Corrosive oesophagitis, and oesophageal strictures

Corrosive oesophagitis is not uncommon in some communities, as the result of a patient swallowing caustic soda (for making soap), sulphuric acid, or some other corrosive chemical. You will have to treat him in the acute stage, and if necessary in the other stages also. It is useful to be able to oesophagoscope him, but you may be able to manage without doing so. If you don't have ]]the correct bougies, try to improvise them. For malignant strictures, see Section 32.24. Bouginage is always dangerous! Do it with infinite care, if you want to avoid perforating his oesophagus, and killing him.

Martinson FD, ''Corrosive oesophagitis in Nigeria', Tropical Doctor 1978;8:123[nd]126 page441

CORROSIVE OESOPHAGEAL STRICTURES THE ACUTE PHASE After swallowing a corrosive substance, a patient has immediate retrosternal or abdominal pain, he drools, and he may vomit food or blood. He may also have stridor, or symptoms due to the poisonous nature of the substance he has ingested. You may see patches of burnt mucosa on his lips, mouth, or pharynx.

Find out what he took and when. Give him an analgesic. If you see him within 6 hours, when the corrosive agent is still present, lavage his stomach urgently! If there is delay, avoid lavage. Add the antidote to the lavaging fluid. For a corrosive acid, use magnesia, chalk, or washing soda. For an alkali, use vinegar, or the juice of 5 lemons.

If he is unconscious (unlikely in corrosive poisoning), intubate him first.

To lavage his stomach, lay him prone with his head over the end of the bed, remove any false teeth, and preferably insert mouth gags on each side of his mouth. Pass a safety pin through the wall (not the lumen) of a large rubber stomach tube (10 mm for an adult, 8 mm for a child under 2 years), to mark the distance it should pass (adult 50 cm from the tip, 25 cm in a child under 2 years). Pass tepid water into his stomach, never more than 500 ml at time in an adult, and 250 ml in a child. Send the first washouts for analysis. Continue washing out with 500 ml at at time, until you have used 5 litres.

CAUTION ! Check the volume of fluid you have used. A marked discrepancy suggests that his stomach has perforated.

After you have lavaged his stomach, pass a small nasogastric tube (14 to 19 Ch). This will maintain a lumen, reduce adhesions, and let you to feed him.

Set up a drip, and give him an antibiotic. Don't oesophagoscope him now! In a few days, he will be able to swallow round the tube, as the latent stage is approached.

You may be able to persuade a child to swallow a piece of string coated whith honey, one end remaining outside, while the other goes into his stomach. This will maintain a lumen, however small, and may be a useful way of performing retrograde bouginage later.

If possible refer him, if not proceed as follows.

THE LATENT STAGE If he has no severe complications immediately, his pain and dysphagia improve, and he may think himself cured. However, during the next 6 weeks (or much longer), the granulation tissue in his oesophagus steadily contracts, and become densely fibrous.

You may be able to oesophagoscope him at 14 days. Don't try to inspect the whole length of his oesophagus with a rigid instrument.

If you cannot refer him, bougie him after 2 weeks and repeat this with care. How often you should bougie him, whether or not you should replace the nasogastric tube, and the time you should leave it in, will depend on how he progresses. Do a barium or ''Gastrografin' swallow, and X-ray his chest.

THE CHRONIC STAGE If he has not been bougied in the latent stage, he will notice a reversal of the improvement he previously enjoyed. His dysphagia gets worse, but because he has no pain, he does not seek treatment, until he finds he cannot swallow fluids. He is hungry and thirsty, he loses weight, and may vomit due to the obstruction in his oesophagus or stomach. The overspill of his oesophageal contents, held up above the stricture, may cause pulmonary symptoms.

Continue to bougie him as often as is necessary, until you can pass a large bougie (preferably 40 Ch), at 4-monthly intervals, over the period of a year. Most patients will not bougie themselves, and permanent gastrostomies are not accepted, except by patients with malignant strictures, who hardly ever return for follow-up.

DIFFICULTIES [s7]WITH CORROSIVE OESOPHAGEAL STRICTURES If you CANNOT PASS A BOUGIE through his mouth, and you cannot refer him, do a gastrostomy (11.8), and pass a fine Jackson or filiform bougie, with a strong silk thread attached to it, up through his oesophagus, and out through his mouth. Or, use the piece of string he swallowed previously, to pull graded Gabriel[nd]Tucker bougies up his oesophagus to dilate the stricture. After reasonable dilatation, pull a nasogastric tube of appropriate size, as well as a fresh piece of string, up and out of his nose. Use the string for further retrograde bouginage later.

Insert a large de Pezzer or Foley catheter (28 or 30 Ch) through the gastrostomy to keep it open for the same purpose, until you can restart bouginage orally. After a few weeks the acid from his stomach will eat through the balloon, so you will have to replace it.

If all this fails, or if he has a long tight stricture, or multiple ones, he will have to be referred for a stomach, jejunum or colon bypass operation.

REMEMBER, BOUGINAGE IS EXQUISITELY DANGEROUS!