What is the management approach for caustic ingestion?

Management of Caustic Ingestion

Immediate Actions and Critical Contraindications

Do NOT induce emesis, administer activated charcoal, perform gastric lavage, or give neutralizing agents—these interventions are absolutely contraindicated and increase morbidity through re-exposure, aspiration risk, and exothermic tissue damage. 1, 2

What NOT to Do (Critical)

• Never induce vomiting with ipecac or any method—this causes re-exposure of the esophagus to the caustic agent and increases aspiration risk 1, 2
• Never give activated charcoal—it is ineffective for caustic substances and obscures subsequent endoscopic evaluation 1, 2
• Never administer neutralizing agents or antacids—they provide no benefit and may cause exothermic reactions leading to additional tissue injury 2
• Never perform gastric lavage—this increases perforation risk 2
• Do not give water or milk for dilution without specific poison control guidance—insufficient evidence supports this practice and it may cause emesis and aspiration 1, 2, 3

Initial Stabilization

• Immediately assess and secure the airway—this is the first priority, as vapor aspiration can cause airway burns 4, 1
• Remove any remaining caustic substance from the oral cavity and remove contaminated clothing around the mouth/face 1, 3
• Activate emergency medical services if respiratory distress, vomiting, or altered mental status is present 3
• Contact Poison Control Center immediately for guidance 2, 3

Diagnostic Evaluation

Laboratory Assessment

Obtain comprehensive laboratory evaluation including CBC, complete metabolic panel (sodium, potassium, chloride, magnesium, calcium), liver function tests, pH, serum lactate, and β-HCG in women of childbearing age within the first few hours. 4

• Abnormal values predictive of transmural necrosis and poor outcomes include: 4
  • Severe acidosis (low pH, elevated lactate)
  • Deranged liver function tests
  • Leukocytosis and elevated CRP
  • Renal failure
  • Thrombocytopenia
• Monitor serial laboratory values—initial normal values do not rule out transmural necrosis, and kinetics are useful for ongoing management 4
• Be aware of systemic effects: hypocalcemia (phosphoric/hydrofluoric acids), hyponatremia (strong acids/alkalis), hypokalemia, and acidosis 4

Imaging Strategy

Perform emergency contrast-enhanced CT of the neck, thorax, and abdomen 3-6 hours after ingestion—this is the preferred diagnostic modality and outperforms endoscopy in detecting transmural injuries and predicting stricture formation. 4, 1

CT Protocol and Interpretation

• Administer IV nonionic contrast (2 mL/kg) at 2-3 mL/s with 18-25 second acquisition time and 90-second scan delay 4
• The critical finding is absence of post-contrast wall enhancement at any level (esophagus, stomach, duodenum, bowel, colon)—this indicates transmural necrosis and is an absolute indication for emergency surgery 4

CT Grading System for Esophageal Injuries

• Grade I: Homogenous wall enhancement, no edema or mediastinal fat stranding 4
• Grade IIa: Internal mucosal enhancement with hypodense thickened wall, "target" appearance with outer wall enhancement 4
• Grade IIb: Fine rim of external wall enhancement only, necrotic mucosa does not enhance 4
• Grade III: Complete absence of post-contrast wall enhancement—requires emergency surgery 4

Role of Endoscopy

Perform emergency endoscopy only if: 4

1. CT is unavailable
2. CT with contrast is contraindicated (renal failure, iodine allergy)
3. CT suggests transmural necrosis but interpretation is uncertain
4. In pediatric populations

For patients without contraindications to non-operative management, perform upper endoscopy within 12-48 hours to grade injury severity and guide prognosis. 1, 5

• Contraindications to endoscopy: radiological evidence of perforation or burns to supraglottic/epiglottic areas 1
• Consider repeat endoscopy on day 5—this better predicts stricture development than day 1 endoscopy, as initial endoscopy significantly overestimates injury grade 6
• Use a 6-point endoscopic grading system (Zagar's modified classification) to predict complications and guide therapy 5

Treatment Algorithm Based on Injury Severity

Non-Operative Management (Grades I, IIa, IIb without transmural necrosis)

Patients without full-thickness necrosis can be managed non-operatively with close clinical and biological monitoring. 4, 1

Acute Phase Protocol (First Week)

• Keep patient NPO until endoscopy is performed in first 24-48 hours 7
• For Grade 2b and 3 lesions without transmural necrosis, maintain esophageal rest for one week using nasogastric tube 7
• Administer IV fluids and broad-spectrum antibiotics 7
• Give IV ranitidine or proton pump inhibitor 7
• Single-dose steroid may be considered (though evidence is limited) 7
• Monitor serial laboratory values and clinical status closely 4

Feeding Resumption

• Grade I injuries: Patients can typically resume feeding immediately as these heal spontaneously 1
• Higher grade injuries: Resume oral intake only after confirming absence of perforation and adequate healing

Emergency Surgical Intervention

Proceed immediately to emergency surgery for patients with: 4, 1

• Absence of post-contrast wall enhancement on CT (transmural necrosis)
• Free perforation with pneumomediastinum or pneumoperitoneum
• Hemodynamic instability
• Signs of severe sepsis
• Clinical deterioration despite non-operative management

Surgical Options

• For transmural necrosis: Emergency resection can be lifesaving 4, 1
• For perforation with viable tissue: Primary repair with adequate drainage 4
• For extensive necrosis or delayed presentation: External drainage, esophageal exclusion, or resection 4
• Minimally invasive approaches may be considered in stable patients by experienced surgeons 8

Long-Term Management and Stricture Prevention

Stricture Surveillance

• Obtain barium esophagram at 3 weeks to assess for stricture formation 7
• Avoid endoscopic dilation within the first 3 weeks due to higher complication risk including perforation 1, 3

Stricture Management

• For established strictures, endoscopic dilation is the mainstay of treatment 1
• Maintain dilation intervals of less than 2-3 weeks for optimal outcomes 1
• Patients receiving immediate appropriate acute phase management have higher response rates to dilation and lower perforation rates compared to those with delayed or inadequate initial treatment 7
• 60% of patients with optimal acute management recover within the first year, compared to 0% with suboptimal initial treatment 7

Critical Clinical Pearls and Pitfalls

Common Misconceptions

• Clinical symptoms do NOT correlate with injury severity—absence of oral lesions or pain does not rule out serious esophageal or gastric injury 1, 3
• The physical form matters: Solids cause maximum oropharyngeal damage; liquids rapidly transit to cause esophageal and gastric burns 4, 1
• Acid vs. alkali differences: Acids cause coagulative necrosis (eschar formation may limit penetration) and tend to cause more gastric than esophageal injury; alkalis cause liquefactive necrosis with deeper tissue penetration 1, 3

High-Risk Features

• Voluntary ingestion (versus accidental) correlates with larger volume and worse prognosis 4
• Grade 3b injuries have significantly higher risk of prolonged hospitalization, ICU admission, and both gastrointestinal and systemic complications compared to Grade 3a 5
• Quantity ingested is the most important prognostic factor, though reliable information is often lacking 4