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324 Corrosive Ingestion and Oesophageal Replacement

geal injury is excluded by endoscopy. In the presence of stridor and
respiratory problems, however, early endoscopy is hazardous because it
may aggravate the airway obstruction.
Endoscopic grading of corrosive oesophageal and gastric burns is
shown in Table 51.2. Grade I and grade IIA injuries do not result in
strictures, whereas 70% to 100% of circumferential burns (grade IIB)
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and grade III lesions result in strictures.
It has been suggested that most patients with severe injury have one
or more clinical signs or symptoms (drooling, dysphagia, vomiting, and
abdominal pain), and that 50% or more of patients who present with
vomiting, stridor, and drooling have associated oesophageal injury.
Furthermore, asymptomatic patients are deemed to be unlikely to have
lesions that progress to stricture or perforation. Based on these data and
on the absence of proven therapy to prevent stricture, the suggestion is
3,7
that patients require endoscopy only if they are symptomatic. Most
authorities recommend performing upper endoscopy as soon as the
patient is stable. 3,8 Figure 51.1: Multiple oesophageal strictures.
The practice in Egypt is that endoscopy is not done in the acute stage
but postponed for 6 weeks and performed only for symptomatic patients.
Table 51.2: Endoscopic grading of corrosive oesophageal burns.
Grade Finding
Grade I Oedema and erythema
Grade IIA Haemorrhages, erosions, blisters, superficial ulcer,
exudate (patchy or linear)
Grade IIB Circumferential lesions
Grade III Multiple deep brownish-black or gray ulcers
Grade IV Perforation

Radiologic Studies
X-ray
Plain chest and abdominal x-rays should be performed in the acute
phase of caustic injury. This may reveal evidence of perforation such as
pneumothorax, pleural effusion, or air under the diaphragm. If perfora- Figure 51.2: Long oesophageal strictures.
tion is still suspected despite negative plain films, a study with the use
of water-soluble contrast material may reveal extra luminal contrast. 3–7
Computed Tomography Surgery
Computed tomography (CT) of the oesophagus and stomach with orally Although emergency surgery is indicated in cases of perforation, it is
difficult initially to predict which patients will develop this complica-
administered contrast is the most sensitive method of detecting early tion. Early surgery is essential to improve the prognosis in cases of
3
3
perforation. With this approach, life-threatening injuries can be identi- oesophageal or gastric perforation. Although most investigators state
10
9
fied and treated at an early stage. In the chronic stages of the illness, that in selected cases, early surgery would be prudent, the criteria on
maximal wall thickness of oesophageal stricture can be measured with a which to base selection of surgical cases are not well defined. The
3
contrast-enhanced CT scan. 3 reduced mortality achieved through early detection of impending or
Contrast studies (see Figures 51.1 and 51.2) are most useful in actual perforations outweighs the morbidity and mortality rate associat-
evaluating the inlet of the upper gastrointestinal tract, the oesophageal ed with surgical exploration in patients with endoscopically diagnosed
body, and the stomach outlet at approximately 3 weeks after injury. second-degree burns. However, many surgeons have condemned early
3
Oesophageal body strictures can be of variable length, shape, and surgery because the extent of the injury often cannot be delineated,
7
number. Most strictures are at the region of the aortic arch. It is of leaks at anastomotic sites can occur, and surgery will not be needed in
utmost importance to study the inlet of the gastrointestinal tract before the majority of patients.
surgery to plan for the site of the proximal oesophagocolic anastomosis,
and to study the outlet to detect any antral stenosis. Any missed strictures Neutralisation or Flushing
at the inlet or outlet after substitute organ replacement of the oesophagus To be effective, neutralisation of caustics must be done within the first
may affect the success of the surgery. hour after ingestion of the caustic agent. Lye or other alkali can be neu-
Endoscopic Ultrasound tralised with half-strength vinegar, lemon juice, or orange juice. Acids
It is likely that endoscopic ultrasound (EUS) provides better determi- can be neutralised with milk, egg, or antacids.
Sodium bicarbonate is not used because it generates CO , which
2
nation of the depth of injury and may prove to be adjunctive or even might increase the danger of perforation. Water is used only to wash
3–5
superior to endoscopy in staging caustic oesophageal injury.
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the mouth and not for dilution because it will take the remnant to the rest
Treatment Options of the gastrointestinal tract (GIT). Emetics are contraindicated because
The goals of therapy are to prevent and treat perforation as early as pos- vomiting renews the contact of the caustic substance with the oesophagus
sible, to avoid strictures of the oesophagus and stomach, and to replace and can contribute to aspiration or perforation if it is too forceful. 3–5
or bypass the damaged organ to allow normal swallowing of food.