What is the emergency assessment and management of esophageal chemical burns caused by acid or alkali ingestion?

Burns by Acid or Lye of the Esophagus - ENT Oral Exam Notes

Emergency Assessment and Management

Immediate CT scan with contrast is the cornerstone of emergency evaluation and should guide all management decisions, as it accurately predicts transmural necrosis and determines need for emergency surgery 1.

---

Initial Emergency Management

Immediate Actions (First Minutes)

• DO NOT induce vomiting - increases risk of re-exposure and aspiration 2
• Early dilution therapy with water or milk - reduces acute injury if given immediately (within 5 minutes optimal) 3
  • Use small volumes to avoid nausea/vomiting
  • Water dislodges adherent solid particles
  • Milk may provide slightly better protection for cornified epithelial cells 3
• Airway assessment takes absolute priority - look for stridor, drooling, respiratory distress
• Stabilize hemodynamics - IV access, fluid resuscitation
• NPO status immediately

Critical History Points

• Type of agent: Acid vs. alkali (lye/NaOH)
  • Alkalis cause liquefaction necrosis (deeper, progressive injury)
  • Acids cause coagulation necrosis (more superficial, self-limiting)
• Quantity ingested - directly correlates with outcomes 1
• Intentional vs. accidental - intentional ingestions have worse prognosis 1
• Time since ingestion - treatment within 24 hours is lifesaving 1

---

Diagnostic Evaluation

Contrast-Enhanced CT (PRIMARY DIAGNOSTIC TOOL)

CT is superior to endoscopy for predicting transmural necrosis and selecting patients for surgery 1. CT-based algorithms significantly improve outcomes compared to endoscopy-based management 1.

CT Grading System (Predicts Management) 1:

Grade I: Homogeneous esophageal wall enhancement, no edema, no mediastinal fat stranding

• Management: Non-operative

Grade IIa: Internal mucosal enhancement + hypodense thickened wall + outer wall enhancement ("target sign")

• Mediastinal fat stranding present
• Management: Non-operative with close monitoring

Grade IIb: Fine rim of external wall enhancement only

• Necrotic mucosa doesn't enhance
• Esophageal lumen shows liquid density
• Mediastinal fat stranding present
• Management: Non-operative with intensive monitoring

Grade III: Absence of post-contrast wall enhancement = transmural necrosis

• Management: EMERGENCY SURGERY INDICATED 1

---

Endoscopy - Limited Role

Endoscopy is ONLY indicated when 1:

1. CT unavailable
2. CT contrast contraindicated (renal failure, iodine allergy)
3. CT suggests transmural necrosis but interpretation uncertain
4. Pediatric patients (radiation exposure concerns) 1

Major limitation: Cannot accurately predict transmural necrosis 1

Zargar Endoscopic Classification (if endoscopy performed):

• Grade 0: Normal
• Grade 1: Mucosal edema/hyperemia
• Grade 2a: Superficial ulcers, bleeding, exudates
• Grade 2b: Deep discrete/circumferential ulcers
• Grade 3a: Focal necrosis
• Grade 3b: Extensive necrosis

---

Management Algorithm

Non-Operative Management (NOM) Criteria 1:

Patients WITHOUT full-thickness necrosis (CT Grade I, IIa, IIb) can undergo NOM with:

• NPO status
• IV fluids
• Broad-spectrum antibiotics (at first sign of infection, not prophylactic) 2, 4
• Proton pump inhibitors for acid suppression 5
• Close clinical and biological monitoring 1
• Feeding via jejunostomy tube (preferred) or TPN if prolonged NPO needed 6
• ICU admission for Grade IIb injuries

Corticosteroids: Controversial

• Historical use: Methylprednisolone 20-40 mg IV q8h (age-dependent) for moderate burns 2
• Continue prednisone 2 mg/kg PO for 3-4 weeks when oral intake possible 2, 4
• Current evidence insufficient to strongly recommend 1

---

Emergency Surgery Indications 1:

ABSOLUTE INDICATIONS:

1. CT Grade III injury (transmural necrosis/no wall enhancement)
2. Hemodynamic instability
3. Signs of perforation (free air, mediastinal emphysema)
4. Systemic signs of severe sepsis
5. Non-contained contrast extravasation

Surgical Options 1:

• First choice: Emergency resection of necrotic esophagus/stomach
  • Can be lifesaving 1
  • Esophagectomy ± gastrectomy depending on extent
• If repair feasible: Direct repair + adequate drainage
• If repair not feasible: External drainage, esophageal exclusion, or resection
• Damage control approach for unstable patients: Abbreviated source control → ICU resuscitation → definitive repair 1

---

Long-Term Complications and Follow-Up

Stricture Formation (Most Common Complication)

Occurs in 4 months post-ingestion 1

• More common in esophagus than stomach
• Symptoms: Dysphagia, regurgitation → immediate upper GI evaluation 1

Management of Strictures 1:

1. Endoscopic dilation - first-line treatment

   • Start 3-6 weeks post-ingestion 1
   • Best for: Few (<3), short (<5 cm) strictures
   • Interval: 1-3 weeks between sessions
   • Expected: 3-5 sessions for satisfactory results 1

2. Esophageal reconstruction indicated after:

   • 5-7 failed dilation attempts 1
   • Recurrent stricture failures
   • Options: Colon or small bowel interposition 6

---

Critical Pitfalls to Avoid

1. Never rely on absence of oropharyngeal burns - esophageal injury can occur without oral involvement 2
2. Never delay CT beyond 24 hours - timing is critical for survival 1
3. Never perform endoscopy as first-line in adults - CT is superior and safer 1
4. Never miss transmural necrosis - requires immediate surgery, not observation
5. Never use nasogastric tubes - risk of perforation in acute phase
6. Never assume liquid caustics spare the esophagus - they cause maximum damage there 7

---

Special Considerations

Pediatric Patients

• Severe injuries are rare 1
• Endoscopy remains first-line (radiation concerns) 1
• Accidental ingestions more common

Malignancy Risk

• 1000-fold increased risk of esophageal squamous cell carcinoma 6
• Develops 40+ years post-injury
• Regular screening NOT advocated due to low yield 6

---

Multidisciplinary Team Required 1:

• Emergency physicians
• General/thoracic surgeons
• Gastroenterologists
• Interventional radiologists
• Otolaryngologists
• ICU specialists
• Transfer to specialized center strongly recommended 1