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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 : ABCs , 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