A woman, aged 51, was investigated because of nausea, vomiting and dysphagia. She had a psychiatric disorder and, 3 weeks previously, had swallowed a significant volume of concentrated hydrochloric acid. Investigations included upper gastrointestinal endoscopy and a barium meal radiograph. Endoscopy revealed an abnormal antral mucosa with pale and red areas, irregular ulceration and exudate formation (Fig. 1). In addition, there was narrowing in the region of the pylorus that prevented passage of the endoscope into the duodenal cap. A barium meal radiograph showed a stricture (arrow) involving the pylorus and lower antrum of the stomach (Fig. 2). The patient was subsequently treated surgically with a gastrojejunostomy.
Caustic injuries to the upper gastrointestinal tract continue to be a significant problem in most parts of the world. Two-thirds of these events occur because of accidental ingestion by children under the age of 6 years. The remainder occur in older children and adults and sometimes reflect intentional injury associated with various psychiatric disorders. Although both the esophagus and stomach can be damaged by acid and alkalies, acids tend to cause more damage in the stomach and alkalies more damage to the esophagus. The mechanism of damage also varies with the different agents; liquefaction necrosis for alkalies and coagulation necrosis for acids. The degree and extent of caustic injury is closely associated with mortality and with subsequent risks for stricture formation. In the presence of antral stenosis, endoscopic dilatation has been successful in at least some patients. Those with persistent strictures usually require surgery, either a partial gastrectomy or a gastroenterostomy. Although corticosteroids and antibiotics appear to be helpful for acute caustic injuries in animals, there is no persuasive evidence of benefit in humans.