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Chapter 10: Foreign Bodies and Caustic Ingestion
If necrosis is identified extending into the gastric mucosa, direct
visualization of the outer gastric wall should be considered to rule out
transmural necrosis.
G. Postoperative Management
1. Pharmacologic Therapy
Gastric reflux precautions, proton pump inhibitors, histamine H2
receptor blockers, or sucralfate should be considered for patients with
any mucosal injury.
The use of broad-spectrum antibiotics and corticosteroids for second-
and third-degree injuries is controversial. No study has proven their
effectiveness in preventing stricture formation or other subsequent
complications. Broad-spectrum antibiotics are required for symptom-
atic patients (fever, chest pain, tachycardia) with a known perforation,
given their risk of mediastinitis. Use is controversial in asymptomatic
patients, although routinely administered.
2. Alimentation
Patients with first- or second-degree injuries may start a liquid diet
immediately following endoscopy and advance to a regular diet over
24–48 hours if they remain asymptomatic.
A nasogastric feeding tube should be placed under direct visualization
for all patients with third- and fourth-degree injuries. Although its
primary purpose is to allow for adequate nutrition, it also serves as a
mechanical stent if left in place throughout reepithelialization. Close
observation in a hospital setting is mandatory for all patients with these
injuries. Third-degree injuries may progress to fourth-degree injuries
after 48 hours.
Patients with third-degree injuries may attempt a clear diet after 3 days
and advance to a regular diet if they remain asymptomatic. A barium or
gastrografin swallow study should be repeated after 3 days for all
patients with fourth-degree injuries that show clinical improvement
before attempting postoperative intake.
3. Further Workup
Patients with intentional caustic ingestion should be evaluated and
cleared by psychiatry prior to discharge.
A baseline barium swallow should be completed 3 weeks post-incident
in patients with second-degree injuries or higher.