Esophageal Injury, Caustic

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