Severe Corrosive Gastritis: Definition, Pathophysiology, and Management
Severe corrosive gastritis is a potentially life-threatening condition characterized by extensive necrosis of the gastric mucosa and wall following ingestion of strong acids or alkalis, which can lead to perforation, peritonitis, and death if not promptly diagnosed and treated. 1
Etiology and Pathophysiology
Severe corrosive gastritis results from the ingestion of caustic substances, primarily:
- Strong acids and alkalis - most common causes of severe injuries 1
- Oxidants (bleach) - usually cause mild injuries but can occasionally cause severe damage 1
- Ammonia - typically results in superficial hemorrhagic gastritis that may progress over 24-48 hours 1
The severity of injury depends on several factors:
- Physical form of the ingested substance - liquids transit rapidly and cause more damage to the esophagus and stomach 1
- Quantity ingested - larger amounts cause more extensive damage 1
- Concentration of the corrosive agent
- Duration of contact with gastric mucosa
Clinical Presentation
Patients with severe corrosive gastritis may present with:
- Severe abdominal pain
- Hematemesis
- Signs of peritonitis
- Shock
- Metabolic acidosis
- Renal failure 2
Important caveat: Clinical symptoms do not reliably correlate with the extent of gastrointestinal damage; absence of pain or oral lesions does not rule out life-threatening injuries 1.
Diagnostic Evaluation
Initial Laboratory Tests
- Complete blood count
- Serum electrolytes (sodium, potassium, chlorine, magnesium, calcium)
- Renal function tests (urea, creatinine)
- Liver function tests
- Arterial blood gas analysis 1
Imaging
- CT scan with contrast is the gold standard for evaluating the extent of injury 1
- Grade III injuries (most severe) show absence of post-contrast wall enhancement, indicating transmural necrosis 1
- Can predict need for emergency surgery better than endoscopy
Endoscopy
- Indicated when:
- CT is unavailable
- CT with contrast is contraindicated
- CT findings are uncertain
- In pediatric population 1
- The Zargar classification is commonly used to grade injuries, though CT is superior in predicting transmural necrosis 1
Management
Emergency Management
- Resuscitation - fluid resuscitation, correction of electrolyte imbalances, and acid-base disorders
- Contact Poison Control Center to evaluate systemic toxicity 1
- Avoid inducing vomiting as it may cause additional trauma 3
- Do not administer anything by mouth unless advised by poison control 3
Surgical Management
Indications for emergency surgery:
- Full-thickness necrosis of the stomach with or without perforation
- Peritonitis
- Mediastinitis
- Progressive clinical deterioration 2
Surgical procedures may include:
- Esophagogastrectomy (most common)
- Extended procedures if adjacent organs are involved (duodenectomy, pancreaticoduodenectomy, splenectomy) 2
Prognostic factors associated with mortality:
- Renal failure at presentation
- Metabolic acidosis
- Delay of more than 24 hours between ingestion and surgery
- Adjacent organ injury (particularly pancreatic) 2
Non-operative Management
- Indicated for patients without full-thickness necrosis 1
- Close clinical and biological monitoring
- Repeat CT if clinical deterioration occurs
- Enteral feeding via nasogastric tube or jejunostomy if unable to eat orally 1
Long-term Complications and Management
Stricture formation - most common long-term complication, usually occurring within 4 months after ingestion 1
Management of strictures:
- Endoscopic dilation (first-line) - typically started 3-6 weeks after ingestion
- Reconstructive surgery if endoscopic dilation fails after 5-7 attempts 1
Psychiatric evaluation is mandatory before hospital discharge for all patients with intentional ingestion 1
Prevention
- Proper storage of corrosive substances
- Child-proof containers
- Public education about dangers of corrosive substances
- Psychiatric support for at-risk individuals
Early recognition and appropriate management of severe corrosive gastritis are crucial for improving outcomes and preventing long-term complications.