Conservative Management of Acid (Corrosive) Ingestion in a Child

Immediate / Emergency Steps

Diagnosis

• Careful oral/pharyngeal examination - look for oropharyngeal burns, but note: the esophagus can be burned even when the mouth looks normal
• Flexible or rigid esophagoscopy - performed EARLY (within 12-24 h), but advance only to the first level of burn to avoid perforation through necrotic tissue
• Early barium swallow - delineates extent of mucosal injury
• CXR + erect AXR - exclude perforation (pneumomediastinum, free air under diaphragm)

Endoscopic Grading (Guides Management)

Conservative (Non-Operative) Treatment

1. NPO + Nutritional Support

• Keep nil by mouth initially
• Introduce oral fluids only once pain-free swallowing is confirmed (usually Grade I)
• For moderate-severe injury: nasojejunal feeding or gastrostomy tube placement once the child is clinically stable

2. Antibiotics

• Broad-spectrum antibiotics are administered during the acute period to prevent secondary bacterial infection of the denuded mucosa
• (e.g., IV amoxicillin-clavulanate or a cephalosporin)

3. Acid Suppression

• Proton pump inhibitors (PPI) - reduce further acid injury to already-damaged mucosa
• H2 blockers are an alternative

4. Steroids - No Longer Recommended

• Although historically used, steroids have NOT been shown to alter stricture development or modify the extent of injury
• They are no longer part of standard management of caustic injuries
• (A controlled trial of corticosteroids in children with corrosive esophageal injury published in NEJM 1990 showed no benefit)

5. Sucralfate / Mucosal Protective Agents

• May be used as adjuncts for mucosal coating and cytoprotection

6. Analgesics and Supportive Care

• IV morphine/opioids as needed
• Antispasmodics for esophageal spasm
• Close monitoring in ICU/HDU

Follow-Up and Stricture Prevention

• Repeat endoscopy at 3-4 weeks to assess for stricture formation
• If strictures develop: fluoroscopically guided balloon dilatation under general anesthesia, in association with esophagoscopy
• If a gastrostomy tube was placed: retrograde dilatation through the gastrostomy using graduated dilators passed antegrade through a string (the "string method") - the string is placed through the esophagus during early repeat endoscopy
• Dilatation is effective and should be performed when strictures are established (3-4 weeks)

When to Escalate to Surgery

• Perforation (pneumomediastinum, peritonitis)
• Full-thickness gastric necrosis
• Refractory strictures not responding to repeated dilatation
• Severe Grade III injuries may ultimately require esophageal replacement (gastric pull-up, colonic interposition)

Summary Algorithm

Acid ingestion in child
       ↓
Airway assessment → intubate if needed
       ↓
IV access, NPO, analgesia, IV antibiotics, PPI
       ↓
Esophagoscopy (within 12-24h) → Grade I/II/III
       ↓
Grade I: oral feeds when tolerating, discharge with PPI
Grade II/III: NBM, gastrostomy if severe, repeat scope at 3-4 wks
       ↓
Stricture → balloon dilatation under GA ± string method
       ↓
Refractory → surgical esophageal replacement

• No neutralization, no emesis induction, no blind NGT
• Steroids are NOT indicated (evidence shows no benefit)
• Endoscope only to first level of burn - avoid perforation
• Early antibiotics + PPI are the mainstay of conservative treatment
• The mouth can appear normal even when the esophagus is severely burned