What is the management of caustic esophagitis?

Management of Caustic Esophagitis

Emergency surgery should be performed immediately in patients with caustic esophagitis who show evidence of transmural necrosis to prevent death, with all obvious necrotic tissues resected during the initial operation. 1

Initial Assessment and Management

Emergency Evaluation

• Obtain CT scan with contrast as the key imaging study to assess the extent of injury and potential perforation 1
• Evaluate for signs of transmural necrosis (Grade III CT injuries) which require immediate surgical intervention 1
• Look for clinical indicators of severe injury:
  • Hemodynamic instability
  • Peritonitis
  • Mediastinitis
  • Systemic signs of sepsis

Immediate Management

1. Resuscitation

   • Fluid and electrolyte correction
   • Acid-base balance restoration 2

2. Imaging

   • CT with contrast is the preferred initial study to evaluate extent of injury 1
   • In case of perforation, CT contrast study should be performed to assess degree of extravasation 1

3. Surgical Decision-Making

   • Emergency surgery is mandatory if there is evidence of:
     • Transmural necrosis
     • Perforation
     • Peritonitis
     • Mediastinitis 1

Surgical Management

Acute Phase

• Laparotomy remains the standard approach in emergency settings 1
• All obvious transmural necrotic injuries must be resected during the initial procedure 1
• Specific procedures based on extent of injury:
  • Combined esophageal and gastric necrosis: Stripping esophagectomy and gastrectomy through combined abdominal and cervical approach 1
  • Isolated gastric necrosis: Total gastrectomy with preservation of native esophagus 1
  • Concomitant organ necrosis: Extended resections may be required (spleen, colon, bowel, duodenum, pancreas) 1

Important Surgical Considerations

• Esophageal reconstruction should NOT be performed during emergency surgery 1
• Feeding jejunostomy is indicated at the end of the operation 1
• Partial gastric resections are not recommended due to risk of ongoing necrosis 1
• Preoperative tracheobronchial endoscopy is mandatory to detect tracheobronchial necrosis 1

Non-Operative Management

• Can be offered to stable patients without evidence of full-thickness necrosis 1
• Requires close clinical and biological monitoring 1
• In case of limited perforation/extravasation, conservative management with multidisciplinary input may be appropriate 1

Long-Term Management of Strictures

• Intractable strictures are common despite conventional therapy with steroids and antibiotics 3
• Management options for established strictures:
  1. Endoscopic dilatation: Effective for less severe strictures
  2. Esophageal replacement: Required for severe cases 4
     • Colonic interposition has shown good outcomes 4
     • Success depends on good vascular supply and absence of tension in the anastomosis 4

Complications and Pitfalls

Acute Complications

• Massive hemorrhage
• Gastrointestinal tract perforation
• Aorto-enteric or gastrocolic fistulae 2

Long-Term Complications

• Esophageal strictures (occur in up to 20-29% of patients) 5
• Dysphagia
• Increased risk of esophageal cancer 2
• Psychological impact on patients and families 5

Special Considerations

• Severity of injury correlates with amount and concentration of caustic substance ingested 4
• Adult patients typically have more severe injuries compared to pediatric patients due to larger ingestion volumes 2
• Overly aggressive attempts to salvage extensively damaged esophagus may be both futile and dangerous 3
• Psychological support is essential as these injuries may be associated with suicide attempts or other psychological trauma 5

Follow-up Care

• Regular endoscopic assessment for stricture development
• Nutritional rehabilitation during recovery period
• Psychological support for patients and families 2
• Long-term surveillance due to increased risk of malignancy

The management of caustic esophagitis requires prompt assessment and decisive action. The decision between surgical and non-operative management must be made quickly based on the extent of injury, with surgery being lifesaving in cases of transmural necrosis or perforation 1. For long-term management of strictures, a combination of dilatation techniques and, when necessary, esophageal replacement surgery provides the best outcomes for quality of life 4.