What is the next step in management for a pediatric patient who ingested an alkaline caustic fluid 3 hours prior, presenting with mouth and throat pain, and odynophagia (painful swallowing)?

Management of Pediatric Alkaline Caustic Ingestion

This pediatric patient requires urgent contrast-enhanced CT scan within 3-6 hours of ingestion to assess for transmural necrosis and grade injury severity, followed by upper endoscopy within 12-48 hours if CT does not show Grade III injury requiring emergency surgery. 1, 2

Immediate Diagnostic Evaluation

The presence of mouth and throat pain with odynophagia 3 hours post-ingestion indicates significant mucosal injury, but clinical symptoms alone cannot reliably predict the extent of esophageal or gastric damage. 2, 3 The absence of hemoptysis is reassuring but does not exclude severe injury. 3

Contrast-enhanced CT examination should be performed 3-6 hours after ingestion to evaluate for transmural necrosis and grade the severity of injury according to the four-stage classification system. 1, 2 This imaging modality is superior to traditional endoscopy for stratifying patients who require emergency resection versus observation. 4

CT Grading and Management Algorithm

The CT findings will determine the management pathway:

Grade I Injuries

• Patients can be fed immediately and discharged within 24-48 hours as stricture formation risk is nil. 1, 2
• No long-term follow-up required. 5

Grade IIa Injuries

• Low risk (<20%) of stricture formation. 5, 2
• Oral nutrition can be introduced as soon as pain diminishes and the patient can swallow. 5, 2
• Follow-up visit at 4-6 months post-ingestion recommended. 1, 2

Grade IIb Injuries

• High risk (>80%) of stricture formation. 5, 2
• May require nutritional support via nasogastric tube or feeding jejunostomy if pain during swallowing, hypersalivation, or early dysphagia persist. 5, 2
• Mandatory 4-6 month follow-up as most strictures develop within this timeframe. 1, 2

Grade III Injuries (Transmural Necrosis)

• Emergency surgery is indicated immediately to avoid death. 5, 1, 2
• All obvious transmural necrotic tissues should be resected during the initial operation. 5, 1
• A feeding jejunostomy should be placed at the end of the operation. 5, 1

Role of Endoscopy

Upper gastrointestinal endoscopy should be performed within 12-48 hours after caustic ingestion to determine prognosis and guide management, particularly if CT does not show Grade III injury. 2 In pediatric patients, endoscopy remains an important evaluation tool due to concerns about radiation exposure. 2 However, complete assessment of the entire esophagus and stomach is essential, as stopping at the first circumferential burn can miss more severe distal injuries. 6

Avoid endoscopy between 1-3 weeks after injury due to higher procedural risks during the healing phase. 2

Critical Management Pitfalls

• Clinical symptoms do not correlate reliably with the extent of gastrointestinal damage; absence of oral lesions does not rule out serious esophageal or gastric injuries. 2, 3
• Alkaline caustics cause liquefactive necrosis and can penetrate deeply, potentially causing more severe esophageal injury than acids. 2
• Any deterioration in clinical symptoms (rebound tenderness, increasing pain, shock) or laboratory tests (renal failure, acidosis, leukocytosis) suggests evolution to transmural necrosis and should prompt repeat CT evaluation. 5

Additional Considerations

Psychiatric evaluation is mandatory prior to hospital discharge to assess for intentional ingestion and prevent recurrence. 5, 1, 2

The correct answer is neither A, B, nor C as presented. The patient requires urgent CT imaging first to stratify injury severity, not immediate discharge, not urgent bronchoscopy (which would only be indicated for respiratory symptoms or suspected tracheobronchial injury), and not immediate observation in the OR without diagnostic evaluation. 5, 1, 2