Caustic Burns of the Esophagus

Key Features

Essentials of Diagnosis

• 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

General Considerations

• 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

Clinical Findings

• 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

Diagnosis

Laboratory Findings

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

Imaging

• 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

Treatment

• 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 ...