Caustic Ingestion

Acids cause coagulation necrosis; an eschar forms, limiting further damage. Acids tend to affect the stomach more than the esophagus.

Alkalis cause rapid liquefaction necrosis; no eschar forms, and damage continues until the alkali is neutralized or diluted. Alkalis tend to affect the esophagus more than the stomach, but ingestion of large quantities severely affects both.

Solid products tend to leave particles that stick to and burn tissues, discouraging further ingestion and causing localized damage. Because liquid preparations do not stick, larger quantities are easily ingested, and damage may be widespread. Liquids may also be aspirated, leading to upper airway injury.

Initial symptoms of caustic ingestion include drooling and dysphagia. In severe cases, pain, vomiting, and sometimes bleeding develop immediately in the mouth, throat, chest, or abdomen. Airway burns may cause coughing, tachypnea, or stridor.

Swollen, erythematous tissue may be visible intraorally; however, caustic liquids may cause no intraoral burns despite serious injury farther down the gastrointestinal tract.

Esophageal perforation may result in mediastinitis, with severe chest pain, tachycardia, fever, tachypnea, and shock. Gastric perforation may result in peritonitis. Esophageal or gastric perforation may occur within hours, after weeks, or any time in between.

Esophageal strictures can develop over weeks, even if initial symptoms had been mild and treatment had been adequate. Strictures can result in esophageal shortening or narrowing as well as dysphagia and motility disorders.

Survivors of caustic ingestions are at higher risk for development of esophageal carcinoma (1).

• Endoscopy

Because the presence or absence of intraoral burns does not reliably indicate whether the esophagus and stomach are burned, meticulous endoscopy is indicated to check for the presence and severity of esophageal and gastric burns when symptoms or history suggests more than trivial ingestion. Endoscopy does not need to be done immediately; the patient should be stabilized before being considered for endoscopy.

Chest radiographs have limited sensitivity for evaluation of esophageal perforation, so a CT scan of the chest and abdomen should be performed if perforation is suspected (1, 2).

• Gastric emptying and activated charcoal are contraindicated

• Sometimes dilution with oral fluids

In general, acid and alkali ingestions are treated similarly, with supportive care. (CAUTION: Gastric emptying by emesis or lavage is contraindicated because it can reexpose the upper gastrointestinal tract to the caustic agent. Attempts to neutralize a caustic acid by correcting pH with an alkaline substance [and vice versa] are contraindicated because severe exothermic reactions may result. Activated charcoal is contraindicated because it does not absorb caustics and may infiltrate burned tissue and interfere with endoscopic evaluation.Nasogastric tube insertion is controversial because of the concern of further damage to the already compromised esophageal mucosal surface. Direct visualization with endoscopy during insertion may be used to avoid perforating the esophageal mucosa with the nasogastric tube) (1).

Dilution with milk or water is only useful in the first few minutes after ingesting a liquid caustic, but delayed dilution may be useful after ingesting a solid caustic. Dilution should be avoided if patients have nausea, drooling, stridor, or symptoms suggestive of visceral perforation.

Esophageal or gastric perforation is treated with antibiotics and surgery (see Acute Perforation). IV corticosteroids and prophylactic antibiotics are not recommended (2, 3). Strictures are treated with bougienage or, if they are severe or unresponsive, with esophageal bypass by colonic interposition (4).