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CHAPTER 51
Corrosive Ingestion and

Oesophageal Replacement

Sameh Abdel Hay
Hesham Soliman El Safoury
Kokila Lakhoo

Introduction of adjacent vessels results in further necrosis and bacterial colonisation.
Caustic ingestion can produce a progressive and devastating injury to the Granular agents often produce focal injury to the oropharyngeal and
oesophagus and stomach. Caustic material ingestion is most frequently proximal oesophageal mucosa. Liquid alkaline solutions can cause
encountered in children who accidentally swallowed caustic materials or extensive damage to the entire oesophagus and stomach.
1,2
in adults who ingested caustic materials for suicidal purposes. Alkaline Acidic agents produce a coagulation necrosis, resulting in a firm
caustics and acids are the commonest chemicals implicated in caustic protective eschar that delays injury and limits penetration. The naturally
burns. Stricture formation with inability to swallow food after the injury alkaline environment, low viscosity, and rapid transit limit injury of the
is inevitable in some cases. Many different therapies have been recom- oropharynx and oesophagus by the acid compounds. Accordingly, acidic
mended. The literature regarding the treatment of these patients is quite agents were thought to spare the oesophagus and injure the stomach.
controversial and inconclusive. Repeated dilatations to maintain an However, ingestion of highly concentrated sulfuric or hydrochloric acid
adequate lumen diameter were given in patients with chronic strictures. penetrates the oesophageal mucosa and produces severe injury. When
In more severe strictures, due to the complications and ineffectiveness of the stomach is empty, caustic acids will affect the gastric mucosa along
the dilatation, surgical replacement of the oesophagus may be required. the lesser curvature to the antrum, and when the stomach is full, the
The causative caustic agent is either acid or alkali with different acidic agents cause diffuse injury.
reactions and sequelae. The concentration and amount of the ingested Caustic injuries to the gastrointestinal tract are classified
1
material have an important impact on the injury. Lye is a broad term pathologically into three degrees according to the depth of injury, as
3
for a strong alkali used in cleansing agents. For example, sodium and shown in Table 51.1.
potassium hydroxides in granular, paste, and liquid forms are used in
Table 51.1: Degree of oesophageal burns
drain and oven cleansers as well as washing detergents. Also, button
batteries, which contain high concentrations of sodium and potassium Degree of burn Oesophageal depth
hydroxides, can cause severe injuries. Acids are commonly available in First-degree Superficial, confined to mucosa, heal without stricture
toilet bowel cleansers (sulfuric, hydrochloric); battery fluids (sulfuric); formation
3
and swimming pool and slate cleansers (hydrochloric). The majority of
Second-degree Penetration into muscularis layer
cases in Egypt are due to caustic potash, with three to five new cases
every month and an overall ratio of eight alkali cases for every acid case. Third-degree Entire wall of gastrointestinal tract, with or without
Prevention perforation
A public health drive is required to educate the population to the dangers
of these corrosive products. Safe storage of corrosive liquids, out of Clinical Features
reach from children, is needed. Also, corrosive products must be stored The clinical picture on presentations depends mainly on the site and
in containers with hazard labels rather than in soft drink bottles to reduce depth of injury caused by the caustic agent. Early manifestations
the accidental ingestion of corrosive material. include persistent salivation, dysphagia, hoarseness of voice and stridor,
Directives to change the chemical composition of these products retrosternal chest pain, and hematemesis. Severe gastric injury may
and institute safer preparation of button batteries should be given to present as epigastric pain; retching; or emesis of tissue, blood, or coffee-
commercial institutions.
ground material. Fever, shock, dyspnoea, and acute abdomen strongly
Pathogenesis and Pathology indicate oesophageal or gastric perforation.
7
The extent of damage to the gastrointestinal tract depends on the agent, Late complications of caustic injuries include dysphagia due to
its concentration, amount, physical state, and the duration of exposure. the establishment of oesophageal stricture within 1 to 2 months. Early
3,4
Acidic solutions usually cause immediate pain, and—unless ingestion is satiety, weight loss, and progressive emesis suggest gastric outlet
intentional—the agent is rapidly expelled. Alkali solutions, however, are obstruction. Repeated chest infections may indicate acquired tracheo-
often tasteless and odorless and are swallowed before protective reflexes oesophageal stricture.
can be evoked. 1 Diagnosis
Caustic agents in solid form and granules often adhere to the mucous
Due to the poor correlation between signs and symptoms and the degree
membranes of the mouth, thereby preventing further movement of lye
of injury, endoscopic examination of the upper gastrointestinal tract is
into the oesophagus. The most severe caustic injury generally occurs in
essential in most patients with a history of caustic ingestion. There is
the narrowest portion of the oesophagus, usually the midoesophagus in
great controversy regarding the proper timing of the endoscopy. Many
the region of the aortic arch. 5,6
centres have performed the procedure in the first 24 to 48 hours after
The primary difference between alkaline and acidic injury is rapid
ingestion with excellent results, and have found the procedure to be safe
penetration into the tissue by alkali. Alkali has a potent solvent action
and accurate. The endoscopic grading of the injury can predict the treat-
on the lipoprotein lining, producing a liquefaction necrosis. Thrombosis
ment and outcome, and unnecessary treatment is avoided when oesopha-