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Key Features

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Essentials of Diagnosis
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  • Reported history of ingestion, with or without evidence of oropharyngeal injury

  • Odynophagia, drooling, and food refusal typical of esophageal injury

  • Endoscopic evaluation of severity and extent of injury at 24–48 hours postingestion

  • Significant risk for development of esophageal strictures, especially in second- and third-degree lesions

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General Considerations
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  • Acidic substances

    • Typically have a sour taste and therefore lead to limited injury because of the small volume ingested

    • Causes superficial coagulative necrosis with eschar formation

  • Alkali ingestions

    • More benign taste

    • May allow for larger-volume ingestions

    • Causes subsequent liquefactive necrosis that can lead to deeper mucosal penetration

  • Additional factors that determine the severity of injury include

    • Amount ingested

    • Physical state of the agent

    • Duration of mucosal exposure

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Clinical Findings
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  • Ingestion of caustic solids or liquids (pH < 2 or pH > 12)produces esophageal lesions ranging from superficial inflammation to deep necrosis with ulceration, perforation, mediastinitis, or peritonitis

  • Hoarseness, stridor, and dyspnea suggest associated airway injury

  • Odynophagia, drooling, and food refusal are typical with more severe esophageal injury

  • The lips, mouth, and airway should be examined in suspected caustic ingestion

  • However, up to 12% of children without oral lesions can have significant esophageal injury

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Diagnosis
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Laboratory Findings
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  • Elevation of white blood cell count was found to be a sensitive, but not specific, indicator of high-grade injury

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Imaging
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  • Plain radiographs of the chest and abdomen may be performed if there is clinical suspicion of perforation

  • Contrast studies of the esophagus

    • Should be performed when endoscopic evaluation is not available

    • However, they are unlikely to detect grades 1 and 2 lesions

  • Esophagoscopy is often performed

  • However, timing is important because

    • May not indicate the true severity of injury if it is performed too early (< 24–48 hours)

    • May increase the risk of perforation if it is performed too late (> 72 hours) due to formation of granulation tissue

  • Some centers have advocated conservative management with upper GI series within 3 weeks of injury, reserving endoscopic evaluation for those with evidence of stricture

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Treatment
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  • Clinical observation

  • Vomiting should not be induced

  • Avoid administration of buffering agents

  • Intravenous corticosteroids (eg, methylprednisolone, 1–2 mg/kg/d) are given immediately to reduce oral swelling and laryngeal edema

  • Intravenous fluids are necessary if dysphagia prevents oral intake

  • Broad-spectrum antibiotic coverage with third-generation cephalosporins may be considered to decrease stricture formation

  • Acid-blockade is often used to decrease additional injury from acid reflux

  • Topical mitomycin-C has been effective in treatment of refractory caustic strictures of the esophagus

  • Repeated esophageal dilations may be necessary as a stricture develops

  • In complicated cases, esophageal stenting may be beneficial during early management

  • Newer, fully covered, self-expanding, removable esophageal stents

    • Available in pediatric sizes

    • May offer additional options for recurrent caustic strictures

  • Surgical replacement of the esophagus by colonic interposition or gastric tube ...

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