Esophageal thermal injuries associated with food ingestion: an updated scoping review
Review Article

Esophageal thermal injuries associated with food ingestion: an updated scoping review

Alberto Aiolfi1 ORCID logo, Davide Bona1, Matteo Cali1, Tarek Ahmad2, Luigi Bonavina2

1Division of General Surgery, Department of Biomedical Science for Health, IRCCS Ospedale Galeazzi – Sant’Ambrogio, University of Milan, Milan, Italy; 2Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Milan, Italy

Contributions: (I) Conception and design: A Aiolfi, L Bonavina; (II) Administrative support: None; (III) Provision of study materials or patients: A Aiolfi, M Cali, T Ahmad; (IV) Collection and assembly of data: A Aiolfi, M Cali, T Ahmad; (V) Data analysis and interpretation: A Aiolfi, D Bona, L Bonavina; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Alberto Aiolfi, MD, FACS, FEBS (UGI). Division of General Surgery, Department of Biomedical Science for Health, IRCCS Ospedale Galeazzi – Sant’Ambrogio, University of Milan, Via C. Belgioioso, 173, 20157 Milan, Italy. Email: alberto.aiolfi86@gmail.com.

Background: Esophageal thermal injuries (ETIs) associated with food ingestion can lead to severe complications and long-term sequelae. Purpose of the study was to provide a comprehensive overview of these peculiar esophageal burns, including etiology, clinical presentation, diagnostic approaches, and management strategies.

Methods: The study was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). PubMed, EMBASE, Scopus, Web of Science, Cochrane, and Google databases were queried until 31st December 2023. Eligible studies included all articles reporting data, management, and outcomes on ETI.

Results: Twenty-seven patients (23 case reports) experiencing ETI from solid and liquid hot food ingestion were included. Overall, 12 patients suffered from hot solid food ingestion while 15 experienced hot liquid food ingestion causing ETI. Odynophagia, dysphagia, and chest pain were the most commonly reported symptoms. Diagnosis relies on a combination of clinical assessment, endoscopic evaluation, and imaging modalities. A multidisciplinary approach involving both gastroenterologists and surgeons is critical. Management strategies encompass supportive care, such as fluid resuscitation and nutritional support, along with specific interventions like surgical repair and endoscopic dilatation in severe cases.

Conclusions: ETI resulting from the ingestion of hot liquids and solid foods pose a not negligible morbidity and mortality risk. Early recognition, prompt diagnosis, and appropriate management are essential in improving outcomes. Prevention through public education and regulatory measures to minimize the incidence of complications remain paramount to improve patient outcomes and quality of life.

Keywords: Esophageal thermal injury (ETI); esophageal burns; food-related esophageal injury; endoscopic dilation; esophagectomy

Received: 19 March 2024; Accepted: 24 July 2024; Published online: 19 September 2024.

doi: 10.21037/ales-24-15

Highlight box

Key findings

• Esophageal thermal injuries (ETIs) are probably underestimated due to lack of awareness and diagnosis

• ETI is more common in Eastern countries because of food preparations and cultural behaviours.

What is known and what is new?

• ETI may be related to both hot solid and liquid food.

• ETI pose a not-negligible morbidity and mortality risk. Severe complications may occur in up to 7% of patients.

What is the implication, and what should change now?

• Early recognition, prompt diagnosis, and appropriate management are essential in improving outcomes.

• Prevention through public education and regulatory measures to minimize the incidence of ETI is of paramount importance.

Introduction

Acute esophageal thermal injuries (ETIs) may occur secondary to ingestion of hot food and beverages and are more commonly reported in Eastern countries because of differences in food culture. Although infrequent, these lesions are distinct from chemically induced injures due to corrosive substances and are generally reversible (1-3). Odynophagia, chest pain, hematemesis, and melena have been reported as common symptoms after hot food ingestion and mucosal injury (4). The endoscopic assessment may reveal different degrees of esophageal mucosal damage such as linear erythema with white pseudomembranes (“candy-cane” esophagus), superficial ulcers or submucosal blisters (5). These injuries are superficial and usually self-limiting after conservative management [i.e., nil per os, parenteral nutrition, proton pump inhibitors (PPIs), sucralfate].

Since data from the scattered literature reports are heterogeneous and the evidence is scarce, we provide an updated scoping review on symptoms, diagnosis, complications, and treatment of ETI related to food ingestion. We present this article in accordance with the PRISMA-ScR reporting checklist (6) (available at https://ales.amegroups.com/article/view/10.21037/ales-24-15/rc).

Methods

An extensive literature search was conducted to identify all English-written published articles on esophageal burn due to hot liquid and solid food ingestion. PubMed, EMBASE, Scopus, Web of Science, Cochrane, and Google databases were consulted. Keywords and MeSH terms included “esophagus”, “esoph*”, “thermal injury”, and “esophageal burn”, with “AND” until 31st December 2023. The search was completed by consulting the listed references of each article.

All the English-written articles, case reports, case series and observational studies were included in this scoping review. All authors (A.A., D.B., M.C., T.A., and L.B.) independently extracted data from eligible studies. Data extracted included study characteristics (first author name, year, and journal of publication), number of patients, demographic characteristics, symptoms and diagnostic methods, type of ingested food, related complications, treatment, and postoperative outcomes. Studies reporting iatrogenic ETIs related to radiofrequency catheter ablation for atrial arrhythmia or liver radiofrequency ablation were excluded. Quality assessment of the included articles was done according to Murad et al. (7). Institutional Review Board was not required for this review.

Results

The literature search in this review yielded 291 records from all databases (Figure 1). After duplicates removal, 283 records were screened. After title and abstract assessment 41 full-text articles were finally considered. Twenty-seven patients, from 23 studies, were finally included in this scoping review (Table 1). The quality of the included studies revealed a moderate (48%) and high (52%) risk of bias. The median age of the patient population was 47 (range, 11 to 79) years and 63% were males.

Figure 1 PRISMA diagram illustrating the article selection process for the scoping review process.

Table 1

Summary of demographics, clinical manifestations, and endoscopic findings for esophageal thermal injury (ETI)

Author, country/region, publication year Age (years) Sex Ingested bolus Symptoms Timing from event to endoscopy (days) Endoscopic findings Treatment (treatment duration) Follow-up duration (clinical or endoscopic) Risk of bias
Liebermann et al., US, 1982 (1) 22 M Jelly roll (MW) Od + Dph 3 Multiple linear erythematous ulcers No medications 1 week HR
Javors et al., US, 1996 (2) 21 F Lasagna (MW) Od + Dph + Cd 3 Longitudinally linear collection and filling defect H2RA (1 mo) – HR
Dutta et al., US, 1998 (3) 66 M Beverages Od + Cd 30 Necrotic, anucleated nonviable epithelium, CC NR NR HR
72 F Soups Me 21 Necrotic, anucleated nonviable epithelium, CC NR NR
Eliakim et al., Israel, 1999 (8) 20 M Hamburger Od + Dph 12 Single longitudinal ulcer PPI (1 mo) 2 mos HR
Cohen et al., US, 2002 (9) 55 M Smoking freebase cocaine/hot liquids Me 2 Parakeratosis, squamous hyperplasia, inflammatory cell infiltration, CC PPI (1 mo) 12 mos HR
Choi et al., South Korea, 2005 (10) 38 F Tea Od + Cd + H 7 Pseudomembranous mucosa band with hyperemic mucosa, ulcer with granulation tissue PPI (1 mo) 2 mos MR
Kim et al., South Korea, 2006 (11) 56 M Egg (Steamed) Od 5 Geographic ulcer PPI and sucralfate (1 mo) 12 mos HR
Go et al., China, 2007 (12) 69 M Tea Ep + Od + Cd 7 Diffuse pseudomembranous mucosa and erosion/linear plaque, lower esophagus small fibrotic changes PPI (NR) 1 mo MR
Chung et al., South Korea, 2010 (13) 53 M Prawn Od + Cd 3 Partial longitudinal ulcer band/partial pseudomembranous mucosa band PPI (1 mo) 2 mos HR
Kim et al., South Korea, 2012 (14) 63 F Rice cake Cd + Od 7 Esophageal ulcer PPI and sucralfate (1 mo) 1 mo HR
Silberman et al., Israel, 2013 (15) 79 M Lasagna (MW) Dph + Dr + Dph NR Thermal burns larynx and vocal cords, esophagus erythema Dexamethasone NR MR
Lee et al., China, 2014 (16) 45 F Tea Od + H 7 Pseudomembranous mucosa in geographic shape/candy cane appearance, CC PPI, sucralfate (NR) 1 mo MR
52 M Stew Cd 7 Longitudinal pseudomembranous mucosa and erosion H2RA, sucralfate (3 mos) 1 mo
29 M Water Od 1 Pseudomembranous and hyperemic mucosa/whitish fibrosis and edematous hyperemic mucosa PPI, sucralfate (NR) 1 mo
57 F Water A 02-mar Friable mucosa, fibrosis and edema PPI, sucralfate (NR) 1 mo
Kitajima et al., Japan, 2014 (17) 28 M Coffee Od + Dp 40 Failed to pass (circumference stenosis, mucosal swelling)/healing of edematous mucosa Tracheostomy, PPI and parenteral nutrition (NR), endoscopic dilation, esophagectomy 10 mos MR
Wu et al., Taiwan, 2015 (18) 47 F Dumpling Od + Cd 1 Partial longitudinal pseudomembrane PPI (2 mos) NR HR
AC et al., India, 2016 (19) 19 M Tea H – Diffuse ulceration, CC PPI (NR) 1 mo HR
Lim et al., China, 2017 (5) 50 M Pork meat (steamed) Od + Cd NR Diffuse mucosa erosion, along with longitudinal whitish detached membrane H2RA and sucralfate 5 mos MR
Prevost et al., US, 2017 (20) 16 M Tea Od + H 5 Diffuse and circumferential erythema of the entire esophagus PPI, sucralfate, lidocaine, magnesium hydroxide, diphenhydramine (NR) 1 mo MR
Schertl et al., Germany, 2018 (21) 55 F Coffee Od NR Shredded whitish membranes covered almost the full length of the esophagus, even forming 4- to 5-cm-long tubes PPI, oral budesonide (NR) 3 mos HR
Hudgi et al., US, 2020 (22) 32 M NR Cd NR Esophageal erosions, CC PPI (2 mos) – MR
Ochiai et al., Japan, 2020 (23) 59 F Coffee Od 2 Longitudinal hematoma, CC PPI, sucralfate (NR) 1 mos HR
Xu et al., China, 2022 (24) 44 M Porridge Cd + Od NR Intramural hematoma of the esophagus PPI (NR) 0.5 mos MR
Lam et al., US, 2023 (25) 11 F Butternut squash (425 °F) Dph + Dr + V 3 Linear white plaques/pharyngeal burns, mucosal burns at the base of the tongue Ampicillin/sulbactam, dexamethasone, PPI, liquid sucralfate and ketorolac 10 mos MR
Aiolfi et al., Italy, 2023 (26) 38 M Hot potato (MW) Dph + Cd 1 Esophageal perforation Hybrid IL esophagectomy 10 mos MR

M, male; MW, microwave heated; Od, odynophagia; Dph, dysphagia; HR, high risk; F, female; Cd, chest discomfort; H2RA, H2 receptor antagonist; mos, months; NR, not reported; CC, candy cane appearance; Me, melena; H, hematemesis; A, anemia; PPI, proton pump inhibitors; MR, middle risk; Dr, drooling; V, vomiting; IL, Ivor-Lewis.

Overall, 12 of 27 patients suffered from solid food ingestion. Odynophagia and dysphagia were reported in 90% and 85% of patients, respectively. The endoscopic assessment revealed in 90% of patients the presence of longitudinal mucosal ulcers or erythematous lesions. Only one patient presented with “candy-cane” esophageal mucosal appearance. Conservative treatment was accomplished in 92% of patients with antisecretory medications and sucralfate. Esophageal perforation occurred in one patient after the ingestion a microwave heated new potato. The patient underwent urgent hybrid Ivor-Lewis esophagectomy with gastric conduit reconstruction. None of the patients developed long-term complications.

Hot liquid food ingestion causing ETI was described in 15 patients. Ingestion of hot tea beverage was reported in 36% of patients followed by hot water (27%), and hot coffee (11%). Odynophagia was reported in 54% of patients followed by chest pain (36%), and melena/anemia (27%). Pseudomembranous mucosa with superficial erosions were diagnosed at initial endoscopy in 64% of patients, whereas “candy cane” esophagus was detected in 45% of patients. All patients were treated with antisecretory medications and sucralfate. One patient with history of hot coffee ingestion and late presentation (40 days after the index event) developed an esophageal fibrotic stricture after 5 months that required thoracoscopic esophagectomy with colonic interposition (Figure 2).

Figure 2 Visual abstract: esophageal thermal injuries related to hot food ingestion.

Discussion

To the best of our knowledge this is the first scoping review focused on ETI. Although thermal injuries are rarely mentioned among the causes of odynophagia, the esophagus is vulnerable to a range of injuries, including damage caused by exposure to ingested hot food and beverages (1-5). The true prevalence of ETI is probably underestimated due to lack of reporting and lack of timely endoscopic evaluation. It may be influenced by different food culture habits as 52% of the studies reported in this review come from Eastern countries. An endoscopic survey in China found chronic esophagitis in 70% of the local population, suggesting that thermal injury from hot food may be a risk factor for esophagitis and dysplasia (27). ETI occurs when the mucosal layer of the esophagus sustains damage due to direct contact with hot solid or liquid foods (5). ETI represents a medical concern due to the potential for severe injury and complications when hot liquids or solid foods come in contact with the esophageal mucosa. The severity of the burn depends on factors such as temperature, duration of contact, volume ingested, and method of food preparation. Food preparation and the cooking/heating methods are important and should always be investigated. In our study, 15% of patients referred to have used microwave oven for food preparation. Since their introduction in 1947, microwave ovens have been associated with high-risk of oropharyngeal burns (28). Differently from the conventional oven heating that involves heat transfer from outside to inside, microwave heating involves energy conversion from electromagnetic to thermal. During the heating process, electromagnetic waves oscillate within the oven and interact with food particles, leading to heat generation and rise in temperature from inner to outside layers. Food and beverages exposed to microwave radiation can attain temperatures far above the boiling point of water.

Hot beverages like tea, coffee, and soup, as well as solid foods, can cause thermal injury to the esophagus, leading to mucosal damage, inflammation, and potentially, full-thickness burns (29). Macroscopic features may vary according to the timing of endoscopy. It is likely that bullae (second degree burn) represent the initial endoscopic finding at an acute stage (2,10). This is followed by rupture of the mucosal blister and an inflammatory response that results in a whitish pseudomembrane. The “candy-cane” appearance may represent a late stage of the injury (3,19). The clinical presentation of ETI can vary widely and is most commonly related to the extent of injury. Patients may complain of self-limiting odynophagia, dysphagia, and chest pain, but in severe cases there might be evidence of mucosal ulceration, hemorrhage, or even esophageal perforation.

The correct diagnosis requires a comprehensive approach. Accurate history-taking regarding the ingested substance and its temperature is crucial. Upper endoscopy represents the gold standard diagnostic modality to assess the extent of esophageal damage related to thermal injury and to guide clinical decision making. Endoscopic assessment allows direct visualization of the esophageal mucosa thus enabling clinicians to assess the extent and severity of thermal injury. Although the optimal timing for endoscopy is unknown, this should possibly be performed within the first 72 hours from ingestion (20). Longitudinal lesions (81%), mucosal pseudomembranes (74%), mucosal erythema (72%), and ulcers (31%) were commonly reported in the analyzed studies. The “candy-cane” esophagus, observed in 45% of patients who ingested hot liquids, is the result of alternating linear mucosal erythema (red bands) and pseudomembrane (white bands) (9). All these features may be part of the healing process and may be dependent on timing of endoscopy. A standardized endoscopic ETI classification is currently lacking and should be developed. Histological sampling may be useful to confirm the diagnosis (necrosis, inflammatory cell infiltration, activated endothelial cells, granulation tissue, etc.) and rule out other underlying conditions, such as malignancy, infection (i.e., Candida, herpes, or cytomegalovirus), pills esophagitis, and radiation-related mucosal changes (5). Notably, synchronous oral and upper airways involvement may occur in up to 30% of patients and should be ruled-out at the time of initial endoscopy in high-risk cases (17). Finally, endoscopic follow-up is mandatory to assess the healing progress and to monitor the development of possible complications. Imaging studies such as CT scans are useful to evaluate the extent of esophageal wall involvement and to diagnose complications like perforation or mediastinitis (4). Of note, severe immediate (full-thickness perforation) of late (esophageal stricture) complications requiring esophagectomy were reported in 2 of 27 patients (7.4%).

The clinical course of ETI is considered relatively benign and reversible. ETI management involves a multidisciplinary approach and varies based on the severity of injury. Initial management focuses on supportive care, including pain control, fluid resuscitation, and nutritional support. In less severe cases, conservative measures such as PPIs, histamine2-receptor antagonist, and mucosal protectants may suffice. Steroids may be used in case of tracheal edema. The duration of treatment was heterogeneous across the included studies and tailored on a case-by-case basis. Airway evaluation and protection with protective intubation or tracheostomy is mandatory in case of air flow compromise. In patients with extensive injury or complications like stricture formation or perforation, endoscopic management with dilatation or stent placement may be required. Surgical intervention remains necessary in case of life-threatening complications such as perforation or in patients with otherwise intractable stricture (4). None of the included patients had concomitant or developed esophageal cancer during follow-up. While several studies suggest a link between long-term consumption of hot beverages or food and esophageal cancer due to mucosal barrier impairment and chronic inflammation, it is unclear whether this association extends to individuals experiencing a single episode of ETI (30,31). Therefore, the connection between ETI and esophageal cancer remains uncertain and mandates future investigations.

Prevention remains the cornerstone in mitigating the risk of esophageal burns related to hot food and liquid ingestion. Public education regarding the appropriate temperatures for eating food, as well as proper food preparation and handling, is essential. Additionally, regulatory measures to enforce food safety standards and warning labels on hot beverage containers can help raise awareness and prevent inadvertent injuries.

Limitations of the present review are the potential literature underreporting and underestimation of the global effect of ETI. Further, the robustness of our findings is limited because based on level IV evidence case reports.

Conclusions

ETI resulting from the ingestion of hot liquids and solid foods pose a not negligible morbidity and mortality risk. Early recognition, prompt diagnosis, and appropriate management are essential in improving outcomes and minimizing complications. Through increasing awareness of hot food and drinks, and a combination of preventive measures and effective treatment strategies, the burden of ETI can be mitigated, ultimately leading to better patient care and outcomes.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-24-15/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-24-15/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-24-15/coif). L.B. serves as an unpaid editorial board member of Annals of Laparoscopic and Endoscopic Surgery from December 2023 to November 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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doi: 10.21037/ales-24-15
Cite this article as: Aiolfi A, Bona D, Cali M, Ahmad T, Bonavina L. Esophageal thermal injuries associated with food ingestion: an updated scoping review. Ann Laparosc Endosc Surg 2025;10:3.

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