Caustic Ingestion

Caustic ingestion is the swallowing of a corrosive alkali or acid, by accident (children, usually under 5 years, with household products) or in deliberate self-harm (adults, with larger volumes and worse injury). Alkalis (drain and oven cleaners, bleach at high concentration, lye, button batteries and dishwasher detergents) cause liquefactive necrosis, which penetrates deeply, and chiefly injure the esophagus.

Acids (toilet cleaners, battery acid, rust removers) cause coagulative necrosis, which limits depth but injures the stomach (and may spare the esophagus), with a high rate of gastric perforation and pyloric stricture.

The pH and concentration matter (over pH 12 or under pH 2 is highly corrosive), as do the volume and the contact time. Solids and gels adhere to the oropharynx and esophagus, while liquids pass faster.

Injury is graded by endoscopy (Zargar)

• Grade 0: normal
• Grade 1: edema and hyperemia
• Grade 2a: superficial ulcers, friable, hemorrhagic mucosa
• Grade 2b: deep focal or circumferential ulcers
• Grade 3a: focal necrosis (small areas), and 3b extensive necrosis
• Grade 4: perforation

Strictures follow in 70 to 100% of grade 2b and 3 injuries, usually from 3 weeks to 3 months. Complications: perforation with mediastinitis or peritonitis, airway injury and laryngeal edema, hemorrhage, aspiration pneumonia, esophageal stricture and gastric outlet obstruction, and esophageal squamous carcinoma (a risk several hundred times the general level, appearing 15 to 40 years later).

• Burning pain in the mouth, throat, chest and abdomen, drooling, dysphagia, odynophagia, vomiting, hematemesis
• Stridor, hoarseness, dyspnea and oropharyngeal burns suggest airway injury
• Absent oral burns do not exclude significant esophageal injury (up to 10 to 30% of patients with severe injury have no oral lesions)
• Chest pain, subcutaneous emphysema, rigidity and shock suggest perforation
• Red flags: stridor, drooling, hematemesis, severe chest or abdominal pain, peritonism, hypotension, and ingestion of a button battery

1. Resuscitation and airway assessment first, with history of the agent, quantity, time and intent, and the product label or poison center information.
2. Chest and abdominal radiographs (erect): free mediastinal or peritoneal air, pleural effusion, button battery (a double-rim "halo" sign on anteroposterior film and a step-off on lateral film).
3. Laboratory tests: blood count, electrolytes, creatinine, liver tests, lactate, blood gases (acidosis from acid ingestion), coagulation, and group and cross-match.
4. Contrast CT of the neck, chest and abdomen to assess transmural necrosis and perforation, particularly in the symptomatic or unstable patient (CT is also a safe alternative where endoscopy is not possible).
5. Upper gastrointestinal endoscopy within 12 to 24 hours (and generally not later than 48 to 72 hours) in symptomatic patients, and in all deliberate ingestions, to grade injury. It should not be done 5 to 15 days after ingestion because the wall is thinnest.
6. Flexible laryngoscopy for suspected supraglottic injury.

Differentials: pharyngitis, foreign body ingestion, pill esophagitis, corrosive aspiration, esophageal perforation of other cause.

1. Do not induce vomiting. Do not give activated charcoal (it obscures endoscopy and does not adsorb caustics), or neutralizing agents (heat release causes further injury), and avoid blind nasogastric tube placement.
2. Rinse the mouth and skin and eyes with water. Eye exposure: irrigate with 0.9% saline or water for at least 15 to 30 minutes with a Morgan lens, and check pH to 7.0 before stopping.
3. Airway: early endotracheal intubation under direct vision (or tracheostomy) for stridor, voice change or severe oropharyngeal edema, with nebulized epinephrine 1 mg (1 mL of 1:1000) diluted in 4 mL saline as a bridge.
4. Supportive care: nil by mouth, IV crystalloid 20 mL/kg initially, then by response, omeprazole 40 mg IV twice daily (children 1 mg/kg a day), and analgesia (morphine 0.05 to 0.1 mg/kg IV titrated, or paracetamol 1 g IV every 6 hours, children 15 mg/kg).
5. Antibiotics only for perforation, mediastinitis, infection or when high-dose steroids are given: piperacillin-tazobactam 4.5 g IV every 6 hours (children 100 mg/kg of piperacillin every 8 hours).
6. Management by endoscopic grade:
   • Grade 0 and 1: oral intake after 24 hours, discharge with soft diet and review.
   • Grade 2a: feeding after 24 to 48 hours as tolerated, with outpatient stricture surveillance.
   • Grade 2b and 3a: nasogastric feeding tube placed under direct endoscopic vision or enteral feeding by jejunostomy, with parenteral nutrition as an alternative, and close monitoring for stricture.
   • Grade 3b and 4: emergency surgery, with esophagectomy and gastrectomy for transmural necrosis, resection of necrotic bowel, wide drainage and later reconstruction (colon or gastric conduit).
7. Stricture treatment: dilatation with balloon or bougie starting 3 to 4 weeks after injury, repeated at 1 to 2 week intervals, with intralesional triamcinolone 40 mg (10 mg in each of 4 quadrants) at each session for refractory strictures. Temporary removable stent for resistant disease, and esophageal bypass or resection for failure after 6 to 12 sessions.
8. Systemic steroids are not recommended.
9. Button battery in the esophagus (emergency): endoscopic removal within 2 hours of ingestion. For children over 12 months who are alert with a known ingestion in the previous 12 hours, give honey 10 mL orally every 10 minutes for up to 6 doses, or sucralfate 10 mL every 10 minutes for up to 3 doses, on the way to hospital. Do not give if there is suspected perforation, or the child is under 12 months for honey.
10. Deliberate ingestion: psychiatric assessment before discharge, and counsel on safe storage and original containers.

Follow-up: barium swallow or endoscopy at 3 to 4 weeks for grade 2b and above, surveillance for strictures for 6 months, and endoscopic cancer surveillance from 15 to 20 years after severe injury.