When can oral feeding be resumed in a patient with yellow phosphorus ingestion?

Resuming Oral Feeding After Yellow Phosphorus Ingestion

Oral feeding should be reintroduced as soon as the patient can swallow normally, with the timing stratified by the severity of gastrointestinal injury on CT imaging. 1

Immediate Assessment and Risk Stratification

The decision to resume oral feeding depends critically on CT grading of esophageal and gastric injuries, as this predicts both the safety of early feeding and the risk of stricture formation. 1

Grade I CT Injuries (Minimal Mucosal Damage)

• Patients can be fed immediately upon presentation if they can swallow without difficulty 1
• These patients have zero risk of stricture formation and can be discharged within 24-48 hours 1
• No long-term follow-up is required 1

Grade IIa CT Injuries (Moderate Mucosal Damage)

• Oral nutrition should be introduced as soon as pain diminishes and patients can swallow 1
• These patients have a low risk (<20%) of stricture formation 1
• Oral feeding is usually well tolerated in this group 1
• A follow-up visit at 4-6 months post-ingestion is recommended, as most strictures develop within this timeframe 1

Grade IIb CT Injuries (Severe Mucosal Damage)

• Oral intake may be hindered by pain during swallowing, hypersalivation, and early dysphagia 1
• These patients have a high risk (>80%) of stricture formation 1
• If symptoms persist beyond the acute phase, nutritional support via long-term parenteral nutrition or feeding jejunostomy is required 1
• A 4-6 months post-ingestion visit is mandatory 1

Grade III CT Injuries (Transmural Necrosis)

• Patients with full-thickness necrosis require immediate surgical intervention, not oral feeding 1
• Emergency surgery should be performed as soon as possible to prevent death 1
• A feeding jejunostomy should be placed at the end of the operation 1

Clinical Monitoring Algorithm

Close clinical and biological monitoring is mandatory for all patients managed non-operatively. 1

• Monitor for deterioration in clinical symptoms: rebound tenderness, increasing abdominal pain, shock, need for ventilator support 1
• Monitor laboratory parameters: renal failure, acidosis, leukocytosis 1
• Any deterioration should prompt repeat CT examination and consideration for surgery, as 5% of patients progress to transmural necrosis 1

Important Clinical Caveats

Psychiatric Evaluation

Psychiatric evaluation is mandatory in all patients prior to hospital discharge, as yellow phosphorus ingestion is often intentional 1. Long-term control of psychiatric disease is critical to prevent recurrence 1.

Gastrointestinal Complications

Yellow phosphorus causes direct mucosal burns and systemic toxicity affecting multiple organ systems 2, 3. The time lag between ingestion and symptom onset varies from minutes to 24 hours 2. Contrary to older literature, garlic odor, phosphorescent vomitus, and mucosal burns occur in only a small percentage of cases 2.

Multisystem Toxicity

Yellow phosphorus is a protoplasmic poison causing hepatic, cardiac, renal, and multiorgan failure 4, 5. Mortality rates are highest (73%) when initial symptoms include CNS manifestations (restlessness, irritability, drowsiness, stupor, coma) rather than isolated GI symptoms (23% mortality) 2.

Rare Complications

Acute pancreatitis can occur post-ingestion and may complicate management, particularly if liver transplantation is required for fulminant hepatic failure 4. Myelosuppression and duodenal perforation have also been reported 5, 3.

Practical Implementation

Do not keep patients NPO based solely on the diagnosis of yellow phosphorus ingestion. Instead, perform urgent CT imaging to grade injuries, assess swallowing ability, and initiate feeding trials in appropriate candidates (Grade I and IIa injuries without severe symptoms) 1. For patients who cannot tolerate oral intake, enteral feeding via nasogastric tube or jejunostomy is preferred over parenteral nutrition 1.