Caustic Ingestion Flashcards
Discuss caustic injury.
Children represent up to 80% of the population globally who are exposed to caustic ingestion injury.
Caustic injury to the esophagus may be caused by alkalis and acids, both producing very different injury patterns.
Initial management should prioritize respiratory and cardiovascular stability.
Upper gastrointestinal endoscopy and endoscopic grading of esophageal injury remains the mainstay of diagnosis and may aid management decisions.
Further studies are necessary as there continues to be minimal evidence for the use of adjuvant medical therapy including antacids, antibiotics, and steroid use.
Sequelae such as esophageal strictures may be managed initially with esophageal dilation, with surgical management reserved for failure of dilations.
Long-term endoscopic screening is necessary for the development of esophageal cancer, which may occur decades later from the injury.
What are the substances ingested by children that may cause caustic injury?
Most corrosive substances are divided into either alkalis or acids.
Alkaline substances constitute the majority of ingested matter in Western countries, while acidic material is more common in developing countries.
Do acid and alkaline injuries differ?
Yes.
Acids cause coagulation necrosis with eschar formation. This may limit the tissue penetration and depth of the injury. Since they are usually less viscous, injury is typically more distal in the esophagus.
In contrast, alkali agents combine with tissue proteins and cause liquefactive necrosis and saponification. The higher viscosity and longer contact times produce deeper tissue penetration.
What age groups are at risk for caustic ingestion?
Presentation occurs in a bimodal distribution with the first peak in children under five years old.
Ingestions in this age group are typically accidental.
The second peak occurs in adolescents and are more often related to intentional suicide attempts.
What is the clinical presentation of caustic ingestion in children?
Symptoms may vary depending on the type of substance, amount of exposure, time of presentation, depth and location of the injury.
Reported symptoms may include hoarseness, wheezing, dyspnea, and stridor, which may be indicative of potential respiratory compromise.
Common gastrointestinal symptoms may include drooling, dysphagia, odynophagia, epigastric/chest pain, and hematemesis.
More severe initial presentations may include tracheoesophageal fistula and cardiovascular collapse.
What is the first step in evaluation of a child with caustic injury?
Initial management should include establishing an airway and hemodynamic stabilization. Ongoing airway edema may cause airway obstruction and present the need for emergent airway management.
Should vomiting be induced when a child has ingested a caustic substance?
No—this is actually contraindicated as regurgitation may cause repeat injury and also places the child at risk for aspiration pneumonia.
Similarly, gastric lavage, milk, and activated charcoal are also contraindicated.
What is included in the diagnostic work-up for a child with known caustic ingestion?
An initial chest x-ray may reveal pneumoperitoneum, pneumomediastinum, pneu- mothorax or pleural effusion—all indicative of full-thickness injury.
A water contrast esophagram may confirm any question of full-thickness injury, evaluate the extent, and guide further care.
Endoscopy to grade the severity of injury is indicated and best done within the first 12–48 hours.
The endoscopy is typically limited to the first level of injury to avoid perforation.
A CT scan may show the extent of inflammation and will diagnose perforation.
How is the severity of injury from caustic ingestion graded endoscopically?
Grade & Description
0: Normal
1: Edema and hyperemia of mucosa
2a: Superficial injury with friability, hemorrhage, erosion, or blisters
2b: Conditions in 2a plus limited areas of deeper or circumferential injury
3a: Scattered area of necrosis or brown/black/gray discoloration
3b: Extensive necrosis
4: Perforation
Should a nasogastric tube be placed to assist in management of caustic injury?
Nasogastric tubes are not mandatory, but may be placed to prevent emesis, allow feeding past the esophageal injury, and serve as a stent in circumferential burns. These should not be placed blindly due to risk of esophageal perforation.
What is the typical management of the patient taking into account the endoscopic appearance of the caustic injury?
Patients who are grade 1 and 2a may be allowed oral intake and discharged after a limited in-hospital observation.
Grades 2b and higher require longer hospital observation with adequate nutritional support and will need monitoring for stricture formation during follow-up.
What is the role of antacid therapy and mucosal protection in caustic injury of the esophagus?
H2 blockers, intravenous proton pump inhibitors and sucralfate are often initiated to theoretically allow faster mucosal healing, prevent stress ulcers and provide mucosal protection. The efficacy of gastric acid suppression with H2 blockers or proton-pump inhibitors has not yet been proven although a small prospective study in adults has shown significant endoscopic healing after IV omeprazole infusion. [2] Sucralfate has been shown in a small randomized controlled study to decrease the frequency of stricture formation in advanced corrosive esophagitis, however efficacy has not been established in a larger sample of patients [3].
What is the role of corticosteroids in the prevention of stricture formation?
There is conflicting evidence regarding systemic corticosteroid administration.
Due to this, current recommendations are to avoid use, especially since they also increase the risk of infectious complications.
Several meta-analyses have sug- gested limiting the use of steroids to those patients with established respiratory tract edema.
Intralesional steroid injections (triamcinolone 40–100 mg/session) have been utilized although no consensus exists regarding appropriate dosage and frequency [4, 5].
What is the role of antibiotics in caustic esophageal injury?
No data support routine use of antibiotic prophylaxis.
The use of antibiotics is advised if corticosteroids are initiated, lung involvement is identified, or in the setting of systemic infection and perforation [1].
What are the indications for immediate surgical intervention?
Patients with clinical or radiological evidence of perforation may require immediate laparotomy, or possible thoracotomy, esophagectomy, cervical esophagostomy, gastrectomy, or gastrostomy/jejunostomy tube placement.
