Clinical Guideline Caustic Ingestion

Toxicology consultation prior to initiation is strongly recommended ** Any signs/symptoms indicative of gastrointestinal perforation warrants resuscitation and immediate surgical consultation. The absence of oropharyngeal injury does not reliably rule out potentially serious caustic injury to the gastrointestinal tract (38% patients with esophageal burns found to have no OP burns) Acids cause immediate coagulative necrosis which tends to self-limit injury. Alkalis cause liquifactive necrosis resulting in deeper penetration and more extensive injury.

1.) Decontamination
Blind nasogastric tube insertion is contraindicated due to risk of accidental perforation. Activated charcoal is contraindicated. Do not attempt to neutralize pH with acid or alkaline lavage, this may cause exothermic reaction and potential for thermal injury. Dilution with milk is only found to be effective if given within minutes of ingestion. Unless the patient must be kept NPO for a clearly indicated endoscopy, it is OK to give water or milk if the patient is able and willing to swallow. In general, there is no need for oral dilution.

2.) Evaluation for Perforation

Any signs/symptoms indicative of gastrointestinal perforation warrants resuscitation and immediate surgical consultation. Plain chest and abdominal x-rays are not sensitive, but may aid in the rapid diagnosis of perforation. Contrast studies may also fail to detect perforations, but extravasation of contrast outside of GI tract is diagnostic. Water-soluble contrast is recommended initially as it is less irritating to tissues in case of perforation. CT scanning may have a role in the evaluation of caustic injury but has not been studied.

2.) Endoscopy

Endoscopy is the standard diagnostic tool for evaluation of caustic injury. Scope should be performed preferentially within the first 12 hours, but no later than 24 hours (wound softening starting on the 2nd day may increase the risk of perforation) Debate exists regarding when endoscopy is indicated in asymptomatic patients after caustic ingestion. Because studies have shown repeatedly that a small percentage of patients will have esophageal and/or gastric injury in the absence of oral burns or dysphagia, some experts advocate endoscopy for all patients regardless of symptoms. It is my opinion that endoscopy is unnecessary for asymptomatic patients after unintentional ingestion (See below). Endoscopy is helpful to diagnose and grade the extent of gastrointestinal injury. A nasogastric tube may be placed under endoscopic guidance should significant injuries be discovered. Grade I = no esophageal stricture risk Grade IIB = 75% will develop stricture Grade III = 100% will develop stricture < Grade IIB = no increased cancer risk > Grade IIB = 1000x risk of cancer (latency 20-40 years) Grade II and III = increased risk of severe complications (stricture, motility problems, TE fistula, erosion into great vessels)

Caustic Ingestion

Un-intentional / Pediatric Ingestion

Intentional / Adult Ingestion

Asymptomatic? Yes

No

GI Medicine Consultation

No Endoscopy

3.) Management issues

A.) Steroids NEJM article of pediatric caustic ingestions showed a possible modest benefit of corticosteroids in patients with grade IIB injury only. In primate studies, corticosteroids significantly increased mortality due to overwhelming sepsis. In the same study, mortality returned to baseline when prophylactic antibiotic coverage was given. Recommendation: I do not feel that the evidence supports corticosteroids for any esophageal burn grade. If you do elect to give corticosteroid for grade IIB injury, give with prophylactic antibiotics. B.) Antibiotics There is no data to support the use of prophylactic antibiotics except (possibly) in conjunction with corticosteroids. C.) Nasogastric tube placement Cases of esophageal perforation associated with blind NGT placement are reported. In high-grade injuries placement of an NGT early may be desirable to allow access to the stomach. Recommendation: NG tube should never be placed blindly. In high grade injuries (grade IIB or III), placement of a feeding tube under endoscopic guidance may be helpful to maintain access to the stomach. D.) Antacids H2 blockers or PPIs are not recommended as these medications may allow for increased gastric bacterial growth.

Special Cases:
A.) Household Bleach (sodium hypochlorite) Grade II and III injuries only occur after large volume ingestions of concentrated bleach. Only patients complaining of pain, high concentration ingestions, or large volume ingestions need endoscopic evaluation. B.) Button Batteries may cause serious corrosive injury possibly related to leakage of contents or local discharge of electrical current. Most injuries occur due to impaction in the esophagus and subsequent perforation. Most cases involve large (25 mm) batteries. If any signs / symptoms of perforation, immediate surgical consultation is indicated. Locations:

Airway or Esophagus emergent endoscopic removal Stomach If symptomatic need emergent removal. If asymptomatic, the batteries usually pass out uneventfully with the stool. Consider giving PEG and rechecking in 2 days. (In rare case of child less than 6 years and battery 25mm, consider endoscopic removal) Beyond pylorus follow with repeat x-ray in 7 days. Consider surgical consultation if not passed. C.) Hydrofluoric Acid extreme systemic toxicity is expected. Immediate toxicology or poison center consultation is indicated.

Last revised: 2/2007