Esophageal Injury, Caustic

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

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

Aspiration results in stridor and wheezing

Assess circulatory status

Assess airway patency and oropharyngeal mucosa, including laryngoscopy

Obtain chest and abdominal radiographs to look for pneumonitis, perforation

Endoscopy

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