Which of the following statement(s) is/are correct concerning the management of a patient with a caustic esophageal or gastric injury?

b. Complete endoscopic examination of the esophagus and stomach should be completed

c. Patients requiring operative intervention are best explored through the abdomen 

d. If organ resection is indicated, restoration of alimentary continuity should be deferred until the patient has recovered from the acute insult

Acute caustic ingestion is indication for hospitalization. Initial management centers on stabilizing the patient and assessing the severity of injury. Oral intake should be withheld and hypovolemia corrected with intravenous fluids. Careful observation for evidence of airway obstruction is mandatory. Broad spectrum antibiotics are indicated once the diagnosis of substantial esophageal injury has been established to diminish the risk of pulmonary infection from aspiration as well as bacterial invasion through the damaged esophageal wall. Although corticosteroids have been advocated in the acute phase of caustic ingestion to minimize subsequent stricture formation, their efficacy has not been established. Furthermore, because steroids may mask signs of sepsis, visceral perforation, and impair healing, their use in caustic esophageal injury is potentially deleterious and therefore is not recommended.

A contrast esophogram is the best way to make the diagnosis of esophageal perforation and should be performed if the diagnosis is suspected at the time of admission or in subsequent followup. Esophagoscopy should be performed soon after admission to establish whether significant esophageal injury has occurred and to permit grading of the severity of injury. Although in the past it was taught that the endoscope should not be advanced beyond the first burned area, more recently complete examination of the esophagus and stomach has been recommended, especially if severe burns are not detected proximally. The use of a pediatric endoscope and adequate sedation can allow this procedure to be accomplished safely. Patients with caustic liquid ingestion that necessitate operative intervention are generally best explored through the abdomen. This approach permits assessment of the injury to the intraabdominal organs as well as resection of areas of full thickness gastric necrosis. Although only the lower esophagus is well visualized through the diaphragmatic hiatus, if an esophageal resection is required, transhiatal esophagectomy without thoracotomy is readily performed by the addition of a cervical incision. When esophageal gastric resection for acute caustic injury is required, restoration of alimentary continuity should be deferred until the patient has recovered from the acute insult and the development of chronic stricture formation and retained organs can be evaluated. Esophageal stricture formation following second and third degree burns is the rule, and dilatation therapy has been the traditional therapy for chronic caustic esophageal strictures. It is important that dilatation not be instituted until at least six to eight weeks after the injury, when reepithelialization is complete, in order to minimize the risk of perforation.