Treatment of Corrosive Poisoning
The management of corrosive poisoning requires immediate airway assessment, hemodynamic stabilization, and early endoscopic evaluation within 12-24 hours to determine injury severity, with surgical intervention indicated for transmural necrosis. 1
Initial Assessment and Management
Immediate Priorities
- Secure airway, breathing, and circulation
- Assess for signs of perforation (abdominal pain, peritoneal signs, pneumomediastinum)
- Monitor for systemic toxicity (hypocalcemia, hyponatremia, hypokalemia)
- Obtain chest and abdominal radiographs to assess for free air 1
Critical Contraindications
- DO NOT induce vomiting
- DO NOT attempt neutralization of the corrosive substance
- DO NOT perform gastric lavage
- DO NOT administer activated charcoal (ineffective and contraindicated) 2, 3
- DO NOT give anything by mouth if the patient is unconscious or having convulsions 2
Diagnostic Evaluation
Imaging and Endoscopy
- Contrast-enhanced CT scan 3-6 hours post-ingestion to assess injury extent and detect transmural necrosis 1
- Esophagogastroduodenoscopy within 12-24 hours (gold standard) using Zargar classification:
- Grade I: Mild injury
- Grade IIa: Moderate injury without necrosis
- Grade IIb: Moderate injury with necrosis
- Grade III: Transmural necrosis 1
Treatment Approach
Supportive Care
- Withhold oral feeding initially
- Provide IV fluids and electrolyte management
- Administer proton pump inhibitors to reduce acid secretion
- Provide nutritional support (parenteral or enteral via feeding tube) 1, 4
- Consider antibiotics if signs of infection are present 1
Surgical Management
- Immediate surgical intervention for:
- Grade III injuries (transmural necrosis)
- Evidence of perforation
- Severe systemic toxicity 1
- Surgical procedures may include:
- Total gastrectomy with esophagojejunostomy reconstruction
- Placement of feeding jejunostomy for nutritional support
- Inspection of adjacent organs for concomitant necrosis 1
Long-term Management
Stricture Management
- Begin endoscopic dilation 3-6 weeks after ingestion
- Use either bougie or balloon dilators based on stricture nature
- Employ graded stepwise approach to dilation (13-20 mm)
- Consider fluoroscopic guidance for refractory strictures 1
Follow-up Care
- Regular endoscopic surveillance due to increased risk of esophageal carcinoma
- Psychiatric evaluation mandatory prior to discharge, especially for intentional ingestions
- Consider esophageal bypass for extensive, refractory strictures 1
Prognostic Factors
- Severity of initial injury correlates with risk of stricture formation
- Strong alkalis (pH>12) and strong acids (pH<2) cause the most severe injuries 5
- Early signs of severe injury include drooling, hoarseness, stridor, and mucosal sloughing 6
- Mortality rates of approximately 8-9% have been reported 7
Common Pitfalls to Avoid
- Delaying endoscopic evaluation beyond 24 hours
- Attempting neutralization, which can generate heat and worsen tissue damage
- Overlooking psychiatric assessment in intentional ingestions
- Failing to monitor for delayed complications such as stricture formation
- Neglecting long-term cancer surveillance in patients with severe injuries
Remember that corrosive poisoning represents a serious medical emergency requiring prompt, specialized care to minimize mortality and long-term morbidity.