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Caustic Injury

Accidental caustic injury mainly occur in children but in some cases these lesions occur in teenagers like swallowing of caustic liquids in suicide attempts, when children take some chemicals. If the greater quantities of chemicals are swallowed, which happen to be alkalies accidentally than acids because strong acids can produce an immediate burning and pain in the mouth. The swallowing of the caustic substances causes both acute and chronic injuries. In acute phase the degree and extent of the lesion depends upon:
  • The nature of the substance swallowed
  • Its concentration
  • The quantities swallowed
  • The time for which the substance is in contact with the tissues
Alkalies and acids affect tissues in different manner. Alkalies dissolve tissues and therefore, penetrate deeply into tissues while acids cause a coagulative necrosis (due to the coagulation of the proteins), which limits their penetration. Alkalies affect the greater areas of the surface. Alkalies and other real caustic agents cause so called liquidified necrosis (water balloon like dystrophy occurs following the cyst formation). There are three pathological stages after the caustic substances are taken:
  1. Severe phase, which is characterized by acute swelling of the mucous membrane. Clinically it corresponds to severe traumatic shock phase. It lasts for about 5 days.
  2. Next the sloughing of the necrotic masses occurs with period of ulceration. Clinically it corresponds the pseudorecuperative period (here the esophageal wall remain weak, most thinner and vulnerable). It lasts for about 5-12 days.
  3. pathologically third phase corresponds to cicatrisation and scarring, which begins by the third week following injury. Clinically it corresponds to the period of long-term complications e.g. bleeding, stenosis, malignancy, hernia etc…
The lesions usually occur in the physiological narrowing of the esophagus. In the first phase the clinical picture is determined by the degree and extent of the lesion. In the initial phase complains are pain in the mouth and substernal region, hypersalivation, pain during swallowing and dysphagia. Fever corresponds to the stage of inflammation. In the second phase dysphagia and pain in many cases disappear. In this phase intoxication due to transmission of toxic substance into blood from necrotic masses occur. In the third phase complains of dysphagia reappear.

Treatment:
  • If patient takes acid (in summer or winter), we should give a small amount of alkalies e.g. egg’s white, milk or antacids but no sodium bicarbonate as it produces carbon dioxide gas and increases intraesophageal pressure, which causes the deep perforation and finally the washing the stomach with slight warm water. If patient took alkalies, it can be neutralized by half strength vinegar, lemon or orange juice.
  • In traumatic shock, narcotic analgesics should be given intravenously (I.V). Shock has two phases: excretory phase where arterial pressure remains normal and torpid phase where blood pressure is low with increase in pulse rate which later becomes normal.
  • Magistral veins, subcutaneous veins and central veins can be catheterized by the administration of the fluids I.V.
  • Corticosteroids
  • Antibiotics.
After the recovery of the shock we begin the dilation of esophagus by bougie.
Types of bougie:
  • Blind bougie (with X-ray or endoscopically controlled)
  • Ante grade bougie (via mouth)
  • Retrograde bougie (via stomach)
  • Bougie with end.
Surgical interventions are indicated when:
  • Stenosis through the whole length of esophagus occurs
  • Marked irregularity and pocketing on Barium swallow
  • Perforation
  • Fistula formation
  • Mediastinitis with dilation or if it is impossible to dilate with bougie or patient is unable to undergo prolonged period of dilation
Esophagectomy:
Currently stomach, jejunum and colon are the organs used to replace the esophagus through either the posterior mediastinum or retrosternal route (Jejunum has the capacity to secrete more fluid). Two types of anastomosis are:
  1. Subcutaneous (anterosternal)
  2. Retrosternal (no complication)
 For planning, there is the selection for the proximal anastomosis (cervical, esophagus, piriform sinuses or posterior larynx). The site of the upper anastomosis depends on the extent of the pharyngeal and cervical esophageal damage. When the cervical esophagus is destroyed and piriform sinus remains open then the anastomosis can be made to the hypopharynx. If the piriform sinuses are completely stenosed, then transglottic approach is used to perform an anastomosis with the posterior oropharyngeal wall. In both cases the patient must relearn to swallow. Recovery is long and difficult and during this time several endoscopic dilations are required.

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This article has been written by Dr. M. Javed Abbas.
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21:00 21/12/2002