What is the cut-off time beyond which endoscopy should be delayed in cases of corrosive ingestion?

Timing of Endoscopy in Corrosive Ingestion

Endoscopy should be performed within the first 12-48 hours after caustic ingestion, and should be avoided between 1-3 weeks post-ingestion due to significantly higher risk of complications during this healing phase. 1

Initial Assessment and Diagnostic Approach

• Contrast-enhanced CT is the preferred initial diagnostic tool and should be performed 3-6 hours after ingestion as it is more accurate than endoscopy in detecting transmural injuries and better predicts risk of stricture formation 1, 2, 3
• Upper gastrointestinal endoscopy should be performed within the first 12-48 hours after caustic ingestion to determine prognosis and guide management 1
• Endoscopy is indicated only in specific situations when CT is unavailable or contraindicated (renal failure, iodine allergy), when CT findings are uncertain, or in pediatric patients to avoid radiation exposure 1, 2
• The Zargar endoscopic classification is commonly used for grading injuries, though it has limitations in predicting stricture formation compared to CT 1, 4

Critical Time Windows for Endoscopy

• Early endoscopy (within 12-48 hours): Provides valuable information for initial assessment and management planning 1
• Avoid endoscopy between 1-3 weeks post-ingestion: This period is associated with higher procedural risks due to ongoing tissue healing and weakened esophageal walls 1
• After 3 weeks: Endoscopic evaluation can be safely resumed to assess stricture formation and plan for potential dilatation 1

Management Based on Timing

• First 12-48 hours: Perform initial endoscopic evaluation with gentle air insufflation or preferably CO2 to determine injury extent 1
• 1-3 weeks post-ingestion: Avoid endoscopic procedures due to increased risk of perforation as this is when scar retraction begins 1
• 3-6 weeks post-ingestion: Consider endoscopic dilatation for patients who develop strictures 1

Complications and Risk Factors

• The perforation rate for caustic strictures is higher than standard benign esophageal stricture dilatation, ranging from 0.4% to 32% 1
• Complication rates are lower when procedures are performed by experienced practitioners 1
• Stricture formation typically occurs within 4 months after ingestion, with esophageal involvement more common than gastric 1, 5

Special Considerations

• Pediatric patients: Endoscopy remains the upfront evaluation method due to concerns about radiation exposure from CT 1, 2
• Patients with high-grade esophageal mucosal injury have significantly higher risk of stricture formation 5
• The time interval between subsequent dilatations for strictures should be less than 2-3 weeks 1

Management Algorithm

1. Initial assessment: Perform contrast-enhanced CT 3-6 hours after ingestion 1, 3
2. Early endoscopy: Within 12-48 hours to grade injury using Zargar classification 1, 6
3. Avoid procedures: Between 1-3 weeks post-ingestion 1
4. Stricture management: Begin endoscopic dilatation 3-6 weeks after ingestion for patients with few (<3) short (<5 cm) esophageal strictures 1
5. Follow-up: Monitor for stricture development, which typically occurs within 4 months 1, 5