Endoscopy

Endoscopy is an important tool used to evaluate the location and severity of injury to the esophagus, stomach, and duodenum after caustic ingestion. Indications for endoscopy vary. Some authorities recommend endoscopy in all cases of caustic ingestions, whereas others advocate endoscopy based on signs and symptoms.9 Endoscopy is generally indicated in the presence of any signs or symptoms of serious injury (vomiting, drooling, dyspnea, or stridor), in the presence of oral-pharyngeal burns, and after intentional ingestions.

Zargar and colleagues4 developed the most commonly referenced system for endoscopic staging of upper GI tract caustic injuries and prospectively demonstrated the safety of using the endoscope in caustic ingestions. Injuries are divided into four grades ( Table 175-3.). Patients with grade 2b and 3 injuries are at risk of long-term sequelae, including stricture formation. Patients with grade 3 lesions are at greatest risk of perforation, fistula, and hemorrhage.

Traditionally, endoscopists terminated their examination at the first sign of severe esophageal injury (grade 2b or 3). However, a more complete exam to document all injuries to the esophagus, stomach, and duodenum may outweigh the risk of perforation. Most experts agree that the timing of the endoscopy should be within the first several hours of ingestions and that follow-up exams should be avoided between days 5 and 15. Other noninvasive diagnostic means to evaluate and follow caustic GI injuries include abdominal computed tomography (CT) and ultrasonography. For patients not requiring emergent laparotomy, CT may be used to screen for intraabdominal necrosis outside the GI tract or in areas not reachable with the endoscope. Sonographic evaluation, both transabdominal and endoscopic, has been advocated for evaluation and follow-up of gastric injury after caustic ingestion. 10

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