1. Faculty of surgery
Songkhla hospital

2. 1. Alkalis:
 Cleaning agents (NaOH), drain openers, bleaches, toilet bowel
cleaners, and detergents…
2. Acids
 Toilet bowel cleaners ( sulfuric, hydrochloric ), anti rust
compounds ( hydrochloric, oxalic, hydrofluoric ), swimming
pool cleaners ( hydrofluoric )

3. Alkalis
 PH > 7
 Tasteless, odorless →larger
amounts
 liquefaction necrosis => direct
extension, deeper injuries
 Esophageal injury is common
 In stomach, partial neutralization
by gastric acid may result limited
injury
 Duodenal injury is less common
Acid
 PH < 7
 Pungent odor and noxious
taste
 coagulation necrosis =>
formation of a coagulum
layer : limit the depth of
injury
 Less esophageal injury
 More gastric injury
 As the acid toward the
pylorus, pylorospasm
impairs emptying into the
duodenum

4.  Corrosive properties of the ingested substance
 Amount, concentration, and physical form
(solid or liquid) of the agent
 Duration of contact with the mucosa

5. 1. Vary widely
 Hoarseness, stridor, dyspnea => Airway evaluation
 Perforation: (During first 2 weeks)
 Retro-sternal or back pain
 Localized abdominal tenderness, rebound, rigidity,
Psoas sign, obturator sign
 Massive hematemesis
 Dysphagia, odynophagia, drooling, nausea, vomiting
2. Early signs and symptoms may not correlate with the severity
and extent of tissue injury
3. Oropharyngeal burns (-) :10-30% esophageal burns(+)
Oropharyngeal burns (+) : 70% esophageal burns(-)

6.  Avoid:
 The use of emetics: re-exposes
 Neutralizing agents: thermal injury
 Gastric lavage: may induce retching
and vomiting which can compound
injury

7.  Primary survey
 Keep NPO
 IV fluids administer
 Gastric acid suppression with intravenous PPI
 Adequate pain relief with intravenous narcotics
 Airway evaluation - laryngoscopy
 R/O perforation - Plain films of chest and abdomen
 Observation for Clinical signs of
perforation, mediastinitis, or peritonitis
 Broad spectrum antibiotics - given for patients with Grade
3 caustic injury or high suspicion for esophageal perforation.
 Endoscope

8. 1. Timing:
 No later than 24 hours
 Usually avoided from 5-15 days
2. Purpose:
 Grading, manage appropriately
3. Risk of perforation:
 Low, under adequate sedation
4. Extent:
 Advance until a circumferential second or third degree burn is
seen
 To first part of duodenum

9.  Grade 0: Normal
 Grade 1: Mucosal edema and hyperemia
 Grade 2A: Superficial ulcers, bleeding, exudates
=> Excellent prognosis
 Grade 2B: Deep focal or circumferential ulcers
 Grade 3A: Focal necrosis
=> Develop strictures: 70-100%
 Grade 3B: Extensive necrosis
=> Early mortality rate: 65%

11. a
(Gr.IIa)
b
(Gr.IIb)
C
(Gr.IIIa)
d
(Gr.IIIb)

12. 1. Patients with mild or no injury
○ may be discharged.
2. Patients with grade 1 or 2A injury
○ require no therapy.
○ a liquid diet may be initiated
○ advanced to a regular diet in 24 to 48 hours.
3. Patients with grade 2B or 3 injuries
○ should have nasoenteric tube feeding initiated after 24
hours.
○ oral liquids are allowed after the first 48 hours if the
patient is able to swallow saliva.
○ steroids ???.
*Patients with grade 3 injuries should be carefully
observed for signs of perforation over at least a one-week.
Prophylactic esophageal stenting is not recommended.

13.  In animal studies: incidence of stricture formation
 In human studies: Inconclusive so far
 NEJM. 1990:
 Prospective study over an 18-year period
 No benefit
 Related only to the severity of the corrosive
injury
 Toxicol Rev. 2005:
 1991-2004 in the
English, German, French, Spanish
 No benefit

14.  Clinical signs of perforation, mediastinitis, or peritonitis are
indications for emergency surgery.
 Esophagectomy may be required for patients with severe
strictures.
 Minimally invasive esophagectomy approach may be preferred
because it is associated with a decreased hospital stay
compared with standard esophagectomy.
 The most important factors to guarantee a successful outcome
for surgery are good vascular supply and absence of tension at
the anastomosis.
 If the stomach is damaged as well as the esophagus, a colonic
interposition can be used to create a new conduit.

15.  The prognosis is variable and depends upon
the grade of esophageal injury and the
underlying medical condition of the patient.
 Most deaths are due to the sequelae of
perforation and mediastinitis.

16. Esophageal stricture
Esophageal carcinoma

17. 1. Stricture formation
 one-third of patients suffered caustic esophageal injury develop
esophageal strictures
 Primarily in those with grade 2B or 3 injury
 Peak incidence: two months
 Occur as early as two weeks or as late as years after ingestion
 Barium swallow examination is useful in the evaluation

19. 1. Endoscopic dilatation
 The goal: dilate the esophageal lumen to 15 mm
 Perforation rate: 0.5%
 Special consideration:
 Long, eccentric strictures: risk of perforation increased
 Thick-walled strictures: recur rapidly
 Multiple sessions: elective esophageal resection
2. Intraluminal stent
 Temporary placement of a self-expanding plastic stent
 Successful in case reports
3. Surgery
 Esophagectomy with colonic interposition
 Gastric transposition: high leak rate
 Perform 6 months later

21. 2. Esophageal carcinoma
 Incidence: 1000 to 3000-fold increase
 3% have history of caustic ingestion
 Mean latency: 41 years (13-71years)
 Scar carcinoma:
 Less distensible => dysphagia presents earlier
 Lymphatic spread and direct extension
 Endoscope surveillance
 Begin 15-20 years after ingestion
 The time interval : No more than every 1-3 years

24.  Severity depend upon: the amount, concentration, physical form
and the duration of contact with the mucosa.
 The absence of oropharyngeal burns does not preclude the
presence of esophageal or gastric injury.
 The use of emetics, neutralizing agents, or nasogastric intubation to
remove remaining caustic material is contraindicated.
 Gastrointestinal endoscopy should be performed in first 24 hours.
 Endoscopy is contraindicated if hemodynamic instability, evidence
of perforation, severe respiratory distress, or severe oropharyngeal
or glottic edema and necrosis.
 Clinical signs of perforation, mediastinitis or peritonitis are
indications for emergency surgery.
 Long-term complications include esophageal strictures and
esophageal squamous cell carcinoma. Endoscopic surveillance for
cancer is recommended at 15-20 years after ingestion.