Esophagitis, Corrosive

• • History of ingestion of caustic liquids or solids

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

  • Chest pain and dysphagia

Epidemiology

• • 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

Symptoms and Signs

• • 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

Laboratory Findings

• • Systemic acidosis and coagulopathy with severe injury

Imaging Findings

• • 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

• • 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

Rule Out

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

  • Simultaneous gastric injury

• • Laryngoscopy

  • Fiberoptic nasopharyngoscopy

  • Chest film

  • Early endoscopy

  • Contrast radiography

When to Admit

• • All cases

  • Mild exposures without symptoms may be discharged after brief observation

• • Fluid resuscitation and airway protection

Surgery

• • Laparotomy

  • Resection of areas of necrosis

  • Cervical esophagostomy

  • Oversew distal segment

  • Feeding jejunostomy

Indications

• • Perforation

  • Grade III injury

  • Severe grade II injury

  • Shock, peritonitis, worsening symptoms

Contraindications