What is the Zargar classification used for in assessing caustic esophageal and gastric injuries?

Zargar Classification for Caustic Esophageal and Gastric Injuries

The Zargar endoscopic classification is the most commonly employed system for grading caustic injuries to the esophagus and stomach, used to assess injury severity and predict complications such as stricture formation, though it has been increasingly outperformed by CT-based evaluation in recent years. 1

Zargar Classification System

The Zargar classification grades caustic injuries based on endoscopic findings:

• Grade 0: Normal mucosa
• Grade 1: Edema and hyperemia of the mucosa
• Grade 2a: Superficial ulcerations, erosions, and exudates
• Grade 2b: Deep discrete or circumferential ulcerations
• Grade 3a: Focal necrosis
• Grade 3b: Extensive necrosis

Clinical Significance and Outcomes

The classification helps predict important clinical outcomes:

• Stricture formation risk:

  • Grade 1: 0%
  • Grade 2a: 0%
  • Grade 2b: 28%
  • Grade 3a: 50%
  • Grade 3b: 76% 2

• Management decisions:

  • Grade 3a esophageal injuries and Grade 3a gastric injuries may require immediate surgical intervention due to transmural necrosis 3
  • Grade 3b injuries typically require aggressive surgical management, especially with perforation and peritonitis 3

Current Role in Clinical Practice

While historically the mainstay of management algorithms, the Zargar classification now has a more limited role:

• CT has emerged as superior to endoscopy in detecting transmural injuries and predicting stricture formation 1, 2
• Emergency CT outperforms endoscopy with an AUC of 85.1 vs. 77.8 for predicting esophageal stricture formation 2

When to Use Zargar Classification

Endoscopy with Zargar classification is now primarily indicated when:

1. CT is unavailable
2. CT with contrast is contraindicated (renal failure, iodine allergy)
3. CT findings are difficult to interpret
4. In pediatric populations (to avoid radiation exposure) 1

Limitations and Pitfalls

• Major drawback: inability to accurately predict transmural necrosis, which may lead to either futile surgery or inappropriate conservative management 1
• CT-based algorithms for selecting patients for emergency surgery have significantly improved outcomes compared to endoscopy-based management 1
• The classification's ability to predict stricture formation remains controversial 1

Follow-up and Complications

• Stricture formation is the most common long-term complication, typically occurring within 4 months after ingestion 1
• Grade III injuries of the esophagus (OR 3.079) and stomach (OR 18.972) are independent risk factors for developing esophageal strictures and gastric outlet obstruction, respectively 4

For optimal patient outcomes, clinicians should consider using CT as the primary diagnostic tool for caustic injuries, reserving endoscopy with Zargar classification for specific situations where CT cannot be employed.