Caustic ingestion
Caustic ingestion | |
---|---|
Specialty | Gastroenterology, Intensive care medicine, Pulmonology |
Symptoms | Pain, drooling, vomiting, bleeding, mouth and tongue swelling, eye irritation[1] |
Complications | Esophageal stricture, esophageal cancer, aspiration pneumonia[1][2] |
Usual onset | Immediate |
Prevention | Safe storage of caustic substances[3] |
Treatment | Surgery, medications, observation [1] |
Caustic ingestion occurs when someone accidentally or deliberately ingests a
The severity of the injury can be determined by endoscopy of the upper digestive tract, although CT scanning may be more useful to determine whether surgery may be required.[4]
During the healing process,
Signs and symptoms
Immediate manifestations of caustic substance ingestions include erosions of mucosal surfaces of the gastrointestinal tract or airway (which can cause bleeding if the erosions extend to a blood vessel), mouth and tongue swelling, drooling or hypersalivation, nausea, vomiting,
Later manifestations of caustic substance ingestions include esophageal strictures or stenosis; which can result in chronic pain and malnutrition.[1] Esophageal strictures more commonly occur after more severe mucosal injury, occurring in to 71% and 100% of grade 2b and 3 mucosal lesions respectively.[2] Remote manifestations of caustic ingestions include esophageal cancer. People who have a history of caustic substance ingestion are 1000-3000 times more likely to develop esophageal cancer with most cases occurring 10–30 years after the ingestion.[2]
Pathophysiology
Diagnosis
Classification
The severity of injuries to the mucosa of the gastrointestinal tract is commonly rated using the Zargar criteria.[5]
Category | Findings |
---|---|
0 | Normal examination |
1 | Mucosal edema and erythema |
2a | Superficial ulcerations or erosions, friability, blister formation, exudates, hemorrhages |
2b | Deep ulcerations (either discrete or circumferential) as well as the findings described in 2a |
3a | Multiple small, scattered areas of necrosis |
3b | Extensive necrosis |
Treatment
Common treatments used for toxic substance ingestions are ineffective, or are even harmful, when implemented in ingestions of caustic substances. Clinical attempts to empty the stomach can cause further injuries.[1] Activated charcoal does not neutralize caustics and can also obscure endoscopic visualization.[1] There is no known clinical benefit of neutralization of the caustic substances; neutralization releases heat as well as causing gaseous distention and vomiting, all of which can worsen injuries.[1]
Signs of airway compromise including decreased level of consciousness, stridor, change in voice, inability to control oral secretions necessitate intubation and mechanical ventillation.[1] IV fluids are often needed to maintain hydration and replace insensible water losses.
Endoscopy should be done within the first 24–48 hours of ingestion as subsequent wound softening increases the risk of perforation.[1] Endoscopically inserted nasogastric tubes can serve as a stent to prevent esophageal strictures as well as allow tube feedings.[1] A CT scan, often enhanced with contrast, can also be used to evaluate injuries.[1]
The most common surgical methods of treatment in children include esophageal dilation and esophageal replacement as less commonly implantation of an esophageal stent.[3]
Epidemiology
In general, most ingestions in children involve exploratory ingestions of small amounts of caustic substances, with the rare exception being cases of child abuse where larger amounts are often ingested. Caustic ingestions in adults usually involve larger amounts of ingested material during attempts of self harm.
Prevention
Preventative measures have been recommended that are intended to decrease the risk of accidental ingestion of caustic substances including:[3]
- Keeping caustic substances in locked cabinets or on upper shelves
- Not storing chemical substances in food or drink containers
- Not keeping large amounts of detergent in the home
- Not mentioning a drug as "candy" when giving it as medication
- Keeping the phone number for poison control in the home
- Keeping caustic substances in labelled containers