Esophagus Acid/Alkali

Question 1

What kind of necrosis occurs with a caustic esophageal injury from alkali?

Answer 1

Liquefaction necrosis

Question 2

What kind of necrosis occurs with a caustic esophageal injury from acid?

Answer 2

Coagulation necrosis

Question 3

What are the 3 phases of tissue injury from alkali ingestion?

Answer 3

Acute necrosis, ulceration and granulation, cicatrization, and scarring

Question 4

What is a grade I caustic injury to the esophagus and the associated endoscopic findings?

Answer 4

Superficial mucosal burn, mucosal edema, and hyperemia

Question 5

What is a grade IIA caustic injury to the esophagus, and what are the associated endoscopic findings?

Answer 5

Transmucosal injury, patchy ulcerations, exudates, sloughing mucosa

Question 6

What is a grade IIB caustic injury to the esophagus, and what are the associated endoscopic findings?

Answer 6

Transmucosal injury, circumferential injury

Question 7

What is a grade III caustic injury to the esophagus, and what are the associated endoscopic findings?

Answer 7

Transmural injury with periesophageal/perigastric extension; deep ulcerations; black/gray discoloration; full-thickness necrosis

Question 8

Which grade or grades of caustic injury will progress to stricture?

Answer 8

Grades IIB and III

Question 9

Treatment for a patient who presents within the first hour following alkali ingestion:

Answer 9

Neutralization with half-strength vinegar or citrus juice

Question 10

Treatment for a patient who presents within the first hour following acid ingestion:

Answer 10

Neutralization with milk, egg whites, or antacids

Question 11

Management for a patient with no evidence of burn on endoscopy or physical exam following corrosive ingestion in the acute phase:

Answer 11

Observation and oral nutrition when the patient can painlessly swallow saliva

Question 12

Management for a patient with an endoscopically identified first-degree burn following corrosive ingestion in the acute phase:

Answer 12

48 hours of observation and oral nutrition when the patient can painlessly swallow saliva; repeat endoscopy and barium esophagram are performed in follow-up at intervals of 1, 2, and 8 months

Question 13

Management for a patient with an endoscopically identified second- or third-degree burn following corrosive ingestion in the acute phase:

Answer 13

Monitor in the ICU and keep NPO with IV fluids; start IV antibiotics and a proton pump inhibitor; if evidence of acute airway involvement, airway obstruction can be relieved with aerosolized steroids with the possible need for fiber-optic intubation

Question 14

How can the diagnosis of corrosive injury to the esophagus/stomach be made if not originally secured with endoscopy?

Answer 14

Exploratory laparoscopy in stable patients or laparotomy in unstable patients

Question 15

After performing an exploratory laparotomy/laparoscopy after corrosive injury, a viable stomach and esophagus are encountered; what should be performed?

Answer 15

The viable stomach and esophagus are left in situ, and a feeding jejunostomy tube is placed with endoscopic placement of an esophageal stent

Question 16

After performing an exploratory laparotomy/laparoscopy after corrosive injury, a questionable esophagus and stomach are encountered; what should be performed?

Answer 16

The questionable esophagus and stomach are left in situ with a second-look operation performed in 36 hours, with further management based on the findings

Question 17

After performing an exploratory laparotomy/laparoscopy after corrosive injury, full-thickness necrosis, or perforation of the esophagus/stomach is found, what should be performed?

Answer 17

Resection of the esophagus, stomach, and all affected surrounding organs and tissues; creation of an end-cervical esophagostomy; and placement of a feeding jejunostomy

Question 18

How is a patient who develops an esophageal stricture secondary to corrosive injury managed?

Answer 18

After re-epithelialization, aggressive treatment with bougie dilation, regardless of symptoms; dilations performed daily for 2 to 3 weeks, then every other day for 2 to 3 weeks, then weekly for months and lengthening the interval as time passes

Question 19

Name some types of conduits that can be used for esophageal reconstruction:

Answer 19

Gastric pull-up, jejunal interposition, colon interposition