Caustic Ingestions Follow-up

Updated: Oct 27, 2018
  • Author: Eric M Kardon, MD, FACEP; Chief Editor: David Vearrier, MD, MPH  more...
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Follow-up

Further Outpatient Care

Adult patients with an unintentional exposure may be discharged after a 2- to 4-hour observation period if the clinician has no unique concerns regarding the ingested substance (eg, large volume, high concentration, agent with potential for systemic toxicity) and the patient meets all the following criteria:

  • Asymptomatic
  • Clear sensorium
  • Able to ingest oral fluids without difficulty
  • Demonstrate easy speech
  • Reliable
  • Familiar with delayed symptoms and able to return if any occur

Postdischarge arrangements may include the following:

  • Psychiatric evaluation for all patients with intentional ingestion
  • Follow-up esophagram 3-4 weeks postingestion

Treatment of esophageal stricture

Esophageal stricture can develop as early as 3 weeks after caustic ingestion, but typically occurs 8 weeks or longer afterwards. Strictures can be treated with esophageal dilatation, using bougies (usually Savary) or balloon catheters. Savary bougies are considered more reliable for treatment of consolidated and fibrotic strictures or long, tortuous ones, and bougie dilatation may pose lower risk of perforation, with rates as high as 30% reported with balloon dilatation of caustic strictures. [16]

However, in a study by Uygun et al, fluoroscopically guided esophageal balloon dilatation (EBD) was found to be a safe procedure, with a low rate of complications; and it had a 100% success rate. In their review of of 369 EBD sessions in 38 children (aged 14 months to 14 years, median 3.5 years) with caustic esophageal strictures, six (1.6%) esophageal perforations occurred in five patients (13.2%). [20]

Ugyun et al recommend that in children, dilatation should be performed gently with balloons of gradually increasing appropriate diameters over consecutive sessions. In addition, the study findings showed that EBD treatment was significantly faster and shorter in patients who began EBD earlier (mean, 15 days) after caustic ingestion than in those who began it later (mean, 34 days). [20]

When esophageal dilatation is not possible or fails to provide an adequate esophageal caliber in the long-term, esophageal replacement by retrosternal stomach or, preferably, right colonic interposition should be considered. Arguments can be made for either bypass or resection of the native esophagus. [16]

Esophageal cancer

Patients who have experienced caustic injury are at increased risk for esophageal cancer (both adenocarcinoma and squamous cell carcinoma), typically developing 1 to 3 decades after ingestion. Consequently, long-term endoscopic screening is recommended for these patients. [16]

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Further Inpatient Care

Admit, for observation and possible endoscopy, all small children, symptomatic patients, those with altered mental status, and those whose ingestions are worrisome for other reasons, such as large volumes, high concentrations, or unique issues such as those posed by hydrogen fluoride or phenol. Admit all symptomatic patients to the ICU to closely monitor their airway status and to watch for signs of perforation.

Ensure that all patients take nothing per mouth (NPO) until the extent of injury has been determined. Begin an intravenous line to administer fluids and medications.

Administer parenteral analgesics as needed for pain. Monitor for signs of sedation and respiratory depression.

Rollin et al have proposed an algorithm for surgical management of caustic ingestion injuries in adult patients. [6]

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Transfer

If an ICU bed is not available or if endoscopy is not available when indicated, transfer is advised.

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Deterrence/Prevention

In the home, caustic substances should be kept in their original labeled containers to avoid accidental ingestion. They should be stored out of reach of toddler-aged children.

In the workplace, policies and procedures need to be developed and disseminated, so that employee exposures can be treated quickly and effectively.

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Complications

Complications may include the following:

  • Airway edema or obstruction may occur immediately or up to 48 hours following an alkaline exposure.
  • Gastroesophageal perforation may occur acutely.
  • Upper gastrointestinal hemorrhage may occur acutely in caustic exposure

  • Secondary complications include mediastinitis, pericarditis, pleuritis, tracheoesophageal fistula formation, esophageal-aortic fistula formation, and peritonitis.

  • Delayed perforation may occur as many as 4 days after an acid exposure.

  • Delayed upper GI bleeding may occur in acid burns 3-4 days after exposure as the eschar sloughs.

  • Deep circumferential or deep focal burns may result in strictures in more than 70% of patients; these strictures typically develop 2-4 weeks postingestion.

  • Gastric outlet obstruction may develop 3-4 weeks after an acid exposure.

  • Though many button batteries may pass through the GI tract without causing damage, they can result in perforation at any time during their course through the gastrointestinal system, particularly if they are damaged.

  • Zinc chloride, mercuric chloride, and phenol can all cause significant systemic toxicity.

  • Cardiac arrest from sudden hypocalcemia may occur in patients who have ingested hydrogen fluoride–containing substances. Patients have been successfully resuscitated with aggressive use of intravenous calcium chloride.

  • Long-term risks include squamous cell carcinoma, which occurs in 1-4% of all significant exposures and may occur as late as 40 years after exposure.

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Prognosis

The prognosis is directly proportional to the degree of tissue damage, which is primarily a function of the duration of exposure and the physical properties of the agent involved. These include the pH, the volume, and concentration of the agent; its ability to penetrate tissues; and its titratable reserve. The titratable reserve is a term that reflects the amount tissue required to neutralize a given amount of agent.

Some agents have the ability to cause systemic toxicity that affects the prognosis in addition to their caustic properties. These include the following:

  • Phenol
  • Zinc chloride
  • Mercuric chloride
  • Hydrogen fluoride
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Patient Education

See the list below:

  • Caustic agents should be stored in their original child-resistant containers. Many accidental childhood ingestions occur as a result of caustic substances being placed in easily accessed containers, such as milk cartons or soda bottles.

  • The reduced concentration of household products compared with their industrial strength counterparts has also been helpful in mitigating the severity of childhood exposures to agents such as household cleaners.

  • For patient education information, see the First Aid and Injuries Center, as well as Battery Ingestion.

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