CAUSTIC INJURY OF THEESOPHAGUS

Liquefaction necrosis and results in a deep burn

Esophageal injury more severeMore frequently swallowed accidentally

than acid due to less burning pain

Alkaline

Acid

Coagulative necrosis and results in forming an eschar that limits tissue penetration

Gastric injury more severe due to pyloric spasm

PATHOLOGICAL PHASE

1. Acute necrotic or initial phase: 1-4 days post injury: inflammatory reaction & tissue necrosis: pain in the mouth & substernum

PATHOLOGICAL PHASE

2. Ulceration & granulation phase: subacute or latent phase: 3-5 days post injury & last 10-12 days: tissue necrosis & tissue sloughs result in mucosal defect, inflamed base and fillinggranulation tissue: weakest esophagus

PATHOLOGICAL PHASE

3. Cicatrization & scarring phase: begins the third week following injury: contracting connective tissue & narrowing esophagus: stricture formation

Initial complaints consist of pain in the mouthand substernal region & pain on swallowingHypersalivation, fever, bleeding vomitus Initial complaints disappear during latent phaseDysphagia reappears during scarring phase, 60% within 1 month and 80% within 2 months If no dysphagia within 8 months, no stricture willoccur

CLINICAL MANIFESTATIONS

Serious systemic reaction such as hypovolumia and acidosis

Renal damage caused by strong acidsRespiratory complication such as

laryngospasm or edema or aspirated pneumonia

CLINICAL MANIFESTATIONS

Oropharyngeal examinationEsophageal burns can be present withoutsymptoms or evidence of oropharyngeal burnsEarly esophagoscopy is recommended 12-24 hours post injury & the scope shouldnot be introduced beyond the proximal esophageal lesion to assess severity for treatment plan

CLINICAL MANIFESTATIONS

Perforation or peritonitisAirway obstruction>48 hours post injury

CONTRAINDICATION FOR EARLYESOPHAGOSCOPY

Grade 1 : superficial mucosal hyperemiaGrade 2A : superficial ulcerGrade 2B : deep ulcer or circumferential ulcerGrade 3A : focal necrosis & escharGrade 3B : extensive necrosis & eschar

ENDOSCOPIC GRADING OF CAUSTIC INJURY

Not reliable means for early injury

Early : water soluble contrast for suspicious perforationLate : barium swallow in later follow up to identify strictures

RADIOGRAPHIC EXAMINATION

Grade 1, 2A : observe 24-48 hr: without painful swallowing, starting oral diet and discharge with antacid

Grade 2B, 3A : ICU care ~ 1wk: NPO, IV, ATB,PPI

ACUTE PHASE TREATMENT

Neutralizing agent may be effective within the first hourContraindication : NG tube, lavage, induction ofemesis, esophagoscopy after 48 hr. Without strong evidence support for stricture prevention

: steroid, intraluminal stent, early dilatation, antifibrotic agent (penicillamine)

ACUTE PHASE TREATMENT

Hoarseness, stridor, dyspnea suggest laryngeal edema or epiglottic injuryPrompting airway evaluation with bronchoscopy or laryngoscopy and possible intubation or tracheostomy to maintain airway patency

ACUTE PHASE TREATMENT

Presence of symptoms & signs of perforationsuch as shock, acidosis, sepsis, mediastinitis, peritonitisTranshiatal esophagectomy, cervical esophagostomy, feeding jejunostomyGastric resection for gastric necrosisDelayed reconstruction after 6 months

INDICATION FOR EARLY SURGERY

Optimal time for dilation is 3- 4 weeks post injuryPre-dilation esophagogramAntegrade dilationTucker retrograde dilationGoal : up to 42- 44F but accept 36-38FFrequency: severe q 2 wkmild to moderate q 3- 4 wkDuration: 6-12 months

MANAGEMENT OF STRICTURES

perforation, fistulaFailure dilationPatient preferenceMalignancy

INDICATION FOR SURGERY FOR STRICTURE

SUMMARY MANAGEMENT OF ACUTE

CAUSTIC INJURYHistory and physical examinationSevere : ABCs , upright chest x-ray, abdominal films: early intubation or tracheostomyif airway obstruction is suspectedPerforation : emergency resectionNo perforation : esophagoscopy brochoscopy

Grade 1 ,2A : 48 hr observation: NPO, advance diet as tolerated: worsening symptom treat as 2B,3Grade 2B ,3A : NPO, antibiotics, PPI, ICU observation: deterioration emergency resection

SUMMARY MANAGEMENT OF ACUTE

CAUSTIC INJURY