Corrosive Strictures, Classification, Features, Investigations

Describe the clinical features, investigations and principles of management of corrosive strictures, oespha-geal perforations, diverticulum (benign disorders).

Corrosive Oesophageal Stricture

These caustics are taken accidentally or in attempted suicide. The agents are sodium hydroxide, sulphuric acid, household bleach. The acids affect acidic stomach mucosa. The squamous epithelium of oesophagus is relatively resistant to acids (also due to rapidity of flow of fluids).

Corrosive Stricture Causes 

Read And Learn More: Gastrointestinal Surgery Notes

• Corrosive (caustic) injuries
• Carcinoma
• Columnar lined oesophagus—Barrett’s oesophagus
• Capsules of tetracycline group of antibiotics
• C vitamins—potassium compounds
• Chronic reflux due to GORD, results in Schatzki ring— a stricture at lower oesophagus at squamocolumnar junction. It is a circular ring consisting of fibrous tissue and cellular infiltrates.
• The alkali—sodium hydroxide affects oesophageal mucosa more than gastric mucosa. Alkali ingestion is more common than acid ingestion.
• Alkali ingestion is more devastating than acid.
• Alkali ingestion almost always leads to significant destruction of oesophagus.
• The corrosive injuries may involve oropharynx, larynx, oesophagus, stomach and sometimes intestines also.

Corrosive Stricture Classification 

• Superficial: Erythema, oedema, blisters, etc. Re- epithelialisation of mucosa is complete by 6th week.
• Deep: Circumferential ulcers, produces scarring and contractures. Major injury of the stomach produces gastric outlet obstruction.

Corrosive Stricture Clinical Features

• Severe pain, drooling of saliva, inability to swallow.
• Retrosternal burning, abdominal guarding and rigidity.
• Hoarseness, stridor, laryngeal oedema, if there is laryngeal injury.
• Dysphagia occurs later due to stricture.

Important Examinations in Corrosive Injury

• Examination of the oral cavity, chest and abdomen.
• Auscultation of the lungs
• Examination of upper airway
• Abdominal examination—guarding and rigidity of the abdomen indicate perforation.

Corrosive Stricture Investigations

• Early endoscopy—within 12-24 hours—to grade the injury.
• CT scan can reveal any perforation in the thorax or in the abdomen.

Corrosive Stricture Treatment: Can be divided into acute and chronic cases. In acute cases, treatment depends upon the severity of the injury or burn.

• Acute cases: Any surgical intervention should be done only in selected referral centres. Kindly follow the instructions given below.
• Chronic cases present with stricture that need regular dilatation. This is ideally done after 6 weeks (the time for re-epithelialisation of oesophagus)
  • Colonic pull-up is the choice for impassable strictures, only after adequate nutrition is achieved through feeding jejunostomy.

Complications of Stricture

• Development of malignancy (3 to 5%)
• Progressive nutritional deficiency
• Recurrent respiratory tract infection.

Dilatation of the Stricture

• Indicated in all cases of symptomatic oesophageal stricture.
• Peptic strictures, corrosive strictures, anastomotic strictures following oesophagogastric anastomosis in  of perforation.
• Flexible oesophagoscopy is done and a guidewire is passed. The scope is withdrawn. Solid dilators of increasing diameter are passed over the guidewire.
• A stricture should be dilated to at least 16 mm in diameter to restore normal swallowing.
• Peptic strictures are easy to dilate as they are short.
• Beware of a GE junction stricture. It may be malignant. Once it is dilated, a growth may be seen. Take a biopsy.
• Pneumatic dilatation can also be used.

Ten Commandments Of Acute Corrosive Injury

1. Neutralisation of the ingested material
2. Alkalis are neutralised by half strength vinegar, citrus juices
3. Acids are neutralised by milk, egg white, antacids
4. Avoid emetics and sodium bicarbonates
5. Stabilise the patient and arrange upper GI scopy— classify the degree of injury.
6. No burns: Observe, small amount of clear fluids may be allowed orally
7. First degree burns: Observation for 48 hours. If he can swallow saliva, clear fluids can be started. Repeat endoscopies after a month, 3 or 6 months later to rule out stricture.
8. Second degree burns: Intravenous fluids, nil per oral, acid suppression, relieve airway obstruction, parenteral nutrition
9. Cervical oesophagostomy, staple the GE junction, feeding jejunostomy. 6 weeks later, gastric pull up and oesophagogastric anastomosis, in cases of perforation.
10. Call for senior surgeon’s help