Caustic Ingestions Workup
- Author: Eric M Kardon, MD, FACEP; Chief Editor: Asim Tarabar, MD more...
Laboratory studies may include the following:
pH testing of product: A pH less than 2 or greater than 12.5 indicates greater potential for severe tissue damage,  but a pH outside of this range does not preclude significant injury
pH testing of saliva: Unexpected high or low values may confirm ingestion in questionable cases; however, a neutral pH cannot rule out a caustic ingestion
Complete blood count (CBC) and electrolyte, blood urea nitrogen (BUN), creatinine, and arterial blood gas ( ABG) levels may all be helpful as baseline values and as indications of systemic toxicity
Liver function tests and a disseminated intravascular coagulation (DIC) panel may also be helpful to establish baselines or, if abnormal, confirm severe injury following acid ingestions
Urinalysis and urine output may help guide fluid replacement
Blood type and crossmatch are indicated for any potential surgical candidates or those with the potential for gastrointestinal bleeding
Obtain aspirin and acetaminophen levels as well as an electrocardiogram (ECG) in any patient whose intent may have been suicidal.
In cases of hydrofluoric acid (HF) ingestion, precipitous falls in calcium level may lead to sudden cardiac arrest. Although ionized calcium levels are likely to have too long a turnaround to be clinically useful, cardiac monitoring and serial ECGs may help anticipate this event
Obtain an upright chest radiograph in all cases of caustic ingestion. Findings may include pneumomediastinum or other findings suggestive of mediastinitis, pleural effusions, pneumoperitoneum, aspiration pneumonitis, or a button battery (metallic foreign body). However, the absence of findings does not preclude perforation or other significant injury.
Abdominal radiographic findings may include pneumoperitoneum, ascites, or an ingested button battery (metallic foreign body). If contrast studies are obtained, water-soluble contrast agents are recommended because they are less irritating to the tissues in cases of perforation.
Computed tomography (CT) scans will often be able to delineate small amounts of extraluminal air, not seen on plain radiographs.
Lurie et al evaluated the role of chest and abdominal CT in assessing the severity of acute corrosive ingestion and concluded that CT should not be the only basis for surgical decisions during the initial phase of acute corrosive ingestions. They noted that CT can underestimate the severity of corrosive ingestion as compared with endoscopy. In their retrospective study of 23 patients, endoscopy findings were graded as 0, 1, 2a, 2b, 3a, and 3b (Zargar criteria); and CT findings were graded as 0, 1, 2, and 3. Endoscopy grading was found to be higher than CT grading in 14 patients (66%).
Airway protection is critical following caustic ingestion if there is any indication of airway compromise. This can develop rapidly and be complicated by multiple factors. See Emergency Department Care. Cardiac monitoring is indicated for any patient with a caustic ingestion.
Large-bore intravenous access allows administration of fluids and medications as needed.
Endoscopy is generally indicated for the following patients:
Symptomatic older children and adults
Patients with abnormal mental status
Those with intentional ingestions
Patients in whom injury is suspected for other reasons (eg, ingestion of large volumes or concentrated products)
However, because of the risk of increased injury, esophagoscopy should not be performed in patients with evidence of esophageal or gastrointestinal perforation, significant airway edema, or necrosis and in those who are hemodynamically unstable.
Obtaining meaningful information from endoscopy after treatment with activated charcoal is very difficult. Routine use of activated charcoal is not recommended in caustic ingestions.
Endoscopic ultrasonography has been shown to more accurately show the depth of lesions than endoscopy alone. Further studies will be necessary to determine the utility of this procedure in aiding in diagnosis and treatment.
Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Heard SE. 2007 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). 2008 Dec. 46(10):927-1057. [Medline]. [Full Text].
Kay M, Wyllie R. Caustic ingestions in children. Curr Opin Pediatr. 2009 Jun 18. [Medline].
Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffin SL. 2008 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 26th Annual Report. Clin Toxicol (Phila). 2009 Dec. 47(10):911-1084. [Medline].
Mowry JB, Spyker DA, Brooks DE, McMillan N, Schauben JL. 2014 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 32nd Annual Report. Clin Toxicol (Phila). 2015. 53 (10):962-1147. [Medline]. [Full Text].
Rollin M, Jaulim A, Vaz F, Sandhu G, Wood S, Birchall M, et al. Caustic ingestion injury of the upper aerodigestive tract in adults. Ann R Coll Surg Engl. 2015 May. 97 (4):304-7. [Medline]. [Full Text].
Denney W, Ahmad N, Dillard B, Nowicki MJ. Children will eat the strangest things: a 10-year retrospective analysis of foreign body and caustic ingestions from a single academic center. Pediatr Emerg Care. 2012 Aug. 28(8):731-4. [Medline].
Elshabrawi M, A-Kader HH. Caustic ingestion in children. Expert Rev Gastroenterol Hepatol. 2011 Oct. 5(5):637-45. [Medline].
Chang JM, Liu NJ, Pai BC, Liu YH, Tsai MH, Lee CS, et al. The role of age in predicting the outcome of caustic ingestion in adults: a retrospective analysis. BMC Gastroenterol. 2011 Jun 14. 11:72. [Medline]. [Full Text].
Riffat F, Cheng A. Pediatric caustic ingestion: 50 consecutive cases and a review of the literature. Dis Esophagus. 2009. 22(1):89-94. [Medline].
Lurie Y, Slotky M, Fischer D, Shreter R, Bentur Y. The role of chest and abdominal computed tomography in assessing the severity of acute corrosive ingestion. Clin Toxicol (Phila). 2013 Nov. 51(9):834-7. [Medline].
Kamijo Y, Kondo I, Watanabe M, Kan'o T, Ide A, Soma K. Gastric stenosis in severe corrosive gastritis: prognostic evaluation by endoscopic ultrasonography. Clin Toxicol. 2007. 45(3):284-6. [Medline].
Uygun I, Arslan MS, Aydogdu B, Okur MH, Otcu S. Fluoroscopic balloon dilatation for caustic esophageal stricture in children: an 8-year experience. J Pediatr Surg. 2013 Nov. 48(11):2230-4. [Medline].
Gorman RL, Khin-Maung-Gyi MT, Klein-Schwartz W, Oderda GM, Benson B, Litovitz T, et al. Initial symptoms as predictors of esophageal injury in alkaline corrosive ingestions. Am J Emerg Med. 1992 May. 10(3):189-94. [Medline].
Havanond C, Havanond P. Initial signs and symptoms as prognostic indicators of severe gastrointestinal tract injury due to corrosive ingestion. J Emerg Med. 2007 Nov. 33(4):349-53. [Medline].
Homan CS, Maitra SR, Lane BP, Thode HC Jr, Finkelshteyn J, Davidson L. Effective treatment for acute alkali injury to the esophagus using weak-acid neutralization therapy: an ex-vivo study. Acad Emerg Med. 1995 Nov. 2(11):952-8. [Medline].
Homan CS, Maitra SR, Lane BP, Thode HC, Sable M. Therapeutic effects of water and milk for acute alkali injury of the esophagus. Ann Emerg Med. 1994 Jul. 24(1):14-20. [Medline].
Kim SJ, Cho SB, Cho JM, et al. CT imaging of gastric and hepatic complications after ingestion of glacial acetic acid. J Comput Assist Tomogr. 2007 Jul-Aug. 31(4):564-8. [Medline].
Pelclová D, Navrátil T. Do corticosteroids prevent oesophageal stricture after corrosive ingestion?. Toxicol Rev. 2005. 24(2):125-9. [Medline].
Poley JW, Steyerberg EW, Kuipers EJ, Dees J, Hartmans R, Tilanus HW, et al. Ingestion of acid and alkaline agents: outcome and prognostic value of early upper endoscopy. Gastrointest Endosc. 2004 Sep. 60(3):372-7. [Medline].
Salzman M, O'Malley RN. Updates on the evaluation and management of caustic exposures. Emerg Med Clin North Am. 2007 May. 25(2):459-76. [Medline].
Turner A, Robinson P. Respiratory and gastrointestinal complications of caustic ingestion in children. Emerg Med J. 2005 May. 22(5):359-61. [Medline].