What is the treatment for acid ingestion?

Treatment of Acid Ingestion

Immediate medical attention is required for acid ingestion, with management focused on stabilizing vital signs, avoiding dilution or neutralization attempts, and early endoscopic evaluation to determine injury severity and guide further treatment.

Initial Management

Immediate Actions

• Do not attempt to induce vomiting - this can cause re-exposure of the esophagus to the corrosive substance 1
• Do not attempt neutralization of the acid with alkaline substances 1, 2
• Do not perform gastric lavage as this may increase risk of perforation 2
• Activated charcoal is ineffective and contraindicated 2
• Withhold all oral intake immediately to prevent further injury 2

Stabilization (First 1-2 Hours)

• Secure airway if respiratory distress is present - early intubation may be necessary if there is evidence of upper airway injury or edema 3
• Establish IV access for fluid resuscitation
• Assess and correct fluid and electrolyte imbalances 2
• Monitor vital signs continuously
• Assess for signs of perforation (severe pain, peritoneal signs, subcutaneous emphysema)

Diagnostic Evaluation

Endoscopy

• Early upper endoscopy (within 12-24 hours) is the gold standard for assessment of injury severity 4
• Endoscopy findings are typically graded using the Zargar classification 3:
  • Grade 0: Normal mucosa
  • Grade 1: Edema and hyperemia
  • Grade 2A: Superficial ulcerations, erosions, and exudates
  • Grade 2B: Deep discrete or circumferential ulcerations
  • Grade 3A: Small scattered areas of necrosis
  • Grade 3B: Extensive necrosis
  • Grade 4: Perforation

Imaging

• CT scan may help assess extent of injury, particularly when perforation is suspected 3
• Chest and abdominal X-rays to evaluate for free air if perforation is suspected

Treatment Based on Injury Severity

Mild Injury (Grade 0-1)

• NPO (nothing by mouth) for 24-48 hours
• IV fluids for hydration
• Proton pump inhibitors (PPI) therapy:
  • Pantoprazole 40mg IV/PO daily or twice daily 5
  • Omeprazole 20-40mg PO daily 6
• Advance to clear liquids if no complications develop, then progress diet as tolerated
• Discharge when able to tolerate oral intake

Moderate Injury (Grade 2)

• NPO for at least 48-72 hours
• IV fluids and electrolyte replacement
• High-dose PPI therapy (e.g., pantoprazole 40mg IV twice daily) 5
• Consider broad-spectrum antibiotics if evidence of infection
• Consider corticosteroids (controversial, based on clinical judgment)
• Advance diet gradually after 48-72 hours if no complications
• Close follow-up to monitor for stricture development

Severe Injury (Grade 3-4)

• NPO with consideration for nutritional support (parenteral or enteral via jejunostomy)
• Intensive care monitoring
• High-dose PPI therapy 5, 6
• Broad-spectrum antibiotics
• Surgical consultation for potential intervention
• If perforation occurs, immediate surgical intervention is required 7, 8

Complications and Long-term Management

Acute Complications (Days 1-14)

• Perforation (more common with acid ingestion, 6% vs 0% with alkali) 4
• Hemorrhage
• Systemic complications (acidosis, renal failure, hepatic injury)
• Mortality (significantly higher with acid ingestion, 14% vs 2% with alkali) 4

Late Complications (Weeks to Months)

• Stricture formation (occurs in 15-17% of cases) 4
• Gastric outlet obstruction (common with acid ingestion) 7
• Management of strictures:
  • Endoscopic dilation (successful in approximately 34% of cases) 4
  • Surgical intervention for refractory strictures

Prognosis and Follow-up

• Acid ingestion has worse outcomes compared to alkali ingestion 4:

  • Longer hospital stays (9.9 vs 7.2 days)
  • Higher ICU admission rates (44% vs 22%)
  • More systemic complications (24% vs 3%)
  • Higher mortality (14% vs 2%)

• The grade of mucosal injury on initial endoscopy is the strongest predictor of complications and mortality (relative risk 9,95% CI 3, 30) 4

• Follow-up endoscopy should be performed at 2-3 weeks to assess healing and detect early stricture formation

Key Pitfalls to Avoid

1. Do not delay medical attention - even if the patient appears stable initially, severe complications can develop after an asymptomatic interval 7

2. Avoid common first aid mistakes:

   • Do not give diluents (water/milk) after 60 minutes post-ingestion 2
   • Do not attempt to neutralize the acid 1, 2
   • Do not induce vomiting 2
   • Do not perform gastric lavage 2

3. Do not underestimate acid ingestions - they often cause more severe gastric injury and have higher mortality than alkali ingestions 4

4. Do not delay endoscopy - early endoscopy (within 24 hours) provides critical prognostic information and guides management 4