What is the proper management for a child who accidentally ingested caustic lye, presenting with redness of the lips, mouth, and pharynx?

Management of Caustic Lye Ingestion in a Child with Oral and Pharyngeal Burns

Early esophagoscopy is the most appropriate initial management for a child who has accidentally ingested caustic lye and presents with redness of lips, mouth, and pharynx. 1, 2

Diagnostic Approach

• Emergency contrast-enhanced CT examination should be performed 3-6 hours after ingestion to evaluate the extent of injury and detect potential transmural necrosis 3
• CT findings are graded according to a four-stage classification, with Grade III indicating transmural necrosis requiring emergency surgery 3, 1
• In pediatric patients, endoscopy remains the upfront evaluation tool due to concerns about radiation exposure 3, 1
• Endoscopy should be performed early to determine the presence and severity of esophageal injury, but should only be advanced to the uppermost level of burn injury to avoid complications 4, 2

Management Based on Injury Severity

For Non-Severe Injuries (CT Grade I-II or Endoscopic Grade I-II)

• Patients with Grade I CT injuries can be fed immediately and discharged within 24-48 hours as stricture formation risk is nil 3
• Patients with Grade IIa CT esophageal injuries have a low risk (<20%) of stricture formation and oral nutrition can be introduced as soon as pain diminishes 3
• Patients with Grade IIb CT esophageal injuries are at high risk (>80%) of stricture formation and may require nutritional support 3

For Severe Injuries (CT Grade III or Endoscopic Grade III)

• Emergency surgery is indicated if evaluation suggests transmural necrosis of the gastrointestinal tract 3
• All obvious transmural necrotic injuries should be resected during the initial operation 3
• A feeding jejunostomy is indicated at the end of the operation to provide nutritional support during recovery 3

Nutritional Support Options

• Oral feeding should be reintroduced as soon as patients can swallow normally in cases of mild injury 3
• Enteral feeding via nasogastric tubes is an option for temporary nutritional support in moderate cases 3
• Feeding jejunostomy is recommended in patients with severe injuries who undergo surgery or in those unable to eat due to pain or dysphagia 3
• Parenteral nutrition may be necessary in some cases of Grade IIb injuries with persistent symptoms 3

Antibiotic Therapy

• Antibiotics are not routinely indicated unless there is evidence of perforation, mediastinitis, or systemic infection 4, 5
• When used as part of management for severe burns, antibiotics should be combined with other therapeutic measures 4

Follow-up and Long-term Management

• Patients with Grade II CT injuries should have a follow-up visit 4-6 months post-ingestion as most strictures develop within this timeframe 3
• Endoscopic dilation should be attempted 3-6 weeks after ingestion in patients who develop strictures 3
• Reconstructive esophageal surgery should be considered after recurrent failure of endoscopic dilation 3
• Psychiatric evaluation is mandatory in all patients prior to hospital discharge 3

Important Caveats

• Clinical symptoms do not correlate reliably with the extent of gastrointestinal damage; absence of pain and oral lesions does not rule out serious injuries 3
• In asymptomatic children after accidental caustic ingestion, endoscopy may not be mandatory as the negative predictive value of absence of symptoms is high 6
• Avoid endoscopy between 1-3 weeks after injury due to higher procedural risks 1
• Steroid administration has not shown clear benefit in preventing stricture formation 7