What is the management approach for acid ingestion?

Management of Acid Ingestion

Acid ingestion is a medical emergency requiring immediate assessment of airway stability, rapid diagnostic endoscopy within 12-24 hours to grade injury severity, and aggressive supportive care including bowel rest, proton pump inhibitors, antibiotics, and consideration of early surgical intervention for perforation or transmural necrosis. 1, 2

Immediate Assessment and Stabilization

Airway Management

• Secure the airway immediately if there is evidence of upper airway edema, respiratory distress, or severe oropharyngeal burns, as patients can rapidly deteriorate and require endotracheal intubation 2
• Assess for stridor, drooling, or inability to handle secretions as indicators of impending airway compromise 2

Initial Evaluation

• Identify the specific acid ingested (hydrochloric, sulfuric, acetic acid), concentration, volume, and whether ingestion was intentional or accidental, as this determines injury severity and prognosis 1
• Contact Poison Control Centers immediately to evaluate systemic toxicity potential 1
• Obtain arterial blood gas to assess for severe metabolic acidosis, which indicates significant acid absorption and systemic toxicity 3

Laboratory Assessment

• Draw renal function tests (BUN, creatinine) to assess kidney injury from systemic absorption 1
• Check complete blood count for evidence of hemolysis (particularly with acetic acid ingestion) 4
• Obtain liver function tests and C-reactive protein, as elevations suggest transmural necrosis 1
• Measure coagulation studies to detect disseminated intravascular coagulation 4
• Perform β-HCG in women of childbearing age 1

Diagnostic Imaging

Esophagogastroduodenoscopy (EGD)

• Perform EGD within 12-24 hours as the gold standard for determining presence and severity of corrosive injury 1, 2
• Use Zargar grading system to classify injury severity, which directly guides management decisions 2
• EGD is safe when performed early and provides critical prognostic information 5

Cross-Sectional Imaging

• Obtain CT scan of chest and abdomen if perforation is suspected based on clinical deterioration, peritoneal signs, or pneumomediastinum 2
• CT increasingly plays a role in defining extent of injury and detecting complications 2

Medical Management

Acid Suppression

• Initiate high-dose proton pump inhibitor therapy immediately (twice-daily dosing) to minimize ongoing acid-mediated injury 1, 2
• Continue PPI therapy indefinitely for patients with severe mucosal injury (Zargar grade 2B or higher) 1

Supportive Care

• Institute complete bowel rest (NPO status) to allow mucosal healing 2
• Administer broad-spectrum antibiotics to prevent secondary infection of necrotic tissue 2
• Consider corticosteroids in select cases, though evidence is limited and controversial 2

Management of Systemic Complications

• For hemolysis (particularly with acetic acid): Initiate plasma separation/plasmapheresis as the most rapid detoxification method 4
• Perform exchange transfusion if severe hemolysis develops 4
• Administer low-dose heparin and antithrombin III for disseminated intravascular coagulation 4
• Initiate hemodialysis for acute renal failure secondary to hemoglobinuria or direct nephrotoxicity 4

Surgical Intervention

Indications for Surgery

• Esophageal or gastric perforation requires immediate surgical exploration 2, 6
• Transmural necrosis identified on imaging or during endoscopy mandates surgical evaluation 1, 3
• Massive gastric hemorrhage unresponsive to medical management 6
• Total gastrectomy may be necessary for extensive gastric necrosis 3

Timing Considerations

• Early complications (perforation, hemorrhage) require urgent intervention 6
• Late complications (stricture formation) typically develop after an asymptomatic interval of weeks to months 6

Prognostic Factors and Outcomes

Severity Predictors

• Zargar grade at initial endoscopy is the strongest predictor of systemic complications, GI complications, and mortality (relative risk 9 for high-grade injuries) 5
• Acid ingestion carries significantly worse prognosis than alkali ingestion, with higher rates of ICU admission (44% vs 22%), systemic complications (24% vs 3%), perforation (6% vs 0%), and mortality (14% vs 2%) 5
• Glacial acetic acid ingestion is particularly lethal, with 400ml of 25% solution considered a lethal dose 4

Expected Complications

• Gastric outlet obstruction is the most common late complication, developing in 15-17% of patients 6, 5
• Stricture formation occurs equally with acid and alkali ingestion 5
• Strong acids preferentially injure the stomach rather than esophagus (opposite pattern from alkali) 6

Long-Term Management

Stricture Management

• Only 34% of patients with strictures respond to endoscopic dilation alone 5
• Most patients ultimately require surgical intervention (primary or secondary) for stricture management 5

Monitoring

• Serial endoscopy to assess healing and detect stricture formation 6
• Maintain indefinite PPI therapy for patients with severe initial injury 1

Critical Pitfalls to Avoid

• The absence of severe symptoms immediately after acid ingestion is misleading—patients can develop life-threatening complications after an asymptomatic interval 6
• Do not delay endoscopy beyond 24 hours, as early grading is essential for risk stratification 5
• Avoid nasogastric tube placement or induced emesis, which can worsen injury 2
• Do not underestimate systemic toxicity—acid ingestion causes both local tissue injury and systemic absorption with metabolic consequences 3, 4