oropharynx or become
lodged in the upper esophagus, where injury
is more severe.

8.  With alkali ingestion
◦ Tissue penetration + liquefactive necrosis.
◦ Destruction of Epithelium and sub mucosa which may
extend to the muscle layer.
◦ Ischemia and thrombosis are dominant early processes.
◦ Friable eschar develops.
◦ Tissue destruction continues until alkali is neutralized.

9.  With Acid Ingestion
 Coagulation Necrosis of mucosa
 Hard eschar formation
 Limitation of acid penetration through
mucosa occurs.

10.  Cricopharyngeal area
 Mid esophagus, where it is crossed by aortic
arch and left bronchus.
 Above the GE Junction

11.  Immediate spasm and disorganized motility
occur
 Resulting in delayed emptying and even
gastic regurgitation.
 Hemorrhage, thrombosis and marked
inflammation with edema seen in first 24-
hours

12.  After 48-hours thrombosis of submucosal
vessels occurs, leading to local necrosis and
gangrene.
 Bacterial contamination leading to
development of small intramural abscesses
occur.
 After several days, necrotic tissue is
sloughed, edema decreases and
neovascularization begins.

13.  Scar formation begins in 3rd week.
 During 3rd to 6th week adhesions forms,
narrowing or obliterating the esophageal
lumen.
 In transmural injury, necrosis extends to
surrounding mediastinum, leading to
mediastinitis or tracheo-esophageal or even
aorta-esophageal fistulas.

14.  Mitomycin C has been reported to be efficient
at a dose of 1mg/ml, applied locally with a
soaked swab for 4-minutes immediately
after dilatation.

15.  Few symptoms and signs – One quarter
 Pain oropharyngeal burns
 Esophageal injuries unlikely if only the tongue
or soft palate involved.
 Acid Ingestion is associated with rapid transit
through the esophagus. Leading to
pylorospasm.

16.  Inflammatory edema of oropharynx.
 Agitation and tachycardia
 Drooling and inability to swallow indicate
severe posterior pharyngeal or upper
esophageal injury.
 Acute obstruction of upper airway resulting
from pharyngeal and laryngeal edema.

17.  Maintain Adequate Airway and oxygenation.
 CVS stability.
 Few patients require immediate intervention
for airway maintenance.
 History regarding noxious agent, its
composition and concentration and
circumstances of ingestion.

18.  Inducing vomiting
 Incurring ingestion of any liquid,
 Passing NG tube.
 All are contraindicated,
 Why?

19.  Fiberoptic endoscopy is both accurate and
safe, especially done within 24-48 Hrs, after
ingestion.
 TC labeled sucralfate radio-isotope scanning
of esophagus is a screening device
 Lack of sucralfate adherence indicating the
absence of significant injury.

20.  In the presence of pharyngeal burns with
stridor, early esophagoscopy is
contraindicated because of risk of
aggravating airway obstruction.
 IDL is useful to access upper airway.
 Fever systemic sepsis and upper abdominal
signs are indicative of perforation.

21.  Water soluble contrast esophagogram may be
useful to detect perforation.

24.  For patients with First degree burns (grade 1
injury) – No Specific treatment is necessary.
 Liquid Oral is started and extended to solids.
 If solids are tolerated, child can be discharged.
 Follow up at 2-3 weeks.
 Contrast Examination is done if symptoms of
Dysphagia are noted.

25.  Patient with moderate or severe injuries
require further treatment, aimed at
prevention of stricture formation, Up to 50%
developed strictures.
 Most patients with grade 2A Injuries recover
completely, close follow up, endoscopy and
dilatation are required.

26.  Grade 3B Injuries are rare in peads
 These require immediate and aggressive
surgery, if extensive necrosis and perforation
are present, especially if stomach is involved.

27.  In clinical trials using a variety of dosing
regimens, no statistical difference in
prevention of stricture formation was evident.
 Steroids are not useful for stricture formation
 More recently, the use of high-dose steroids
(dexamethasone1mg/kg/day) has been
advocated.

28.  For patients with severe injuries, NG tube may be
passed for early feeding purposes.
 Oral feeding commences as soon as patient can
swallow saliva.
 If dysphagia occurs, esophagogram can identify
extent of involvement.
 Use of anti-fungal agents, antacids and H2
blockers or proton pump inhibitors is
widespread, but no proved efficacy.

29. Stricture formation
If structure demonstrated on contrast radiography, done
10-14 days, after injury, a program of dilatation is
commensed.
Dilators used are
1. Mercury filled bougies.
2. Flexible graded bougie dilatation
3.guide wire directed metal olives
4. Various balloon dilators
Dilatation should be attempted with great care

31. Initial dilatation is done under G.A with flexible
guide wire introduced.
Dilatation should be done once a week.
Started with catheters that are one or two french
sizes smaller than estimated dm of stricture.

32. If dilatation fails and a dense stricture develops it requires
Rx
Localized strictures may be resected with end to end
anastomosis
Local injection of steroids(1% triamcenolone acetate) and
mitomycin into short strictures is also effective
Esophageal stenting by means of indwelling NG tube is
also advocated

33. Stents used are silicone and PTFE .
Should remain in place for 6 wks until healing
occurs.
Stents also used in management of esophageal
fistulas resulting from caustic injury or dilatation
therapy

34.  There is still a great need
◦ For adult education
◦ For legislation
◦ To ensure correct labeling and safe packaging and
to restrict the strength and availability of caustic
agents.