Caustic Injury to the Esophagus

The potentially catastrophic presentation and lifelong complications that result from caustic ingestion make it one of the most challenging clinical situations in gastroenterology. Patients who present with a history of caustic ingestion, particularly with a strong alkali or acid, should undergo emergent endoscopy once stabilized to assess the degree of oropharyngeal, esophageal, and gastric damage regardless of presence or lack of symptoms. Once staged, patients with moderate to severe injury should be restricted from any oral intake, placed on intravenous fluids, and observed, provided there are no signs of perforation or transmural necrosis that require immediate esophagectomy. For those who will require lengthy periods without oral intake, feeding should be initiated through a jejunostomy tube (preferably) or through total parenteral nutrition. Patients that have survived the first several weeks of injury should be reassessed for esophageal stricture formation. Chronic strictures may require serial dilations initially to establish patency and in some patients, dilation will be needed chronically to maintain the adequate lumen diameter. More severe strictures may require esophagectomy or bypass with colon or small bowel interposition. Finally, although there is an increased incidence of esophageal carcinoma in these patients, regular endoscopic screening is not advocated.