What are the management guidelines for caustic injuries in India?

Management of Caustic Injuries: Indian Guidelines

The Indian Society of Gastroenterology recommends esophagogastroduodenoscopy as the preferred initial evaluation approach for caustic gastrointestinal injuries, with early oral feeding and discharge for low-grade injuries (Zargar grade ≤2a), while high-grade injuries (Zargar grade ≥2b) require hospitalization and intensive monitoring due to high risk of complications. 1

Immediate First Aid and Decontamination

Skin Exposure

• Immediately irrigate exposed skin with running water for at least 15 minutes after any caustic chemical contact 2
• Remove all contaminated clothing, jewelry, and surrounding materials to prevent chemicals from being trapped against the skin 2
• For dry chemical powders (sodium hydroxide, elemental sodium/potassium), brush off the powder before water irrigation 2
• Use personal protective equipment when providing first aid to avoid contaminating yourself 2

Systemic Considerations

• Call emergency medical services immediately if the patient has respiratory symptoms, systemic symptoms, or large chemical exposures 2
• Contact regional poison control centers for chemical-specific treatment recommendations and to evaluate potential systemic toxicity 2

Initial Assessment and Diagnostic Approach

Clinical Evaluation

• Absence of oral lesions or pain does NOT rule out life-threatening gastrointestinal injuries - this is a critical pitfall 2, 3
• Identify the nature (acid vs. alkali), physical form (solid vs. liquid), quantity ingested, and whether ingestion was accidental or intentional 2
• Examine the oropharynx by laryngoscopy first, as supraglottic or epiglottic burns with edema may herald airway obstruction requiring early intubation or tracheostomy 4

Laboratory Investigations

• Obtain CBC, electrolytes (sodium, potassium, chlorine, magnesium, calcium), renal function (urea, creatinine), liver function tests (bilirubin, ALT, AST), arterial pH, serum lactate, and β-HCG in women of childbearing age 2
• Severe acidosis (low pH, high lactate), deranged liver function, leukocytosis, elevated CRP, renal failure, and thrombocytopenia predict transmural necrosis and poor outcomes 2
• Serial laboratory monitoring is essential as initial normal values do not exclude transmural necrosis 2

Imaging Studies

• Plain radiographs of neck, chest, and abdomen may reveal free air indicating perforation 2
• Contrast-enhanced CT of neck, thorax, and abdomen should be performed 3-6 hours after ingestion using IV nonionic contrast (2 mL/kg) with 18-25 second acquisition and 90-second delay 2, 3
• CT is reserved for specific situations per Indian guidelines, as endoscopy remains the primary diagnostic tool 1

CT Grading System

• Grade I: Homogeneous wall enhancement, no edema or fat stranding 2
• Grade IIa: Internal mucosal enhancement with hypodense thickened wall, possible "target" appearance 2
• Grade IIb: Fine rim of external wall enhancement only 2
• Grade III: Absence of post-contrast wall enhancement indicating transmural necrosis - this mandates emergency surgery 2, 3

Endoscopic Evaluation

• Perform esophagogastroduodenoscopy within 12-48 hours after ingestion - this is the preferred initial approach per Indian guidelines 3, 1
• Endoscopy serves as the primary prognostic tool and determines management strategy 5, 1
• Use gentle air insufflation or preferably CO2 to minimize complication risk 3
• Avoid endoscopy between 1-3 weeks post-injury due to higher procedural perforation risk 3
• The risk of procedure-related perforation within the first 24 hours is generally negligible 4

Management Based on Injury Severity

Low-Grade Injuries (Zargar Grade ≤2a)

• Patients can be fed immediately and discharged within 24-48 hours as stricture formation risk is minimal 3, 1
• Introduce oral nutrition as soon as pain diminishes 3
• Nonoperative management is successful in 93% of mild injury cases 5

High-Grade Injuries (Zargar Grade ≥2b)

• Hospitalization is mandatory due to high risk (>80%) of stricture formation and complications 3, 1
• Provide nutritional support via nasogastric tube for temporary needs or feeding jejunostomy for severe cases 3
• Parenteral nutrition may be necessary in Grade IIb injuries with persistent symptoms 3
• Monitor closely for development of perforation, mediastinitis, or peritonitis 4

Emergency Surgical Indications

• Transmural necrosis detected on CT or endoscopy (Grade IIIb/IV injuries) 2, 5
• Gastrointestinal perforation with free air 2
• Development of mediastinitis or peritonitis 4
• Multi-organ failure 4
• Place feeding jejunostomy at the end of emergency surgery to provide nutritional support during recovery 3

Controversial and Contraindicated Treatments

What NOT to Do

• Do NOT induce vomiting - this is contraindicated 6
• Do NOT perform gastric lavage - this is contraindicated 6
• Do NOT routinely use dilution except for solid caustic substances (crystalline or granulated) 6
• Do NOT routinely use corticosteroids - existing data fail to support their use for preventing stricture formation, and they may mask signs of peritonitis 4, 6
• Do NOT routinely use antibiotics - evidence does not support routine prophylactic use 4
• Do NOT attempt endoscopic dilation or stent placement within the first 6 weeks 4

Chemical-Specific Considerations

• Hydrofluoric acid and phenol require decontamination with substances other than water 2, 7
• Some dry chemicals (sodium hydroxide, elemental sodium/potassium) react with water causing additional injury - brush off first 2
• Specific corrosives may cause systemic effects: hypocalcemia (phosphoric/hydrofluoric acids), hyponatremia (strong acids/alkalis), hypokalemia, and acidosis 2

Long-Term Management and Follow-Up

Stricture Management

• Schedule follow-up visit 4-6 months post-ingestion as most strictures develop within this timeframe 3
• Attempt endoscopic dilation 3-6 weeks after ingestion for patients who develop strictures 3
• Consider reconstructive esophageal surgery after recurrent failure of endoscopic dilation 3
• Nutritional support is crucial until nutritional autonomy is established 1

Cancer Surveillance

• There is a 1000- to 3000-fold increased risk of esophageal carcinoma after lye ingestion with latency periods up to 60 years 4
• Long-term endoscopic surveillance is necessary for all significant caustic injuries 4

Psychiatric Evaluation

• Mandatory psychiatric evaluation is required for all patients prior to hospital discharge, particularly for intentional ingestions 3

Key Clinical Pitfalls to Avoid

• Never assume absence of symptoms means absence of injury - clinical presentation does not correlate with injury severity 2, 3
• Do not delay endoscopy beyond 24 hours for optimal prognostic assessment 4
• Avoid the "danger period" of 1-3 weeks post-injury for endoscopic procedures 3
• Do not discharge patients with high-grade injuries early - they require prolonged monitoring 1
• Remember that alkalis generally cause more severe injuries than acids, though both can be devastating 4