Chemical Burns - Disorders of the Esophagus

CHEMICAL BURNS

Chemical burns of the esophagus may be caused by undissolved medications in the esophagus. This occurs more frequently in the elderly than it does among the general adult population. A chem-ical burn may also occur after swallowing of a battery, which may release caustic alkaline. Chemical burns of the esophagus occur most often when a patient, either intentionally or unintention-ally, swallows a strong acid or base (eg, lye). This patient is emo-tionally distraught as well as in acute physical pain. An acute chemical burn of the esophagus may be accompanied by severe burns of the lips, mouth, and pharynx, with pain on swallowing. There may be difficulty in breathing due to either edema of the throat or a collection of mucus in the pharynx.

The patient, who may be profoundly toxic, febrile, and in shock, is treated immediately for shock, pain, and respiratory dis-tress. Esophagoscopy and barium swallow are performed as soon as possible to determine the extent and severity of damage. The patient is given nothing by mouth, and intravenous fluids are ad-ministered. A nasogastric tube may be inserted by the physician. Vomiting and gastric lavage are avoided to prevent further expo-sure of the esophagus to the caustic agent. The use of cortico-steroids to reduce inflammation and minimize subsequent scarring and stricture formation is of questionable value. The value of the prophylactic use of antibiotics for these patients has also been questioned; however, these treatments continue to be prescribed (Schaffer & Herbert, 2000).

After the acute phase has subsided, the patient may need nutri-tional support via enteral or parenteral feedings. The patient may require further treatment to prevent or manage strictures of the esophagus. Dilation by bougienage may be sufficient, but dilation treatment may need to be repeated periodically. (In bougienage,cylindrical rubber tubes of different sizes, called bougies, are ad-vanced into the esophagus via the oral cavity. Progressively larger bougies are used to dilate the esophagus. The procedure usually is performed in the endoscopy suite or clinic by the gastroenterolo-gist.) For strictures that do not respond to dilation, surgical man-agement is necessary. Reconstruction may be accomplished by esophagectomy and colon interposition to replace the portion of esophagus removed.