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:

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