Corrosive Esophagitis

A 50 year old woman was seen in emergency after ingesting a chemical substance . Esophagogastrodudenoscopy was performed and the picture is shown below.

Initial esophagoscopy. (A) Middle esophagus shows whitish discoloration. (B) Distal esophagus shows exudates with easy touch bleeding.

The case was diagnosed as Corrosive Esophagitis 

Corrosive Esophagitis Case Discussion

Introduction

Inflammation and damage to the esophagus after ingestion of a caustic chemical is called corrosive or caustic esophagitis. Similar to a burn, this injury may be temporary or lead to permanent stricture (narrowing or stenosis) of the esophagus that requires corrective surgery.
Severe injury can quickly lead to esophageal perforation, mediastinitis, and death from infection, shock, and massive hemorrhage (due to aortic perforation).

Causes
The most common chemical injury to the esophagus follows the ingestion of lye or other strong alkalies; less commonly, injury follows the ingestion of strong acids. The type and amount of chemical ingested determine the severity and location of the damage.
In children, household chemical ingestion is accidental; in adults, it’s usually a suicide attempt or gesture. The chemical may damage only the mucosa or submucosa, or it may damage all layers of the esophagus.

Pathology

Esophageal tissue damage occurs in three phases: 

1. in the acute phase, edema and inflammation; 
2. in the latent phase, ulceration, exudation, and tissue sloughing; and
3.  in the chronic phase, diffuse scarring.

Signs and symptoms
Effects vary from none to intense pain in the mouth and anterior chest, marked salivation, inability to swallow, and tachypnea. Bloody vomitus that contains pieces of esophageal tissue signals severe damage. Signs of esophageal perforation and mediastinitis, especially crepitation, indicate destruction of the entire esophagus. Inability to speak suggests laryngeal damage.
The acute phase subsides in 3 to 4 days, enabling the patient to eat again. Fever suggests secondary infection. Symptoms of dysphagia return if stricture develops, usually within weeks.

Diagnosis
A history of chemical ingestion and physical examination that reveals oropharyngeal burns (including white membranes and edema of the soft palate and uvula) usually confirm the diagnosis. The type and amount of the chemical ingested must be identified; sometimes this can be done by examining empty containers of the ingested material or by calling the poison control center.
Endoscopy (in the first 24 hours after ingestion) delineates the extent and location of the esophageal injury and assesses the depth of the burn. This procedure may also be performed a week after ingestion to assess stricture development.

Treatment
The patient may be treated conservatively through monitoring his condition, or he may require bougienage or surgery.
Bougienage
This procedure involves passing a slender, flexible, cylindrical instrument called a bougie into the esophagus to dilate it and minimize stricture.
Surgery
Immediate surgery may be necessary for esophageal perforation; it may also be performed later to correct stricture that isn’t treatable with bougienage. Corrective surgery may involve transplanting a piece of the colon to the damaged esophagus. Even after surgery, stricture may recur at the site of the anastomosis.
Supportive treatment
Other treatment includes I.V. therapy, to replace fluids, and total parenteral nutrition while the patient can’t swallow, gradually progressing to clear liquids and a soft diet.