Caustic esophageal injury

Caustic ingestion is one of the most devastating sources of injury to the esophagus. The damage is fast and extensive upon contact with the injurious substance. Knowledge of the specific caustic swallowed is important as damage may be minor or catastrophic depending upon the type and amount swallowed. Stabilization of the patient is most important initially as esophageal perforation is of greatest concern and will require immediate esophagectomy if suspected and the patient is not moribund. If surgery is not required, then airway assessment and urgent endoscopy is indicated regardless of the degree of oral ulceration, to assess the degree of injury. This will be the most important determinant of prognosis and therapy with low injury grades requiring observation and higher grades mandating long hospitalizations with total parenteral nutrition and/or jejunostomy tube feedings. There are few evidenced based trials evaluating the routine use of antibiotics and steroids in these patients so the decision to use them should be case specific and based on clinical judgement. In patients with severe injury, long term complications, particularly strictures, will need aggressive and often life long dilatations, if not surgical esophageal resection. Although routine screening for esophageal cancer is not wholly endorsed, one must recognize the significantly higher incidence of squamous cell cancer in these patients.