Caustic Ingestions

Author Credentials 

William O. Collins, MD
Associate Professor
Department of Otolaryngology
University of Florida College of Medicine
Gainesville, FL

Module Summary

Caustic ingestions are much less frequent due to regulation of foreign substances. Nevertheless, otolaryngologists may encounter these patients, and it is critical to understand the pathophysiology behind the mechanisms of tissue damage associated with caustic ingestions. In understanding how the tissue damage occurs, the clinician can better understand the pattern of tissue injury and potential for both short and long term sequelae.

Module Learning Objectives 
  1. Recognize the difference between acidic and alkaline ingestions, and potential differences in clinical presentation.
  2. Describe the strategy for prompt diagnosis and assessment of the patients with caustic ingestions.
  3. Explain the therapeutic strategies for management of caustic ingestion.

 

Pathogenesis

Learning Objectives 

To understand the cellular effects of caustic ingestion, including differentiation between acidic and alkaline injuries.

 

 

References 
  1. Chiang M, Chen Y. Tracheoesophageal fistula secondary to disc battery ingestion. Am J Otolaryngol. 2000;21:333-36.
  2. Riding KH, Alper CM. Burns and Acquired Strictures of the Esophagus. In Pediatric Otolaryngology, Fourth Edition. Ed. Bluestone CD, Stool SE, Alper CM, et al. Saunders. Philadelphia, PA; 2003:1313-1323

Basic Science

Learning Objectives 

To describe the different mechanisms of tissue injury with acidic vs. alkaline ingestions.

 

 

References 
  1. Riding KH, Alper CM. Burns and Acquired Strictures of the Esophagus. In Pediatric Otolaryngology, Fourth Edition. Ed. Bluestone CD, Stool SE, Alper CM, et al. Saunders. Philadelphia, PA; 2003:1313-1323.

Incidence

Learning Objectives 

To describe the incidence of caustic ingestion.

 

 

References 
  1. Sharpe SJ, Rochette LM, Smith GA. Pediatric battery-related emergency department visits in the United States, 1990-2009. Pediatrics. 2012 Jun;129(6):1111-1117.
  2. Lin VYW, Daniel SJ, Papsin BC. Button batteries in the ear, nose, and upper aerodigestive tract. Int J Pediatr Otorhinolaryngol. 2004;68:473-479.
  3. PMID: 16891276 Dogan Y, Erkan T, Cokugras FC, Kutlu T. Caustic gastroesophageal lesions in childhood: an analysis of 473 cases. Clin Paediatr (Phila). 2006 Jun;45(5):435-438.

Patient Evaluation

Learning Objectives 

To describe common presenting signs and symptoms of caustic ingestion.

 

References 
  1. Gaudreault P, Parent M, McGuigan MA, et al. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics. 1983;71:767-70.
  2. Gupta SK, Croffie JM,[[ Fitzgerald JF. Is esophagogastroduodenoscopy necessary in all caustic ingestions? J Pediatr Gastroenterol Nutr. 2001;32:50-53.
  3. Lamireau T, Rebouissoux L, Denis D, et al. Accidental caustic ingestion in children: is endoscopy always mandatory? J Pediatr Gastroenterol Nutr. 2001;33:(1):81-84.
  4. Millar AJW, Numanoglu A, Mann M, et al. Detection of caustic esophageal injury with technetium 99m-labelled sucralfate. J Pediatr Surg. 2001;36:262-65.

Imaging

Learning Objectives 

To describe the role of radiographic imaging in the evaluation of patients with a caustic ingestion:

  • Plain Xrays
  • CT scanning
  • Barium swallow

 

 

References 
  1. Gaudreault P, Parent M, McGuigan MA, et al. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics. 1983;71:767-70.
  2. Riding KH, Alper CM. Burns and Acquired Strictures of the Esophagus. In Pediatric Otolaryngology, Fourth Edition. Ed. Bluestone CD, Stool SE, Alper CM, et al. Saunders. Philadelphia, PA; 2003:1313-1323.

Treatment

Learning Objectives 

To describe treatment strategies in the evaluation and management of caustic ingestions.

 

References 
  1. Friedman EM. Caustic ingestions and foreign body aspirations: an overlooked form of child abuse. Ann Otol Rhinol Laryngol. 1987;96:709-712.
  2. Gundogdu HZ, Tanyel FC, Buyukpamukcu N, et al. Conservative treatment of caustic esophageal strictures in children. J Pediatr Surg. 1992;27:767-70.

Medical Therapies

Learning Objectives 

To identify possible medical adjuvant therapies which can help to mitigate the damage from caustic ingestions.

 

References 
  1. Anderson KD, Rouse TM, Randolph JG. A controlled trial of corticosteroids in children with corrosive injury of the esophagus. N Engl J Med. 1990;323:637-40.
  2. Ein SH. Gastric tubes in children with caustic esophageal injury: a 32-year review. J Pediatr Surg. 1998;33:1363-365.
  3. Gundogdu HZ, Tanyel FC, Buyukpamukcu N, et al. Conservative treatment of caustic esophageal strictures in children. J Pediatr Surg. 1992;27:767-70.
  4. Pelclova D, Navratil T. Do Corticosteroids Prevent Oesophageal Stricture After Corrosive Ingestion? Toxicol Rev. 2005;24(2):125-129.

Pharmacology

Learning Objectives 

To describe the mechanisms by which medical therapies aid in the treatment of caustic ingestions.

 

References 
  1. Anderson KD, Rouse TM, Randolph JG. A controlled trial of corticosteroids in children with corrosive injury of the esophagus. N Engl J Med. 1990;323:637-40.

Surgical Therapies

Learning Objectives 

To describe the options for surgical management of caustic ingestions, including endoscopic and open approaches.

 

References 
  1. Cattan P, Chiche P, Berney T, et al. Surgical approach by cervicosternolaparatomy for the treatment of extended cervical stenoses after reconstruction for caustic injury. J Thorac Cardiovasc Surg. 2001;122(2):384-86.
  2. Wijburg FA, Beukers MM, Heymans HS, et al. Nasogastric intubation as sole treatment of caustic esophageal lesions. Ann Otol Rhinol Laryngol. 1985;94:337-41.
  3. Riding KH, Alper CM. Burns and Acquired Strictures of the Esophagus. In Pediatric Otolaryngology, Fourth Edition. Ed. Bluestone CD, Stool SE, Alper CM, et al. Saunders. Philadelphia, PA; 2003:1313-1323

Case Studies

  1. An 11 month old male is found crying with an open bottle of bleach spilled around him. He is drooling, but in no distress. What type of agent is common household bleach? What would be the proper treatment strategy?
  2. A 2 year old female with underlying severe sensorineural hearing loss has developed progressive dysphagia over several hours. She is now drooling, and refuses to take anything by mouth. She is taken to the ED for evaluation. Her hearing aids have been left at home. What is the best diagnostic approach to this child?  What imaging modalities might be indicated? What findings on those studies would necessitate surgical intervention, and what factors would dictate the timing of those interventions?

 

Complications

Learning Objectives 

To describe both short & long term complications of caustic ingestions.

 

References 
  1. Tewfik TL, Schloss MD. Ingestion of lye and other corrosive agents: a study of 86 infant and child cases. J Otolaryngol. 1980;9(1):72-77.
  2. PMID: 15843706  Turner A, Robinson P. Respiratory and Gastrointestinal Complications of Caustic Ingestion in Children. Emerg Med J. 2005 May; 22(5):359-361.
  3. Riding KH, Alper CM. Burns and Acquired Strictures of the Esophagus. In Pediatric Otolaryngology, Fourth Edition. Ed. Bluestone CD, Stool SE, Alper CM, et al. Saunders. Philadelphia, PA; 2003:1313-1323

Review

Review Questions 
  1. What is the typical tissue injury with acidic vs. alkaline substances? Which causes a deeper mucosal injury?
  2. What are some non-operative therapies that can be utilized in patients with a caustic ingestion injury to their esophagus?
  3. What are the stages of caustic ingestion as they relate to esophageal injury patterns?

 

Resources 

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  1. Annual Meeting Webcast (AMW):