What is the most appropriate next step in managing a patient with caustic ingestion and substernal chest pain?

From the Guidelines

The most appropriate next step in management for this 18-year-old woman who attempted suicide by ingesting hydrochloric acid solution is esophagoscopy (option D).

Reasons for Esophagoscopy

• Esophagoscopy should be performed urgently to assess the extent and severity of corrosive injury to the esophagus and stomach.
• This procedure allows direct visualization of the damaged tissues, helps determine the depth of injury, and guides further management decisions.
• In cases of acid ingestion, immediate endoscopic evaluation is crucial because acids tend to cause coagulation necrosis, which can lead to severe complications including perforation, stricture formation, and mediastinitis.
• The patient's symptoms of substernal chest pain suggest esophageal involvement, making direct visualization necessary.

Why Other Options are Not Preferred

• Sodium bicarbonate administration is contraindicated as it may cause an exothermic reaction and worsen tissue damage 1.
• Barium studies are contraindicated in suspected perforation cases.
• CT scan would be less helpful than direct visualization, and nasogastric tube placement could potentially cause perforation in damaged tissues.
• According to the guidelines, emergency endoscopy should be performed if CT is unavailable, or if CT suggests transmural esophageal necrosis but interpretation is difficult/uncertain 1.

Importance of Prompt Endoscopic Evaluation

• Prompt endoscopic evaluation remains the standard of care for assessing corrosive injuries to the upper gastrointestinal tract.
• Endoscopy is the main diagnostic tool of esophageal/gastric strictures in symptomatic patients 1.
• The Zargar endoscopic classification of caustic injuries is most commonly employed, although its ability to predict stricture formation remains controversial and is outperformed by CT 1.
• Endoscopic dilation is the upfront treatment of esophageal strictures, and should be attempted 3–6 weeks after ingestion in patients with few (< 3) short (< 5 cm) esophageal strictures 1.

From the Research

Next Steps in Management

The patient has ingested a hydrochloric acid solution and is experiencing substernal chest pain. Given the severity of the situation, it is crucial to prioritize the most appropriate next step in management.

• The patient's symptoms and history suggest potential esophageal injury, which can have devastating consequences if not managed promptly and appropriately 2.
• In cases of suspected esophageal injury, especially due to corrosive substances, immediate assessment and intervention are critical to prevent further damage and complications.
• Among the provided options, esophagoscopy is a direct method to visualize the esophagus and assess the extent of injury, which is essential for guiding further management decisions.
• While barium swallow tests and CT scans can provide valuable information, they may not be the immediate next step in the emergency setting where direct visualization and potential intervention via esophagoscopy could be more critical.
• Administration of sodium bicarbonate solution, placement of a nasogastric tube, and other options may have roles in management but are not the most direct approach to assessing and addressing potential esophageal damage from acid ingestion.

Considerations for Diagnostic Approaches

• Barium swallow tests are useful for diagnosing certain esophageal conditions, including achalasia, and can provide information on esophageal function and structure 3, 4, 5.
• However, in the acute setting of corrosive ingestion, the priority is to assess and manage the immediate damage to the esophagus, making esophagoscopy a more appropriate initial diagnostic and potentially therapeutic step.
• CT scans of the chest can also be useful in evaluating the extent of injury and complications but may not be the first line in assessing esophageal damage directly related to acid ingestion.