What is the management for alkali ingestion?

Management of Alkali Ingestion

The immediate management of alkali ingestion should focus on stabilizing vital parameters, avoiding dilution attempts beyond 60 minutes post-ingestion, and arranging urgent endoscopic evaluation to determine the extent of injury, as these substances can cause progressive and devastating damage to the esophagus and stomach through liquefaction necrosis. 1, 2

Initial Assessment and Stabilization

• Immediately assess and stabilize airway, breathing, and circulation
• Do NOT induce vomiting, as this may cause additional trauma or perforation 3
• Do NOT attempt neutralization of the alkali substance 1
• Do NOT perform gastric lavage 1
• Do NOT administer activated charcoal or ipecac 3
• Contact Poison Control Center (800-222-1222 in US) for guidance 3

Dilution Considerations

• Dilution with water or milk may be considered ONLY if:

  • It can be done within 60 minutes of ingestion 1
  • The patient is fully conscious with intact airway protective reflexes
  • No signs of perforation are present

• Important caveats regarding dilution:

  • Some evidence suggests early dilution with water or milk may reduce acute alkali injury 4
  • However, other research advises against dilution except in cases of solid caustic substances (crystalline or granulated) 5
  • The American Heart Association notes insufficient evidence for or against dilution therapy 3

Diagnostic Evaluation

• Obtain complete history if possible:

  • Identify the specific alkali agent, quantity, and time of ingestion 3
  • Determine if ingestion was accidental or intentional 3

• Laboratory tests:

  • Complete blood count
  • Serum electrolytes (sodium, potassium, chlorine, calcium)
  • Renal function tests
  • Liver function tests
  • Blood gas analysis 3

• Imaging:

  • Plain radiographs of chest and abdomen to assess for perforation
  • CT scan if perforation is suspected 3

• Endoscopy:

  • The most reliable diagnostic procedure to determine presence and severity of corrosive esophageal lesions 1
  • Should be performed within 6-12 hours of ingestion 5
  • Allows classification of injury severity (grades 1-3)

Treatment Based on Severity

Mild Injury (Grade 1)

• Withhold oral feeding initially
• Monitor for complications
• Start clear liquids after 24-48 hours if no complications
• Advance diet as tolerated

Moderate Injury (Grade 2a/2b)

• Nothing by mouth
• IV fluids and electrolyte replacement
• Consider proton pump inhibitors
• Monitor for stricture development
• Grade 2b injuries have higher risk of developing strictures 2

Severe Injury (Grade 3)

• Nothing by mouth
• IV fluids and nutrition
• Intensive monitoring
• High risk for acute complications (perforation, mediastinitis)
• Surgical consultation for possible intervention
• Almost all survivors develop esophageal or gastric strictures requiring intervention 2

Surgical Management

• Indications for surgical intervention:

  • Perforation with extensive pleural/mediastinal contamination
  • Severe necrosis
  • Life-threatening complications

• Surgical approaches:

  • Esophagotomy with primary closure for limited contamination
  • Esophagectomy with primary or delayed reconstruction for extensive damage 3
  • Minimally invasive techniques should be considered first-line in referral centers 3

Long-term Management

• Regular follow-up endoscopy to monitor for stricture development
• Endoscopic dilation for strictures
• Surveillance for malignancy development (increased risk of esophageal cancer)
• Nutritional support and counseling 6

Prognosis

• Depends on severity of initial injury
• Grade 2a injuries typically recover without sequelae
• Grade 2b and 3 injuries often develop esophageal or gastric strictures requiring intervention
• Mortality is highest with grade 3 injuries (approximately 13%) 2

Remember that symptoms and signs do not reliably predict the extent and severity of injury, making early endoscopic evaluation crucial for proper management and prognosis 2.