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Caustic Esophageal Injury Revision Notes

Introduction

Caustic esophageal injury involves damage to the esophageal wall due to ingestion of acidic or alkaline substances, leading to an inflammatory response that can be life-threatening.

History and Clinical Presentation

History Taking

  • Substance Ingested
    • Name of Substance: Identify the specific chemical or product.
    • Texture: Determine if it was a liquid or solid.
    • Quantity Ingested: Estimate the amount consumed (though often unreliable).
    • Timing: Note the time elapsed since ingestion.
  • Circumstances of Ingestion
    • Accidental Ingestion
      • Population: Mostly children under 5 years.
      • Common Substances: Household cleaners, often alkaline.
      • Risk Factors: Unlabeled containers, poor safety measures.
    • Intentional Ingestion
      • Population: Adolescents and adults as an act of self-harm.
      • Common Substances: Larger quantities, potentially more severe injuries.
  • Symptoms
    • Dysphagia: Difficulty swallowing.
    • Odynophagia: Painful swallowing.
    • Refusal to Drink: Particularly in pediatric patients.
    • Chest Pain: May indicate esophageal injury.
    • Vomiting: Risk of re-exposure and aspiration.
    • Epigastric Pain: Suggests gastric injury or perforation.

Clinical Examination

  • Vital Signs
    • Airway Patency: Assess for respiratory distress.
    • Hemodynamic Stability: Monitor for signs of shock.
  • Oral Examination
    • Mucosal Injury: Look for burns, ulcers in the mouth.
    • Drooling: Indicates difficulty swallowing and potential esophageal injury.
    • Hoarseness and Stridor
      • Hoarseness: May indicate laryngeal injury.
      • Stridor: Suggests airway obstruction.
  • Abdominal Examination
    • Tenderness: May signal gastric injury or perforation.
    • Guarding/Rebound Tenderness: Signs of peritonitis.

Correlation of Symptoms with Injury Severity

  • Symptom Presence
    • Symptomatic Patients: More likely to have significant esophageal injury.
    • Asymptomatic Patients: Can still have serious injuries; endoscopy is recommended.
  • Predictive Signs
    • Drooling and Buccal Burns: Increase the likelihood of severe esophageal damage.
    • White Blood Cell Count: Elevated counts may correlate with injury severity.

Clinical Phases of Injury

  1. Acute Phase (First 72 hours)
    • Necrosis and Inflammation
    • Presentation: Severe pain, drooling, dysphagia.
  2. Intermediate Phase (3 days to 3 weeks)
    • Ulceration and Granulation
    • Risk: Esophageal wall is weakest; risk of perforation persists.
  3. Chronic Phase (After 3 weeks)
    • Stricture Formation
    • Symptoms: Progressive dysphagia, weight loss.

Radiodiagnosis

Imaging Techniques

  • Chest Radiograph
    • Purpose: Initial assessment for mediastinal air and pleural effusions indicating perforation.

  • Computed Tomography (CT) Scan

    • Utility: Assesses the depth of esophageal injury and surrounding tissue involvement.

    • CT Grading System (Based on Table 47.3):

      • Grade 0: No visible injury.
      • Grade 1: Edema of the esophageal wall.
      • Grade 2: Moderate-to-severe wall edema with or without peri-esophageal fat stranding.
      • Grade 3: Transmural necrosis with or without perforation.

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    • Interpretation: Higher grades correlate with increased risk of complications like perforation and stricture formation.

    • Role in Management:
      • Guides the decision between conservative management and surgical intervention.
      • Helps predict the need for esophagectomy in severe cases.

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  • Endoscopy

    • Timing: Performed within the first 24-48 hours of ingestion.
    • Purpose: Direct visualization to grade mucosal injuries.
    • Grading System (Based on Table 47.2):
      • Grade 1: Superficial mucosal edema and erythema.
      • Grade 2a: Superficial ulcers, blisters, exudates.
      • Grade 2b: Deep or circumferential ulcers.
      • Grade 3a: Focal necrosis.
      • Grade 3b: Extensive necrosis.
      • Grade 4: Perforation.
    • Precautions: Careful advancement to prevent perforation.

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Operative Techniques

Indications for Surgery

  • Grade 3b or 4 Injuries: Require emergent surgical intervention due to risk of transmural necrosis and perforation.

Preoperative Preparation

  • Airway Management: Secure airway in patients with respiratory distress.
  • Hemodynamic Stabilization: Intravenous fluids and broad-spectrum antibiotics.
  • Imaging: CT scan to assess the extent of injury.

Surgical Procedures

Damage Control Surgery Principles

  • Assessment: Evaluate viability of the esophagus and stomach.
  • Resection: Remove necrotic or nonviable tissue.
  • Hemostasis: Control bleeding.
  • Deferral of Reconstruction: Delay until patient stabilization.

Specific Techniques

  • Esophagectomy with Cervical Esophagostomy
    • Indication: Nonviable esophagus.
    • Procedure:
      • Resection of the affected esophagus.
      • Creation of a cervical esophagostomy for saliva diversion.
      • Placement of a feeding jejunostomy for nutrition.
  • Gastrectomy
    • Indication: Necrosis of the stomach.
    • Procedure: Removal of the necrotic stomach tissue.
  • Feeding Jejunostomy
    • Purpose: Long-term enteral nutrition.

Intraoperative Considerations

  • Avoid Injury: Careful dissection to prevent damage to the airway and thoracic duct.
  • Second-Look Operations: Reassessment in 12-24 hours if tissue viability is uncertain.

Pre- and Post-Operative Management

Acute Phase Management

Medical Management

  • Airway, Breathing, Circulation (ABCs): Prioritize stabilization.
  • Avoid Emesis Induction: Prevent re-exposure to the caustic agent.
  • Antibiotics
    • Indication: Prevent bacterial infiltration in high-grade injuries.
  • Proton Pump Inhibitors (PPIs)
    • Use: Controversial; may reduce gastric acidity but lacks strong evidence.
  • Steroids
    • Recommendation: Not beneficial; may increase risk of perforation and infection.

Nutritional Support

  • Grades 1 and 2a
    • Oral Intake: Trial of oral feeding.
  • Grades 2b and 3a
    • Nil Per Os (NPO): No oral intake.
    • Total Parenteral Nutrition (TPN): Nutritional support until healing.
  • Feeding Jejunostomy
    • Indication: Expected prolonged NPO status.

Monitoring and Follow-Up

  • Vital Signs: Continuous monitoring for signs of perforation or sepsis.
  • Repeat Endoscopy: Assess healing before initiating oral intake.
  • CT Scans: Monitor for complications.

Complications

Identification and Prevention

  • Immediate Complications
    • Perforation
      • Signs: Severe chest pain, fever, tachycardia.
      • Prevention: Early surgical intervention in high-grade injuries.
  • Intermediate Complications
    • Stricture Formation
      • Risk Factors: Grades 2 and 3 injuries.
      • Prevention: Controversial use of steroids, stenting, or dilation.
  • Long-Term Complications
    • Esophageal Strictures
      • Management: Endoscopic dilation, stenting, or surgical reconstruction.
    • Dysmotility
      • Symptoms: Difficulty swallowing, reflux.
      • Management: Dietary modifications, prokinetic agents.
    • Gastroesophageal Reflux Disease (GERD)
      • Risk: Increased due to esophageal damage.
      • Management: PPIs, lifestyle changes.
    • Malignancy Risk
      • Types: Squamous cell carcinoma or adenocarcinoma.
      • Latency Period: 15-40 years post-injury.
      • Surveillance: Regular endoscopic evaluations.

Management Strategies

  • Stricture Dilation
    • Techniques: Savary dilators preferred over balloons.
    • Risks: Perforation; requires skilled operators.
  • Stenting
    • Use: Alternative to repeated dilations.
    • Efficacy: 50-72% success rate.
    • Complications: Stent migration, fistula formation.
  • Surgical Reconstruction
    • Indications: Non-dilatable strictures, failed conservative management.
    • Options:
      • Gastric Conduit: Preferred if the stomach is viable.
      • Colonic Interposition Graft: Used when the stomach is unsuitable.
      • Jejunal Grafts: For extensive pharyngeal injuries.

Diagnostic Workup Algorithm

  1. Initial Assessment
    • Stabilize ABCs.
    • Obtain History: Substance, quantity, timing.
    • Physical Examination: Oral cavity, respiratory status, abdominal signs.
  2. Laboratory Studies
    • Complete Blood Count (CBC)
      • White Blood Cell Count: Elevated counts may indicate severe injury.
    • Serum Electrolytes and Renal Function
      • Acid-Base Status: Metabolic acidosis suggests systemic involvement.
  3. Imaging
    • Chest Radiograph
      • Look for mediastinal air, pleural effusions.
    • CT Scan
      • Assess depth of injury, guide management decisions.
  4. Endoscopy
    • Timing: Within 24-48 hours.
    • Purpose: Grade the injury, assess extent.
  5. Management Decision
    • Grades 1 and 2a: Consider oral intake, monitor.
    • Grades 2b and 3a: NPO, intensive monitoring, possible TPN.
    • Grades 3b and 4: Surgical intervention required.

Summary

  • Caustic esophageal injuries are serious and require prompt assessment and management.
  • Radiodiagnosis with CT scans and endoscopy is crucial for grading the injury and guiding treatment.
  • Operative techniques focus on removing nonviable tissue and planning for future reconstruction.
  • Pre- and post-operative management involves stabilization, nutritional support, and monitoring for complications.
  • Complications can be immediate, intermediate, or long-term, necessitating a multidisciplinary approach for optimal outcomes.

Key Takeaways

  • Early Endoscopy is essential for grading injury severity.
  • Avoid Steroids in management; they do not prevent strictures and may cause harm.
  • Surgical Intervention is indicated for high-grade injuries.
  • Long-Term Surveillance is important due to increased malignancy risk.

Remember to tailor management plans to individual patient needs and continuously reassess throughout the patient's clinical course.

Speed Mock

MCQ 1: Initial Management of Caustic Injury

Question: A 24-year-old female presents with a history of acid ingestion 6 hours ago. She initially received treatment at a local hospital before being referred to your center. On examination, she has tachycardia and tachypnea with a BP of 90/60. What is the next step in management?

  • Endoscopy
  • CT
  • Surgery
  • Stabilize the patient (Answer)

Explanation:

  • Primary Focus: Stabilize airway, breathing, and circulation (ABC) before proceeding with any other interventions.
  • Vital Signs: Tachycardia, tachypnea, and hypotension indicate possible shock, warranting urgent resuscitation.
  • Further Management:
    • After stabilization, a CT scan or endoscopy may be considered, depending on patient stability and specific indications.
    • Endoscopy is usually performed within 24-48 hours for grading the injury, but only after stabilization.

History for Caustic Ingestion Evaluation

  • Age: Distinguishes between typical populations (children for accidental, adults for intentional).
  • Intention: Suicidal (adults/adolescents) vs. accidental (typically in children).
  • Timing: Duration since ingestion is crucial in guiding management.
  • Previous Management:
    • Check for any nasogastric (NG) tube insertion, neutralizing agents, or initial endoscopy.
    • Determine if a feeding jejunostomy (FJ) was performed.
    • Confirm the timing of oral intake initiation, hospital stay duration, and ICU admission if applicable.

MCQ 2: Post-Discharge Management with Feeding Jejunostomy

Question: A patient was discharged after conservative management with a feeding jejunostomy (FJ) due to dysphagia. What is the next step?

  • Surgery
  • Barium (Answer)
  • Endoscopic dilation

Explanation:

  • Follow-Up Imaging: Barium swallow should be performed after 3-4 weeks to assess for esophageal strictures.
  • UGI Endoscopy: Used to evaluate mucosal healing but typically follows initial imaging with barium.
  • Endoscopic Dilation: May be considered if strictures are identified and amenable to dilation.
  • Surgery: Generally deferred for 6-12 months unless complications arise or conservative measures fail.

Management and Follow-Up Notes

  • Timing of Surgery: Often delayed 6-12 months post-ingestion to allow for stabilization and recovery.
  • Nutritional Support: Essential to maintain nutrition, especially if dysphagia persists.
  • Imaging:
    • Barium Swallow: Initial assessment of stricture and esophageal healing after a few weeks.
    • CT Scan: Not routinely required unless complications like perforation are suspected.
  • Endoscopic Dilation: Suitable for single or short-segment strictures without perforation. Avoided during the acute phase (7-21 days post-ingestion).
  • Stenting: Not recommended routinely, particularly in children or patients who decline surgery.
  • Operative Considerations:
    • Intraoperative Stomach Assessment: Check for suitability as a conduit.
    • Resection or Bypass: Choice depends on the extent of injury.
    • Colonic Conduit: Angiography not routinely needed; reserved for cases with compromised vascular supply.

These points highlight the need for systematic follow-up and imaging in managing caustic injuries and the importance of initial stabilization in acute cases.