Management of Caustic Oesophagitis
The management of caustic oesophagitis requires prompt evaluation with endoscopy followed by a combination of supportive care, medical therapy, and possibly endoscopic or surgical intervention depending on injury severity.
Initial Assessment and Management
- Immediate evaluation with endoscopy within 24-36 hours of ingestion is essential to accurately assess the degree of injury and predict risk of stricture formation 1
- CT contrast study should be performed if perforation is suspected to assess the degree of extravasation 2
- Initial supportive measures:
- Nothing by mouth until endoscopic evaluation
- Intravenous fluid resuscitation
- Broad-spectrum antibiotics
- Acid suppression with proton pump inhibitors or H2 blockers (ranitidine) 3
Management Based on Injury Severity
Grade 1 and 2a Burns (Mild to Moderate)
- Patients can typically be discharged after endoscopy
- Resume oral intake as tolerated
- Follow-up to monitor for late complications
Grade 2b and Grade 3 Burns (Severe)
- Nothing by mouth for at least one week except water when swallowing saliva
- Nutritional support via total parenteral nutrition
- After first week, introduce liquid foods if swallowing is not problematic
- Barium meal and upper GI series at 3 weeks to evaluate for stricture formation 3
Stricture Management
- Endoscopic dilatation is effective and safe for improving symptoms in patients with fibrostenotic disease 2
- Both balloon and bougie dilators can be used safely 2
- Dilatation should be performed at 2-week intervals for developing strictures 3
- Clinical outcomes are better when dilatation is combined with effective anti-inflammatory therapy 2
- For intractable strictures unresponsive to dilatation, esophageal replacement surgery may be required 4, 5
Medication Considerations
- Corticosteroids: Evidence regarding systemic steroid use is conflicting. Some studies show no benefit in preventing stricture formation 1, while others suggest potential benefit with local corticosteroid application 6
- Proton pump inhibitors should be given to reduce acid reflux that may worsen injury
Perforation Management
- Eosinophilic oesophagitis is the most common cause of spontaneous perforation of the oesophagus 2
- If perforation occurs with limited extravasation, conservative management is recommended with multidisciplinary input from gastroenterology, surgery, and radiology specialists 2
- Avoid overly aggressive attempts to salvage extensively damaged esophagus as this may jeopardize patient survival 4
Long-term Follow-up
- Regular endoscopic assessment for patients with severe injuries
- Monitor for late complications including stricture formation
- Consider the psychological and socioeconomic impact on patients and families 5
Pitfalls and Caveats
- Symptoms and physical findings are unreliable in predicting the extent of injury; endoscopy is essential 1
- Endoscopists may underestimate the frequency of strictures and narrow lumen 2
- Avoid intraluminal tubes in the acute phase as they may increase risk of perforation 3
- Patient survival should not be compromised by overly aggressive attempts to salvage severely damaged esophagus 4
- Consider the significant socioeconomic and psychological impact of severe caustic injuries, particularly in pediatric cases 5