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  • • History of ingestion of caustic liquids or solids

    • Burns of the lips, mouth, tongue, and oropharynx

    • Chest pain and dysphagia

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Epidemiology

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  • • Extent of injury depends on degree of exposure to the agent (concentration, duration, and quantity)

    • Ingestion of strong alkali produces "liquefaction necrosis," which involves dissolution of protein and collagen, saponification of fats, dehydration of tissues, thrombosis of blood vessels, and severe deep penetrating injuries

    • Acids produce a "coagulation necrosis" involving eschar formation, which tends to shield the deeper tissues from injury

    • -Greatest injury is to the stomach, with the esophagus remaining intact in over 80% of cases

    • Liquid caustics usually produce more extensive esophageal injury than solids

    • Oropharyngeal burns are common but do not predict distal esophageal injury

    • Esophageal perforation may occur as late as 14 days after injury

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Symptoms and Signs

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  • • Inflammatory edema of the lips, mouth, tongue, and oropharynx

    • Pain on attempted swallowing

    • Chest pain

    • Dysphagia

    • Drooling of large amounts of saliva

    • Fever, shock, peritoneal signs with esophageal perforation

    • Tracheobronchitis, coughing, and increased bronchial secretions

    • Stridor and respiratory distress

    • Complete esophageal obstruction due to edema, inflammation, and mucosal sloughing may develop

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Laboratory Findings

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  • • Systemic acidosis and coagulopathy with severe injury

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Imaging Findings

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  • Esophagoscopy

    • -Usually within 12 hours of admission after initial resuscitation

      -The scope is inserted far enough to gauge the degree of burn but not beyond the proximal extent of injury

    Chest film: May identify pneumomediastinum, pneumoperitoneum or pleural effusion, indicating perforation

    Laryngoscopy and fiberoptic nasopharyngoscopy: May show edema, hyperemia, and mucosal sloughing

    • Water soluble contrast radiography may be used to detect perforation

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  • • Esophageal burns can be classified by endoscopic appearance

    • Grade I: Superficial mucosal injury

    • -Mucosal hyperemia and edema

    • Grade II: Partial thickness injury

    • -Mucosal sloughing

      -Ulceration

      -Pseudomembranes

      -Grade IIA, patchy injury; grade IIB, circumferential injury

    • Grade III: Transmural injury with periesophageal and/or perigastric extension

    • -Full thickness necrosis

      -Eschar formation

      -Black or gray ulcers

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Rule Out

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  • • Respiratory distress or severe pharyngeal injury with airway compromise necessitating intubation or tracheostomy

    • Simultaneous gastric injury

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  • • Laryngoscopy

    • Fiberoptic nasopharyngoscopy

    • Chest film

    • Early endoscopy

    • Contrast radiography

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When to Admit

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  • • All cases

    • Mild exposures without symptoms may be discharged after brief observation

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  • • Fluid resuscitation and airway protection

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Surgery

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  • • Laparotomy

    • Resection of areas of necrosis

    • Cervical esophagostomy

    • Oversew distal segment

    • Feeding jejunostomy

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Indications

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  • • Perforation

    • Grade III injury

    • Severe grade II injury

    • Shock, peritonitis, worsening symptoms

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Contraindications

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  • • Grade I injury—observation only

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