Caustic Ingestion

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jvirbalas
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244670
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Caustic Ingestion
Updated:
2014-05-25 20:31:39
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Caustic Ingestion
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Caustic Ingestion
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  1. What types of necrosis are associated with acid and base ingestion?
    • Acids work through coagulation necrosis (desiccation or denaturation of superficial tissue proteins), with formation of an eschar by the reaction which serves to protect the tissue by limiting deeper penetration.
    • Alkaline ingestions cause tissue injury by liquefactive necrosis (saponification of fats and solubilization of proteins). Tissue injury occurs rapidly, within minutes of contact. Since bases are soluble once they form soaps with fat, there is deep diffusion of bases into exposed tissues. Only neutralization of the substance by the tissue itself stops the reaction.
  2. What tissue is most commonly affected by alkali ingestion?
    • Squamous epithelial cells of the oropharynx, hypopharynx, and esophagus (the most commonly involved organ).
    • The stomach is involved in only 20% of all alkaline ingestions.
  3. What tissue is most commonly affected by acid ingestion?
    • The stomach in the most commonly involved organ. The natural acidic pH in the stomach increases the injury and thus there is a relatively high incidence of gastric complications.
    • The esophagus is involved in 6-20% of acid ingestions.
  4. Describe the staging and related prognosis of esophageal burns in caustic ingestion.
    • Grade 0 – normal
    • Grade 1 – mucosal edema or erythema
    • Grade 2A – superficial ulcer, bleeding, exudates [excellent prognosis]
    • Grade 2B – deep focal or circumferential ulcers [Strictures develop in 70-100% of grade 2B or 3A injury]
    • Grade 3A – focal necrosis, deep ulcers with brown, black, or gray discoloration
    • Grade 3B – extensive necrosis [65% early mortality]
    • Grade 4 – perforation
  5. When is esophagoscopy appropriate after caustic ingestion?
    • Endoscopy should be performed between 24-48 hours after ingestion
    • A 2001 study showed that grade III injury without symptoms is quite uncommon (OR 0.13%), and recommended esophagoscopy only in symptomatic pts.
  6. Describe the pharmacologic treatment of esophageal burns after caustic ingestion.
    • PPI: prevent stress ulcers of the stomach
    • Broad spectrum antibiotics: if high suspicion for esophageal perforation
    • Steroids: A preponderance of evidence suggests steroids do not help protect against esophageal strictures. Some evidence shows benefit in grade II injury.
  7. Describe management of caustic ingestion if, on esophagoscopy, you see hyperemia and edema of the mucosa.
    • First degree burn
    • Observation overnight
    • Reflux regimen
    • Esophagram at follow up if symptomatic
  8. Describe management of caustic ingestion if, on esophagoscopy, you see focal injury to the mucosa, submucosa, and muscle.
    • Non circumferential, deep focal ulcer: Grade 2 B (2A is superficial ulcer)
    • Observation overnight
    • Broad spectrum abx for one week
    • Oral steroids, 2-3 week taper
    • Reflux regimen
    • Esophagram at 1 and 3 month follow up, sooner if symptomatic
  9. Describe management of caustic ingestion if, on esophagoscopy, you see circumferential injury to mucosa, submucosa, and muscle.
    • Circumferential second degree burn (2B)
    • Observation overnightConsider NGT, silastic stent, or GT
    • Broad spectrum abx for 1 week
    • Steroids controversial, may mask infection, increase risk of perforation
    • Esophagram at 1 month, then every 3 months for 1 year
  10. Describe management of caustic ingestion if, on esophagoscopy, you see full-thickness burn, black coagulum, pleural and mediastinal involvement.
    • Third degree burn, high mortality
    • Observe
    • May require esophagectomy, gastrectomy, ex lap.
    • May consider NGT, silastic stent, or GT
    • Long term broad spectrum abx
    • Steroids contraindicated
    • Esophagram at 1 month, then every 3 months for 1 year

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