In a 32‑year‑old woman with Zargar grade 2b esophageal injury and gastric and duodenal eschars after initial endoscopy, is repeat diagnostic endoscopy indicated at this stage?

Repeat Diagnostic Endoscopy is NOT Indicated in the Acute Phase for Zargar 2b Injury

In a 32-year-old woman with Zargar grade 2b esophageal injury and gastric/duodenal eschars after initial endoscopy, repeat diagnostic endoscopy should NOT be performed at this acute stage. Instead, management should be guided by CT imaging and clinical monitoring, with endoscopy reserved only for specific indications or for therapeutic intervention weeks later if strictures develop 1.

Rationale Based on Current Guidelines

The WSES 2019 guidelines fundamentally shifted the paradigm away from endoscopy-based management in caustic injuries 1. Here's the algorithmic approach:

Acute Phase Management (Current Stage)

CT imaging has replaced repeat endoscopy as the primary monitoring tool because:

• Endoscopy cannot accurately predict transmural necrosis, which is the critical determinant of surgical need 1
• CT-based algorithms significantly improved patient outcomes compared to endoscopy-based management 1
• The major drawback of endoscopy is exposing patients to either futile surgery or inappropriate "watch and wait" management with risk of death 1

Your patient requires:

• Close clinical and biological monitoring without repeat endoscopy 1
• Repeat CT examination if any clinical deterioration occurs 1
• Non-operative management since Zargar 2b does not indicate full-thickness necrosis 1

When Repeat Endoscopy IS Indicated

Emergency endoscopy should only be performed if 1:

1. CT is unavailable
2. CT with contrast is contraindicated (renal failure, iodine allergy)
3. CT suggests transmural necrosis but interpretation is difficult/uncertain
4. Pediatric population (to avoid radiation)

None of these apply to your patient.

Future Endoscopic Role (3-6 Weeks Later)

Endoscopy becomes relevant again at 3-6 weeks post-ingestion for stricture evaluation and management 1:

• Zargar 2b injuries carry significant stricture risk (47.2% in one series required dilations) 2
• Dysphagia and regurgitation symptoms should prompt endoscopic evaluation 1
• Endoscopic dilation can be started safely between weeks 3-6 after healing of acute injuries 1

Stricture Management Algorithm

If strictures develop:

• First-line: Endoscopic dilation for few (<3) short (<5 cm) strictures 1
• Interval: 1-3 weeks between dilations 1
• Expected sessions: 3-5 sessions typically provide satisfactory results 1
• Surgical consideration: After 5-7 failed dilation attempts 1

Critical Pitfalls to Avoid

Do not perform repeat endoscopy in the acute phase based on outdated protocols. The evidence is clear that CT-based management improved outcomes 1. Recent data from 2022 confirms that Zargar ≥2B injuries require intensive monitoring, but this is clinical and radiographic—not endoscopic 3.

Watch for clinical deterioration that would prompt CT (not endoscopy): worsening pain, fever, sepsis signs, or inability to swallow 1. These indicate potential complications requiring surgical evaluation.

Plan for long-term follow-up: All Zargar ≥2B injury survivors in one series developed strictures 3, so your patient will likely need endoscopic intervention—but at 3-6 weeks, not now.