Caustic ingestion causes chemical injury to the upper gastrointestinal tract. It most commonly affects the oesophagus (alkali) and stomach (acid).
80% occur in children. It has a high morbidity and mortality.
The severity of corrosive burns to the oesophagus depends on:
- Nature of corrosive substance (acid vs alkali)
- Quantity and concentration of the substance
- Duration of contact with the esophageal wall
Caustic Substances
| Substance | pH | Examples | Pathogenesis |
|---|---|---|---|
| Alkaline Substances | > 11.5 | Laundry detergent, lye, hair straightener, disk battery, and drying agents | Causes liquefactive necrosis: deeper penetration and more severe. There is also saponification of fat, dehydration and thrombosis of blood vessels. It is more likely to heal with fibrosis. |
| Acidic Substances | < 2 | Battery fluid, toilet cleaner, sulfuric acid, swimming pool cleaners | Causes coagulative necrosis: the coagulum limits penetration |
| Bleach | ~ 11 | Mild irritation, no significant morbidity |
Esophageal burns
| Degree | Extent | Clinical Features |
|---|---|---|
| First Degree | Superficial mucosal injury | Mild hyperemia and edema |
| Second Degree | Transmucosal injury (mucosa, submucosa, possible muscular) | White exudate, erythema |
| Third Degree | Transmural injury (Full-thickness) | Black coagulum, extension beyond the esophagus |
Endoscopic grading (Zarger)
| Grade | Description |
|---|---|
| Grade 0 | Normal |
| Grade 1 | Edema and hyperemia of the mucosa |
| Grade 2A | Superficial Ulceration |
| Grade 2B | Deep ulceration |
| Grade 3A | Focal necrosis |
| Grade 3B | Extensive necrosis |
| Grade 4 | Perforation |
- Causes
- Accidental ingestion
- Children
- Usually smaller amounts of substance
- Intentional ingestion
- Adults
- Usually in larger amounts and more severe
- Accidental ingestion
- Pathophysiology
- Alkali → liquefactive necrosis and saponification of fats → deep tissue penetration → severe oesophageal damage
- Acid → coagulative necrosis → eschar formation limits spread, but has more gastric injury
- Three stages of esophageal burns
- Acute necrosis
- Granulations: the slough separates leaving a granulating ulcer
- Stricture formation: fibrosis begins after 2 weeks and continues for 2 months or longer
- Signs and symptoms
- Drooling
- Mouth pain
- Stridor due to edema of the epiglottis
- Dysphagia
- Odynophagia
- Refusal to feed in children
- Chest and abdominal pain
- Investigations
- Complete blood count for infection or bleeding
- Arterial blood gas analysis for severity
- Chest X-ray or Abdominal X-ray for perforation
- Pneumomediastinum or pneumoperitoneum
- Endoscopy within 24 – 48 hours to grade injury severity (Zarger) and guide treatment
- Perform too early (<12 hours) and the severity of damage may be missed
- Performed too late (> 48 hours) and the procedure could perforate the oesophagus
- Barium swallow to evaluate for stricture formation or to confirm perforation
- This should be the first diagnostic tool instead of esophagoscopy if the patient arrives > 48 hours
- Treatment
- Airway protection
- Early intubation may be needed since oedema may quickly compromise the airway
- Tracheostomy if there is persistent stridor
- Continuous monitoring
- Give oxygen as needed
- Give intravenous fluids as needed
- DO NOT:
- Lavage or induce vomiting as this will give the substance a “second pass” through the oesophagus, causing more damage
- Attempt to neutralize the acid or base
- Attempt blind nasogastric tube insertion
- Analgesia
- Intravenous corticosteroids to prevent stricture formation
- Corticosteroids are contrandicated in third-degree injuries since they may mask infection and worsen healing
- Proton pump inhibitors (PPIs)
- Nil per os for 7- 10 days
- Serial barium swallows every 2 weeks until healing is complete
- Nasogastric tube or silastic stent for circumferential injuries with minimal necrosis
- Surgery
- Esophagectomy or gastrectomy with exploratory laparotomy to remove necrotic tissue for grade 3 injuries
- For strictures:
- Esophagoscopy and prograde dilatations, if permeable
- Gastrostomy and retrograde dilatation, if impermeable
- Esophageal reconstruction or by-pass, if dilatations are impossible
- Airway protection
- Complications
- Stricture formation
- Especially with circumferential injury
- Pneumonia
- Tracheoesophageal fistula
- Laryngeal edema
- Perforation
- Hemorrhage and Shock
- Mediastinitis
- Peritonitis
- Esophageal carcinoma
- Caustic ingestion increases the risk by 1000x
- Death
- Stricture formation