3. Alkalis
PH > 7
Tasteless, odorless →larger
amounts
liquefaction necrosis => direct
extension, deeper injuries
Esophageal injury is common
In stomach, partial neutralization
by gastric acid may result limited
injury
Duodenal injury is less common
Acid
PH < 7
Pungent odor and noxious
taste
coagulation necrosis =>
formation of a coagulum
layer : limit the depth of
injury
Less esophageal injury
More gastric injury
As the acid toward the
pylorus, pylorospasm
impairs emptying into the
duodenum
4. Corrosive properties of the ingested substance
Amount, concentration, and physical form
(solid or liquid) of the agent
Duration of contact with the mucosa
5. 1. Vary widely
Hoarseness, stridor, dyspnea => Airway evaluation
Perforation: (During first 2 weeks)
Retro-sternal or back pain
Localized abdominal tenderness, rebound, rigidity,
Psoas sign, obturator sign
Massive hematemesis
Dysphagia, odynophagia, drooling, nausea, vomiting
2. Early signs and symptoms may not correlate with the severity
and extent of tissue injury
3. Oropharyngeal burns (-) :10-30% esophageal burns(+)
Oropharyngeal burns (+) : 70% esophageal burns(-)
6. Avoid:
The use of emetics: re-exposes
Neutralizing agents: thermal injury
Gastric lavage: may induce retching
and vomiting which can compound
injury
7. Primary survey
Keep NPO
IV fluids administer
Gastric acid suppression with intravenous PPI
Adequate pain relief with intravenous narcotics
Airway evaluation - laryngoscopy
R/O perforation - Plain films of chest and abdomen
Observation for Clinical signs of
perforation, mediastinitis, or peritonitis
Broad spectrum antibiotics - given for patients with Grade
3 caustic injury or high suspicion for esophageal perforation.
Endoscope
8. 1. Timing:
No later than 24 hours
Usually avoided from 5-15 days
2. Purpose:
Grading, manage appropriately
3. Risk of perforation:
Low, under adequate sedation
4. Extent:
Advance until a circumferential second or third degree burn is
seen
To first part of duodenum
9. Grade 0: Normal
Grade 1: Mucosal edema and hyperemia
Grade 2A: Superficial ulcers, bleeding, exudates
=> Excellent prognosis
Grade 2B: Deep focal or circumferential ulcers
Grade 3A: Focal necrosis
=> Develop strictures: 70-100%
Grade 3B: Extensive necrosis
=> Early mortality rate: 65%
12. 1. Patients with mild or no injury
○ may be discharged.
2. Patients with grade 1 or 2A injury
○ require no therapy.
○ a liquid diet may be initiated
○ advanced to a regular diet in 24 to 48 hours.
3. Patients with grade 2B or 3 injuries
○ should have nasoenteric tube feeding initiated after 24
hours.
○ oral liquids are allowed after the first 48 hours if the
patient is able to swallow saliva.
○ steroids ???.
*Patients with grade 3 injuries should be carefully
observed for signs of perforation over at least a one-week.
Prophylactic esophageal stenting is not recommended.
13. In animal studies: incidence of stricture formation
In human studies: Inconclusive so far
NEJM. 1990:
Prospective study over an 18-year period
No benefit
Related only to the severity of the corrosive
injury
Toxicol Rev. 2005:
1991-2004 in the
English, German, French, Spanish
No benefit
14. Clinical signs of perforation, mediastinitis, or peritonitis are
indications for emergency surgery.
Esophagectomy may be required for patients with severe
strictures.
Minimally invasive esophagectomy approach may be preferred
because it is associated with a decreased hospital stay
compared with standard esophagectomy.
The most important factors to guarantee a successful outcome
for surgery are good vascular supply and absence of tension at
the anastomosis.
If the stomach is damaged as well as the esophagus, a colonic
interposition can be used to create a new conduit.
15. The prognosis is variable and depends upon
the grade of esophageal injury and the
underlying medical condition of the patient.
Most deaths are due to the sequelae of
perforation and mediastinitis.
17. 1. Stricture formation
one-third of patients suffered caustic esophageal injury develop
esophageal strictures
Primarily in those with grade 2B or 3 injury
Peak incidence: two months
Occur as early as two weeks or as late as years after ingestion
Barium swallow examination is useful in the evaluation
19. 1. Endoscopic dilatation
The goal: dilate the esophageal lumen to 15 mm
Perforation rate: 0.5%
Special consideration:
Long, eccentric strictures: risk of perforation increased
Thick-walled strictures: recur rapidly
Multiple sessions: elective esophageal resection
2. Intraluminal stent
Temporary placement of a self-expanding plastic stent
Successful in case reports
3. Surgery
Esophagectomy with colonic interposition
Gastric transposition: high leak rate
Perform 6 months later
21. 2. Esophageal carcinoma
Incidence: 1000 to 3000-fold increase
3% have history of caustic ingestion
Mean latency: 41 years (13-71years)
Scar carcinoma:
Less distensible => dysphagia presents earlier
Lymphatic spread and direct extension
Endoscope surveillance
Begin 15-20 years after ingestion
The time interval : No more than every 1-3 years
24. Severity depend upon: the amount, concentration, physical form
and the duration of contact with the mucosa.
The absence of oropharyngeal burns does not preclude the
presence of esophageal or gastric injury.
The use of emetics, neutralizing agents, or nasogastric intubation to
remove remaining caustic material is contraindicated.
Gastrointestinal endoscopy should be performed in first 24 hours.
Endoscopy is contraindicated if hemodynamic instability, evidence
of perforation, severe respiratory distress, or severe oropharyngeal
or glottic edema and necrosis.
Clinical signs of perforation, mediastinitis or peritonitis are
indications for emergency surgery.
Long-term complications include esophageal strictures and
esophageal squamous cell carcinoma. Endoscopic surveillance for
cancer is recommended at 15-20 years after ingestion.