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Key Features

  • Follows accidental or deliberate (suicidal) ingestion of alkali (drain cleaners, etc) or acid

Clinical Findings

  • Severe burning and chest pain, gagging, dysphagia, and drooling

  • Aspiration results in stridor and wheezing

Diagnosis

  • Assess circulatory status

  • Assess airway patency and oropharyngeal mucosa, including laryngoscopy

  • Obtain chest and abdominal radiographs to look for pneumonitis, perforation

  • Endoscopy

Treatment

  • Supportive treatment, intravenous fluids, analgesics

  • Intravenous proton pump inhibitors to prevent gastric stress ulceration (pantoprazole or esomeprazole, 40 mg twice daily)

  • Nasogastric lavage and oral antidotes should not be administered

  • Laryngoscopy should be performed in patients with respiratory distress to assess the need for tracheostomy

  • Endoscopy within the first 12–24 hours to assess extent and severity of mucosal damage

  • Patients with mild damage (edema, erythema, exudates, or superficial ulcers)

    • Recover quickly

    • Have low risk of stricture

    • May be advanced from liquids to regular diet over 24–48 hours

  • Patients with severe injury (deep or circumferential ulcers or necrosis)

    • Have a high risk (up to 65%) of acute perforation with mediastinitis or peritonitis, bleeding, stricture, or esophageal-tracheal fistulas

    • Must be kept fasting and monitored closely for signs of deterioration that warrant emergency surgery

  • Surgery: esophagectomy and colonic or jejunal interposition, nasoenteric feeding tube

  • Neither corticosteroids nor antibiotics are recommended

  • Strictures develop in up to 70% of patients with serious esophageal injury weeks to months after initial injury, requiring recurrent dilations

  • Endoscopic injection of intralesional corticosteroids (triamcinolone 40 mg) increases the interval between dilations

  • Esophageal squamous carcinoma occurs in 2–3%, warranting endoscopic surveillance 15–20 years after the caustic ingestion

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