Editing Caustic ingestion

== '''Caustic ingestion''' ==

=== '''Aetiology''' ===

** Accidental small-volume ingestion of household products by children
** Most commonly a suicide attempt in adults - more extensive injuries
** Acid
*** Coagulative necrosis
*** Lessens tissue penetration
*** Lower incidence of damage to surrounding organs
** Alkaline
*** Liquefactive necrosis
*** Deeper penetration and damage to surrounding organs
** The difference between tissue effects of acid and alkali is probably exaggerated, as both can cause life-threatening injuries

=== '''Pathophysiology''' ===

** Most deaths due to perforation, mediastinitis and sepsis

=== '''Initial management''' ===

** ABC
** Check for upper airway compromise - dyspnoea, drooling, stridor, hoarseness
*** May require intubation. Need bronchoscopic guidance and preparation to do surgical airway due to potential difficulty.
** NBM
** IV ABx
** Acid-reducing agents
** No blind insertion of NGT/OGT

=== '''Workup''' ===

** CT chest and abdomen with IV and PO contrast first-line (if ok for radiation)
*** CT can help avoid emergency oesophagectomy
** Barium swallow study
** Gastroscopy
*** Most patients should have one to document the degree and extent of injury
*** Aim to do it early, within 24 hours
*** Can use a paediatric endoscope to minimise insufflation and mechanical stress
*** Traditionally, should not proceed past an area of circumferential injury; however, an experienced endoscopist can proceed cautiously if it is thought to be important to see further

=== '''Classification''' ===

*** Big difference between 2a and 2b - no complications in anyone with 2a or less
** CT classification:
***

{| class="wikitable"
|Grade 1
|Normal
|-
|Grade 2
|Wall and soft tissue oedema, increased wall enhancement
|-
|Grade 3
|Transmural necrosis with absent wall enhancement
|}

=== '''Management''' ===

** '''Approach by grade:'''
*** 1 or 2a: supportive care
*** 2B or higher: monitor as inpatient for at least a week, and re-image/operate with deterioration
** '''Supportive care in all patients'''
*** '''IV Abx for those at risk of perforation'''
*** '''NBM'''
** '''Surgery'''
*** '''Indications'''
**** On admission or at any time - full-thickness necrosis or perforation
*** Oesophagogastrectomy is the standard operation
**** Left with cervical oesophagostomy, defunctioned duodenum, and a feeding jejunostomy

=== '''Prognosis''' ===

** Grade 0 or 2a have excellent prognosis
** 2B and 3A have strictures in 70-100%
** 3B early mortality 65%, and mostly require oesophagectomy with reconstruction

=== '''Follow-up of complications''' ===

** Often complicated by strictures
** If 7-10 dilatations required at 2-week intervals, then consider oesophagectomy
*** Obviously depends on expert advice
** Consider intra-lesional and systemic steroids
** Also mitomycin-C may be helpful
** May lead to higher rate of cancer - up to 16%???
*** Likely warrants lifetime surveillance

[[Category:UGIS]]