Resident Manual of Trauma to the Face, Head and Neck

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.

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Resident Manual of Trauma to the Face, Head, and Neck