Corrosive Esophagitis and Stricture
Accidental or intentional ingestion of a caustic chemical produces corrosive esophagitis. This injury is similar to a burn and is characterized by esophageal inflammation and damage. It may be temporary or may lead to permanent stricture (narrowing or stenosis) of the esophagus, which is correctable only through surgery. In children, household chemical ingestion is accidental; in adults, it's usually a suicide attempt or gesture.
The severity and location of the damage depend on the type and amount of chemical ingested. The corrosive agent may damage only the mucosa or submucosa or it may injure all esophageal layers. Tissue damage occurs in three phases: an acute phase, marked by edema and inflammation; a latent phase, characterized by ulceration, exudation, and tissue sloughing; and a chronic phase of diffuse scarring.
Chemicals especially likely to cause very severe corrosive esophagitis include cleaning or disinfectant solutions. Factors that contribute to the development of reflux esophagitis include the caustic nature of the refluxate, the inability to clear the refluxate from the esophagus, the volume of gastric contents, and local mucosal protective functions. Poor lower esophageal segment functioning may be associated with a hiatal hernia, in which the top part of the stomach slides back and forth between the chest and the abdomen. Symptoms may be worsened by alcohol, smoking, sedentary lifestyle and obesity.
Signs and Symptoms
Endoscopy and barium swallow may be ordered to assess the severity of esophageal damage.
Endoscopy may be used to determine the extent of the injury in patients with a history of chemical ingestion and an oropharynx that appears abnormal. However, endoscopy use is controversial because of the risk of perforating the damaged esophagus.
Barium swallow is usually performed 1 week after chemical ingestion and every 3 weeks thereafter as ordered. This test is useful for identifying segmental spasm or fistula but may not reveal mucosal injury. The test is contraindicated if esophageal perforation is suspected.
An immediate priority is to identify the type and amount of chemical ingested. Sometimes, this can be done by examining the empty containers of the ingested material or by calling the local poison control center.
Conservative treatment includes monitoring the patient's condition and administering medications as ordered. Drug therapy may include narcotics for pain relief; corticosteroids, such as prednisone and hydrocortisone, to reduce inflammation and inhibit fibrosis: and a broad-spectrum antibiotic, such as ampicillin, to protect the patient taking a corticosteroid against infection by his own mouth flora. If the patient has burns of the oral mucosa, topically applied agents, such as lidocaine viscous and dyclonine, can provide temporary pain relief and coat the burned area. This protects the area from further injury.
If an esophageal stricture develops, bougienage is performed. In this procedure, a slender, flexible, cylindrical instrument called a bougie is passed into the esophagus to dilate it. If stricture is untreatable with bougienage, surgery is required. Immediate surgery is necessary if the patient develops esophageal perforation. Some patients require corrective surgery, which may involve transplanting a piece of the colon to repair the damaged esophagus. Even after surgery, stricture may recur at the site of the anastomosis.
Supportive treatment includes I.V. therapy (to replace fluids) or total parenteral nutrition if the patient can't swallow. As the patient's condition improves, nutrition can gradually progress to clear liquids, then a soft diet.
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