Caustic injury of the upper gastrointestinal tract: a comprehensive review

Abstract

Prevention has a paramount role in reducing the incidence of corrosive ingestion especially in children, yet this goal is far from being reached in developing countries, where such injuries are largely unreported and their true prevalence simply cannot be extrapolated from random articles or personal experience. The specific pathophysiologic mechanisms are becoming better understood and may have a role in the future management and prevention of long-term consequences, such as esophageal strictures. Whereas the mainstay of diagnosis is considered upper gastrointestinal endoscopy, computed tomography and ultrasound are gaining a more significant role, especially in addressing the need for emergency surgery, whose morbidity and mortality remains high even in the best hands. The need to perform emergency surgery has a persistent long-term negative impact both on survival and functional outcome. Medical or endoscopic prevention of stricture is debatable, yet esophageal stents, absorbable or not, show promising data. Dilatation is the first therapeutic option for strictures and bougies should be considered especially for long, multiple and tortuous narrowing. It is crucial to avoid malnutrition, especially in developing countries where management strategies are influenced by malnutrition and poor clinical conditions. Late reconstructive surgery, mainly using colon transposition, offers the best results in referral centers, either in children or adults, but such a difficult surgical procedure is often unavailable in developing countries. Possible late development of esophageal cancer, though probably overemphasized, entails careful and long-term endoscopic screening.

Keywords: Caustic ingestion; Corrosive stricture; Developing countries; Endoscopic management; Surgical management.

Figure 1

Murine esophagus exposed for 10 min to control (A) and 10% NaOH (B). Reproduced from Osman et al[10].

Figure 2

Endoscopic ultrasound showing involvement of the muscularis propria of esophageal wall. Reproduced from Kamijo et al[37].

Figure 3

Computed tomography grading of esophageal caustic injuries. A: Grade 1; B: Grade 2; C: Grade 3; D: Grade 4. Reproduced from Ryu et al[40]. Arrows show the esophageal wall.

Figure 4

Significantly higher hazard of re-dilatation in patients submitted to late dilatation. P = 0.0008. Reproduced from Contini et al[97].