What is the clinical practice guideline (CPG) for managing acid ingestion?

Clinical Practice Guidelines for Acid Ingestion Management

Immediate management of acid ingestion should focus on stabilizing vital parameters, diluting the ingested substance with water or milk within 60 minutes of ingestion, and avoiding induction of vomiting, neutralization attempts, or gastric lavage to prevent further damage to the gastrointestinal tract. 1

Initial Assessment and Stabilization

• Identify the nature, physical form, and quantity of the ingested agent, as well as whether ingestion was accidental or voluntary, as these are crucial determinants of injury severity 2
• Contact Poison Control Centers to evaluate systemic toxicity of the ingested agent 2
• Perform initial laboratory evaluation including:
  • Complete blood count
  • Serum electrolytes (sodium, potassium, chlorine, magnesium, calcium)
  • Renal function (urea, creatinine)
  • Liver function tests
  • pH and serum lactate
  • Blood alcohol levels (if relevant)
  • β-HCG in young women 2

Immediate Management

• Stabilize all vital parameters (reanimation) as the first priority 1
• Dilute the corrosive substance with water or milk within 60 minutes of ingestion 1
• DO NOT:
  • Induce vomiting
  • Induce diarrhea
  • Attempt neutralization of the corrosive substance
  • Perform gastric lavage
  • Administer activated charcoal (no effect and not indicated) 1
• Withhold all oral feedings 1
• Assess fluid and electrolyte balance carefully 1

Diagnostic Evaluation

• Esophagogastroduodenoscopy (EGD) is the gold standard for determining the presence and severity of corrosive esophageal and gastric lesions 1, 2
• Laboratory abnormalities that may indicate transmural necrosis include:
  • Severe acidosis (low pH, high blood lactate levels)
  • Deranged liver function tests
  • Leukocytosis
  • Elevated CRP 2
• CT imaging may increasingly play a role in defining the extent of injury 3

Injury Patterns and Severity Assessment

• Acids typically cause more severe damage to the stomach, while alkalis usually injure the esophagus 4
• Injury severity is often classified using the Zargar grading system based on endoscopic findings 3
• Acid ingestion, particularly glacial acetic acid, is associated with higher complication rates and mortality than alkali ingestion 5
• Strong acids can induce extensive necrosis of the gastrointestinal tract in cases of massive ingestion 2

Treatment Approach

• Medical management based on injury severity may include:
  • Bowel rest
  • Proton pump inhibitors (PPIs) - standard dosing for GERD is 20mg once daily for 4-8 weeks 6
  • Steroids (in selected cases)
  • Antibiotics (when indicated) 3
• For patients with erosive findings, PPI therapy should be optimized with:
  • Proper timing of dose (30-60 minutes before meals)
  • Potential dose escalation if needed
  • Consideration of switching to a different PPI if response is inadequate 2, 6
• Adjunctive pharmacotherapy may include:
  • Alginate antacids for breakthrough symptoms
  • H2-receptor antagonists for nocturnal symptoms 2
• Surgical intervention may be required in cases of esophageal or gastric perforation 3, 2

Monitoring and Complications

• Watch for development of early complications such as:
  • Massive gastric hemorrhage
  • Perforation 4
• Monitor for late complications including:
  • Gastric outlet obstruction (common even after an asymptomatic interval) 4
  • Stricture formation (occurs in approximately 15% of acid ingestion cases) 5
• Endoscopic treatment of caustic-induced strictures has moderate success; many patients may require surgical intervention 5

Prognostic Factors

• The grade of mucosal injury at endoscopy is the strongest predictive factor for complications and mortality 5
• Early endoscopy provides important prognostic information and is generally considered safe 5
• Patients with severe GERD-like injuries (Los Angeles C or D esophagitis) require indefinite long-term PPI therapy 2

Pitfalls and Caveats

• The absence of severe symptoms soon after acid ingestion can be misleading; serious complications may develop following an asymptomatic interval 4
• Gastric outlet obstruction is a common late complication that may develop even after initial symptoms resolve 4
• Endoscopic dilation alone may be insufficient for treating caustic-induced strictures; many patients ultimately require surgery 5
• Mortality rates are significantly higher with acid ingestion (14%) compared to alkali ingestion (2%) 5