What is the management of hydrochloric acid ingestion?

Management of Hydrochloric Acid Ingestion

Immediate management of hydrochloric acid ingestion should focus on airway protection, fluid resuscitation, and early endoscopic evaluation, while avoiding dilution attempts, neutralization, induced vomiting, or gastric lavage as these interventions may worsen injury. 1

Initial Assessment and Stabilization

• Airway management: Assess for signs of airway compromise (stridor, respiratory distress, oropharyngeal burns)

  • Early endotracheal intubation is indicated for airway protection if there are signs of upper airway involvement 2, 3
  • Monitor for progressive airway edema which can develop hours after ingestion

• Hemodynamic stabilization:

  • Establish IV access and begin fluid resuscitation to correct hypovolemia
  • Monitor for signs of shock due to third-spacing and tissue damage
  • Assess for metabolic acidosis which may require correction 1

• Do NOT perform:

  • Dilution with water or milk (if >60 minutes post-ingestion) 4
  • Neutralization attempts with alkaline substances
  • Induced vomiting or gastric lavage
  • Administration of activated charcoal 1

Diagnostic Evaluation

• Laboratory assessment 1:

  • Complete blood count
  • Electrolytes (sodium, potassium, chlorine, calcium, magnesium)
  • Renal function (BUN, creatinine)
  • Liver function tests
  • Arterial blood gases to assess acid-base status
  • Coagulation profile

• Imaging:

  • Chest and abdominal radiographs to assess for free air indicating perforation 1
  • CT scan of chest and abdomen to evaluate extent of injury and complications 2

• Endoscopy:

  • Perform urgent esophagogastroduodenoscopy (EGD) within 12-24 hours to assess injury severity 1, 2
  • Classify using Zargar grading system to guide management 2
  • Avoid endoscopy if signs of perforation are present

Treatment Based on Injury Severity

Grade I-IIa (Mild to Moderate Injury)

• NPO (nothing by mouth) initially
• IV fluids
• Proton pump inhibitors
• Monitor for complications
• Advance diet as tolerated when clinically stable

Grade IIb-III (Severe Injury)

• Strict NPO
• Nutritional support (parenteral or enteral via jejunostomy)
• High-dose proton pump inhibitors
• Consider broad-spectrum antibiotics if evidence of infection 2
• Consider corticosteroids (controversial) 4

Perforation or Massive Necrosis

• Emergency surgical intervention 5, 6
• Extent of resection depends on degree of injury
• Mortality is extremely high with extensive duodenal involvement (100% in one series) 6

Complications and Their Management

• Immediate complications:

  • Perforation requiring emergency surgery
  • Metabolic acidosis requiring correction
  • Systemic inflammatory response syndrome

• Early complications (days to weeks):

  • Infection/sepsis
  • Fistula formation
  • Bleeding

• Late complications (weeks to months):

  • Stricture formation requiring dilation
  • Nutritional deficiencies
  • Psychological support for intentional ingestions

Prognosis

The prognosis for hydrochloric acid ingestion is poor when there is extensive involvement of the gastrointestinal tract. Mortality rates are reported as high as 48% in some series 5, with nearly 100% mortality when there is complete duodenal necrosis 6.

Special Considerations

• Contact Poison Control Center immediately for guidance on systemic toxicity and management 1
• Psychiatric evaluation for intentional ingestions once medically stable
• Pediatric cases may present with atypical symptoms and require specialized management 3

Hydrochloric acid ingestion represents a true medical emergency with high morbidity and mortality. The extent of injury often exceeds what is visible on initial examination, and rapid, decisive management is essential for improving outcomes.