CORROSIVE/CAUSTIC INJURY OF ESOPHAGUS

Accidental caustic injuries occur mainly in children and are usually taken in small quantity while in adults and in teenage caustic ingestion are usually deliberate in an attempt to suicide and taken in heavy amount. Any substance with pH less than 2 or more than 12 leads to caustic damage

Caustics and corrosives cause tissue injury by a chemical reaction. The vast majority of caustic chemicals are acidic or alkaline substances that damage tissue by accepting a proton (alkaline substance) or donating a proton (acidic substance) in an aqueous solution

Acids are present in battery acids, anti rust compounds and toilet cleaners while Alkalies are

present in drain cleaners, washing powders, hair straightness and bleaches

Alkalies dissolve the tissue and therefore penetrate more deeply while acids cause coagulative necrosis that limits their penetration.

Acids cause more severe damage to the stomach. This typically causes stricture in the pre-pyloric area where the acid pools. With a large amount of acid; small bowel can be involved. Esophageal injury is greater with alkali than with acids

Clinical features: 

Clinical features depend upon degree and extent of lesion. Pain in mouth and substernal region, hypersalivation, dysphagia, epigastric pain and haematemesis.Stridor, hoarseness and laryngitis can occur in case of laryngeal involvement. In case of esophageal perforation; hypotension, fever, chest pain, dyspnea and peritonitis can develop.

Management:

• Resuscitation

• Airway evaluation and protection

• Fluids resuscitation

• PPIs and H2 blockers

• Nasogastric tube insertion should be avoided as it can aggravate the chances of perforation

• Role of neutralizing agents is controversial

• Further evaluation

• After initial resuscitation further evaluation should be performed

• X-ray abdomen and chest are performed to check for air under diaphragm and air in mediastinum signifies perforation and mandated urgent surgical treatment

• Endoscopy should be performed within 12-24 hours to grade the injury and to decide further management plans.

• Endoscopy should be avoided between day 5-15 (tissue softening increases the risk of perforation).third degree burn of hypopharynx is considered as contra; indication to endoscopy (evident on laryngoscopy). Burns are classified into three grades on the basis of endoscopic evaluation

• First degree :mucosal hyperemia and edema

• Second degree limited hemorrhage exudate ulceration and pseudomembrane formation

• Third degree sloughing of mucosa, deep ulcers, massive hemorrhage, complete obstruction of lumen by edema and perforation

• 1st degree and 2nd degree injuries can be managed by conservative treatment and subsequent strictures are treated with serial endoscopic dilatation

• Patients with complex/multiple perforation and widespread necrosis require extensive debridement, esophagectomy or even esophagogastrectomy with jejunum or colonic interposition

• Late sequel of caustic injury

•  Esophageal_stricture (60% chances in grade II injury and 100% chances in grade III injury)

• Gastric strictures (prepyloric especially in acids)

• Esophageal cancer 

• Tracheo-esophageal fistula

• Small strictures can be managed by serial dilatations while large and multiple strictures require esophagectomy with colonic or jejunal interposition graft