Management of Caustic Esophageal Injury

Pathophysiology and Mechanism of Injury

Acids cause coagulative necrosis, which forms an eschar that may limit penetration, while 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

The World Journal of Emergency Surgery recommends emergency contrast-enhanced CT examination should be performed 3-6 hours after ingestion, before and after intravenous contrast injection, to detect transmural injuries and predict esophageal stricture formation better than endoscopy in some cases 1
Upper gastrointestinal endoscopy should be performed within 12-48 hours after caustic ingestion to determine prognosis and guide management, according to Gut 3, 2
Contraindications to endoscopy include radiological suspicion of perforation or burns to the supraglottic and epiglottic areas 3

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, as stated by the World Journal of Emergency Surgery 1, 2
Laboratory evaluation should include CBC, electrolytes, liver function tests, pH, serum lactate, and other relevant tests to identify potential systemic effects, with abnormal values 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, according to the World Journal of Emergency Surgery 4
Emergency surgery should be considered for patients with evidence of transmural necrosis, as recommended by the World Journal of Emergency Surgery 1, 2

Grade I injuries typically heal spontaneously and patients can be fed immediately, although this fact is from Praxis Medical Insights, a similar recommendation is not found in other sources 2
Grade III injuries usually require surgical intervention, with emergency resection of caustic necrosis being lifesaving, as stated by the World Journal of Emergency Surgery 4

Consider avoiding dilatation within 3 weeks of initial caustic ingestion due to higher risk of complications, according to Gut 3
For established strictures, endoscopic dilatation is the mainstay of treatment, with a recommended time interval between dilatations of less than 2-3 weeks, as stated by Gut 3

Clinical symptoms do not correlate reliably with the extent of gastrointestinal damage, with absence of pain and oral lesions not ruling out serious injuries, as stated by the World Journal of Emergency Surgery 1
The physical form of the ingested substance affects the pattern of injury, with solids producing maximum damage to the mouth and pharynx, and liquids causing burns of the esophagus and stomach, according to the World Journal of Emergency Surgery 1

For caustic alkaline ingestion, immediate assessment of airway status is critical, followed by removal of any remaining substance from the oral cavity, and prompt medical attention without attempting dilution with water or milk, as recommended by the American Heart Association 5
Remove contaminated clothing around the mouth and face area to prevent further exposure 5
Call emergency medical services immediately, especially if respiratory symptoms or systemic symptoms are present, to ensure prompt medical attention 5

DO NOT administer diluents (water or milk) without specific medical advice, as there is insufficient evidence supporting this practice and it may spread the caustic substance further, according to the American Heart Association 6, 7, 8
DO NOT administer activated charcoal, as it is ineffective for caustic substances and may obscure subsequent endoscopic evaluation, as stated by the American Heart Association 6, 7, 8
DO NOT delay seeking medical attention to attempt home remedies, as prompt medical attention is critical in managing caustic alkaline ingestions 5