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Chapter 17: Esophagus

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A 33-year-old female arrives at the emergency department following a suspected suicide attempt in which she swallowed an unknown cleaning solution. The patient is obtunded and unable to provide any history. Vital signs are as follows: temperature 98.6°F, blood pressure (BP) 136/88 mmHg, heart rate (HR) 114 bpm, and respiratory rate (RR) 36 breaths/min. On examination, she is drooling from the mouth, and there are visible burns in the oropharynx and crepitus in the neck and upper chest. Which of the following is the most immediate next appropriate step in management?

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(A) Endotracheal intubation

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(B) Administer broad-spectrum intravenous antibiotics

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(C) Perform endoscopy

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(D) Administer intravenous corticosteroids

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(E) Placement of nasogastric tube with continuous gastric lavage

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(A) The presentation of the patient described should raise suspicion for ingestion of a caustic substance. Household agents capable of producing caustic injuries include detergents, bleaches, drain cleaners, and ammonia products. Lye substances, which cause liquefactive necrosis, generally result in deeper penetration and tissue injury than acid agents, which cause coagulative necrosis. It is helpful to ascertain the nature of the product ingested, as this may determine the distribution and severity of injury. However, it will rarely affect subsequent management.

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Following ingestion of a caustic agent, destruction of the superficial epithelium occurs, and necrosis may extend into mucosa and muscularis. The injured tissue is invaded by bacteria and leukocytes. Between the second and fifth days, the necrotic tissue forms a cast and sloughs. Following this phase, granulation tissue forms at the periphery of injury as tissue repair begins. Collagen deposition continues for several months. Scar contraction begins following the second week and frequently results in esophageal shortening and stricture formation.

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The acute clinical course is marked by oral and substernal pain, odynophagia, dysphagia, drooling, and hematemesis. Pulmonary symptoms may occur with aspiration of caustic material. With severe injuries, visceral perforation may occur along with septicemia, mediastinitis, hemorrhage, and possibly death. Initial treatment should follow the usual guidelines for managing trauma patients. The airway should be assessed with the recognition that laryngeal inflammation and edema may progress rapidly to airway obstruction; in this scenario, the patient’s drooling and obtunded state require oropharyngeal intubation in anticipation of this event. The circulatory status should also be addressed and resuscitation with intravenous fluids begun. Broad-spectrum antibiotics are warranted if perforation is suspected. A nasogastric tube may be placed under fluoroscopy to drain gastric contents.

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Any evidence of perforation as demonstrated by physical examination or radiographic studies mandates surgical exploration. Subcutaneous emphysema, fever, hypotension, and peritonitis may be signs of perforation. Esophagography with water-soluble contrast may be performed when perforation is suspected. Endoscopy provides the best means ...

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