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Caustic esophageal injury occurs from accidental (usually children) or deliberate (suicidal) ingestion of liquid or crystalline alkali (drain cleaners, etc) or acid. Ingestion is followed almost immediately by severe burning and varying degrees of chest pain, gagging, dysphagia, and drooling. Aspiration results in stridor and wheezing. Initial examination should be directed to circulatory status as well as assessment of airway patency and the oropharyngeal mucosa, including laryngoscopy. Patients without major symptoms (dyspnea, dysphagia, drooling, hematemesis) or oropharyngeal lesions have a very low likelihood of having severe gastroesophageal injury. All other patients initially should be hospitalized in an ICU. Chest and abdominal radiographs are obtained looking for pneumonitis or free perforation. Initial treatment is supportive, with intravenous fluids, intravenous PPIs to prevent gastric stress ulceration (pantoprazole or esomeprazole, 40 mg twice daily) and analgesics. Nasogastric lavage and oral antidotes may be dangerous and should generally not be administered. Laryngoscopy should be performed in patients with respiratory distress to assess the need for tracheostomy. Endoscopy is usually performed within the first 12–24 hours to assess the extent of injury, especially in patients with significant symptoms or oropharyngeal lesions. Many patients are discovered to have no mucosal injury to the esophagus or stomach, allowing prompt discharge and psychiatric referral. Patients with evidence of mild damage (edema, erythema, exudates or superficial ulcers) recover quickly, have low risk of developing stricture, and may be advanced from liquids to a regular diet over 24–48 hours. Patients with signs of severe injury—deep or circumferential ulcers or necrosis (black discoloration) have a high risk (up to 65%) of acute complications, including perforation with mediastinitis or peritonitis, bleeding, stricture, or esophageal-tracheal fistulas. These patients must be kept fasting and monitored closely for signs of deterioration that warrant emergency surgery with possible esophagectomy and colonic or jejunal interposition. A nasoenteric feeding tube is placed after 24 hours. Oral feedings of liquids may be initiated after 2–3 days if the patient is able to tolerate secretions. Neither corticosteroids nor antibiotics are recommended. Esophageal strictures develop in up to 70% of patients with serious esophageal injury weeks to months after the initial injury, requiring recurrent dilations. Endoscopic injection of intralesional corticosteroids (triamcinolone 40 mg) increases the interval between dilations. The risk of esophageal squamous carcinoma is 2–3%, warranting endoscopic surveillance 15–20 years after the caustic ingestion.

Hoffman  RS  et al. Ingestion of caustic substances. N Engl J Med. 2020;382:1739.
[PubMed: 32348645]  

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