What is the management of acid ingestion in children?

Management of Acid Ingestion in Children

Immediate endoscopy within 6 hours to 4 days post-ingestion is essential to assess injury severity and predict complications, while avoiding any attempts at neutralization, induced vomiting, or gastric lavage. 1

Initial Assessment and Stabilization

Critical First Steps

• Secure the airway immediately – acid ingestion can cause progressive upper airway obstruction developing over hours to days, requiring early intubation in severe cases 2
• Identify the specific corrosive agent including nature, physical form, quantity ingested, and whether ingestion was accidental (typical in children) or intentional 1
• Contact Poison Control Centers to evaluate potential systemic toxicity of the specific agent ingested 1

Key Clinical Caveat

The absence of oral lesions or pain does NOT rule out life-threatening gastrointestinal injuries – clinical symptoms correlate poorly with the extent of internal damage 1. Asymptomatic children can still have severe injuries requiring intervention 3, 4.

Laboratory and Imaging Evaluation

Essential Initial Laboratory Tests

Obtain the following immediately 1:

• Complete blood count (CBC)
• Electrolytes: sodium, potassium, chlorine, magnesium, calcium
• Renal function: urea, creatinine
• Liver function tests: bilirubin, ALT, AST
• Arterial blood gas with pH and serum lactate
• β-HCG in adolescent females

Monitoring for Transmural Necrosis

• Severe acidosis (low pH, elevated lactate) and deranged liver function tests indicate potential transmural necrosis requiring emergency surgical intervention 1
• Serial laboratory values are crucial as initial normal values do not exclude transmural necrosis 1

Endoscopic Evaluation

Timing and Indications

• Perform endoscopy 6 hours to 4 days after injury in all symptomatic patients 1
• Endoscopy is accurate in predicting complications in strong acid ingestions 3
• Endoscopy is NOT necessary in completely asymptomatic children following unintentional ingestion, as they are not at risk for complications 3

Specific Indications for Endoscopy

• Any respiratory symptoms 3
• Presence of one or more gastrointestinal symptoms (vomiting, dysphagia, drooling, abdominal pain) 3, 5
• Suspected strong acid ingestion with any clinical manifestations 3
• To establish prognosis and identify acute complications 3

Unique Pathophysiology of Acid Ingestion

Injury Pattern Differs from Alkali

• Acids primarily damage the stomach rather than the esophagus (opposite of alkali ingestions) 6, 4
• Pylorospasm causes pooling of acid in dependent gastric locations, leading to concentrated injury 4
• Liquid acids transit rapidly through the esophagus but cause severe gastric burns 1

Delayed Presentation

• Symptoms may be delayed for days or weeks after ingestion, which is often misleading 6, 4
• Early complications like massive gastric hemorrhage or perforation are unusual but can occur 6
• Gastric outlet obstruction is a common late complication developing after an asymptomatic interval 6, 4

Acute Complications Requiring Immediate Intervention

Gastric Perforation

• Rare but life-threatening complication requiring emergency surgery 2
• Treatment involves partial gastrectomy and feeding jejunostomy 2
• Suspect with severe abdominal pain, peritoneal signs, or free air on imaging

Airway Compromise

• Progressive upper airway obstruction from oropharyngeal membrane formation 2
• Elective intubation and ventilation indicated for persistent shock despite fluid resuscitation or severe respiratory symptoms 1

Surgical Management

Indications for Surgery

Emergency surgery is indicated for 1:

• Esophageal or gastric perforation with extensive contamination
• Massive hemorrhage
• Mediastinitis or pleural empyema
• Irretrievable complications

Surgical Approach

• Minimally invasive techniques should be first-line in referral centers 1
• Limited contamination: esophagotomy/gastrotomy with primary repair 1
• Extensive contamination: rescue esophagectomy or gastrectomy with delayed reconstruction 1

Long-Term Monitoring

Follow-up for Late Complications

• Esophageal strictures develop in approximately 5% of patients 5
• Gastric outlet obstruction occurs in 1% of cases 5
• Serial endoscopy may be needed to monitor for stricture formation
• Nutritional support via feeding jejunostomy if gastric outlet obstruction develops 2

What NOT to Do

Contraindicated Interventions

• Never attempt neutralization with opposite pH substances 1
• Never induce vomiting – increases exposure time and risk of aspiration 1
• Never perform gastric lavage – risk of perforation and increased tissue damage 1
• Do not prescribe acid suppression therapy (PPIs or H2RAs) – no proven efficacy for caustic injury and may mask ongoing damage 1, 7