What are the recommendations for managing caustic esophageal injury?

Management of Caustic Esophageal Injury

In caustic esophageal injury, upper endoscopy is NOT contraindicated in the acute phase but rather recommended within the first 12-48 hours after ingestion to determine prognosis and guide management. 1

Pathophysiology and Mechanism of Injury

• Acids and alkalis cause different patterns of injury:
  • Acids cause coagulative necrosis, which forms an eschar that may limit penetration 1
  • Alkalis cause liquefactive necrosis, allowing for deeper penetration into tissues and potentially more severe injury 1, 2
  • Acids tend to cause more severe gastric injury than esophageal injury due to rapid transit through the esophagus and pooling in the stomach 1, 2

Initial Assessment and Diagnostic Approach

• Emergency contrast-enhanced CT examination should be performed 3-6 hours after ingestion, before and after intravenous contrast injection 1

  • CT can detect transmural injuries and predict esophageal stricture formation better than endoscopy in some cases 1
  • The main sign of transmural digestive necrosis is absence of post-contrast wall enhancement 1

• Upper gastrointestinal endoscopy should be performed within 12-48 hours after caustic ingestion 1, 2

  • Contraindications to endoscopy include radiological suspicion of perforation or burns to the supraglottic and epiglottic areas 1
  • Early endoscopy helps determine prognosis and guides appropriate management 3

Critical Management Points

• Early induced emesis is absolutely contraindicated as it can cause re-exposure of the esophagus to the caustic agent and increase the risk of aspiration 1, 2

• Laboratory evaluation should include CBC, electrolytes, liver function tests, pH, serum lactate, and other relevant tests to identify potential systemic effects 1

  • Abnormal values such as severe acidosis, deranged liver function tests, leukocytosis, elevated CRP, renal failure, and thrombocytopenia are predictive of transmural necrosis 1

• Patients who do not have full-thickness necrosis can be offered non-operative management with close clinical and biological monitoring 1

• Emergency surgery should be considered for patients with evidence of transmural necrosis 1, 2

Management Based on Injury Severity

• Grade I injuries (superficial) typically heal spontaneously and patients can be fed immediately 2, 3

• Grade II injuries (moderate):

  • Grade IIa: Low risk of stricture formation (<20%), oral nutrition can be introduced as pain diminishes 2
  • Grade IIb: High risk of stricture formation (>80%), may require nutritional support 2, 3

• Grade III injuries (deep/severe):

  • Usually require surgical intervention 2, 3
  • Emergency resection of caustic necrosis can be lifesaving 1

Prevention and Management of Strictures

• Consider avoiding dilatation within 3 weeks of initial caustic ingestion due to higher risk of complications 1

• For established strictures, endoscopic dilatation is the mainstay of treatment 1, 4

  • Time interval between dilatations should be less than 2-3 weeks 1
  • The perforation rate for caustic strictures is higher than standard benign esophageal stricture dilatation 1

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 1, 5

• The physical form of the ingested substance affects the pattern of injury:

  • Solids produce maximum damage to the mouth and pharynx
  • Liquids transit rapidly and cause burns of the esophagus and stomach 1

• Psychiatric evaluation is mandatory in all patients with intentional ingestion prior to hospital discharge 2