Medication Summary
Supportive care, rather than specific antidotes, is the mainstay of management following caustic ingestions. Medications useful for this purpose include antibiotics, proton pump inhibitors, and analgesics. A systematic review and meta-analysis by Katibe et al concluded that the available evidence does not support the use of corticosteroids for the prevention of esophageal strictures following caustic ingestion, but noted that the overall quality of the evidence is limited. [24]
A significant exception to this would be the aggressive administration of intravenous calcium for dysrhythmias precipitated by hypocalcemia from hydrogen fluoride ingestion. Such therapy is best performed with the guidance of the toxicologist at the local poison center.
Antibiotic, Cephalosporin (Third Generation)
Class Summary
These agents should be administered if evidence of perforation exists. A third-generation cephalosporin or ampicillin/sulbactam may be considered.
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Bactericidal activity results from inhibiting cell wall synthesis by binding to one or more penicillin-binding proteins. Exerts antimicrobial effect by interfering with synthesis of peptidoglycan, a major structural component of bacterial cell wall. Bacteria eventually lyse due to the ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.
Highly stable in presence of beta-lactamases, both penicillinase and cephalosporinase, of gram-negative and gram-positive bacteria. Approximately 33-67% of dose excreted unchanged in urine, and remainder secreted in bile and ultimately in feces as microbiologically inactive compounds. Reversibly binds to human plasma proteins, and binding has been reported to decrease from 95% bound at plasma concentrations < 25 mcg/mL to 85% bound at 300 mcg/mL.
Antibiotic, Penicillin and Beta-lactamase Inhibitor
Class Summary
These agents should be administered if evidence of perforation exists. A third-generation cephalosporin or ampicillin/sulbactam may be considered.
Ampicillin and sulbactam (Unasyn)
Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally.
Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.
Proton Pump Inhibitor
Class Summary
Proton pump inhibitors reduce exposure of injured esophagus to gastric acid, which may result in decreased stricture formation.
Pantoprazole (Protonix)
Indicated for short-term treatment of GERD associated with erosive esophagitis. Also effective in treating gastric ulcers, including those caused by Helicobacter pylori.
Analgesic, Narcotic
Class Summary
Narcotic analgesics should be used to reduce the pain associated with these ingestions.
Morphine
DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect obtained.
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Caustic ingestions. Endoscopic view of the esophagus in a patient who ingested hydrochloric acid (Lime-a-way). Note the extensive thrombosis of the esophageal submucosal vessels giving the appearance similar to chicken wire. Courtesy of Ferdinando L Mirarchi, DO, Fred P Harchelroad, Jr, MD, Sangeeta Gulati, MD, and George J Brodmerkel, Jr, MD.
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Caustic ingestions. Endoscopic view of the esophagus in a patient who ingested hydrochloric acid (Lime-a-way). Note the appearance of the thrombosed esophageal submucosal vessels giving the appearance of chicken wire. Courtesy of Ferdinando L Mirarchi, DO, Fred P Harchelroad, Jr, MD, Sangeeta Gulati, MD, and George J Brodmerkel, Jr, MD.
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Caustic ingestions. Endoscopic view of the esophagus in a patient who ingested hydrochloric acid (Lime-a-way). Note the extensive burn and thrombosis of the submucosal esophageal vessels, which gives the appearance of chicken wire. Courtesy of Ferdinando L Mirarchi, DO, Fred P Harchelroad, Jr, MD, Sangeeta Gulati, MD, and George J Brodmerkel, Jr, MD.
Tables
| Grade | Findings | Complication risk |
|---|---|---|
| 0 | None | None |
| 1 | Swelling and redness of mucosa | Low risk for development of outlet obstruction of strictures |
| 2A | Superficial ulcers, bleeding, friability | Low risk for development of outlet obstruction of strictures |
| 2B | Deep ulcers, bleeding, friability | High risk for strictures, low risk for perforation |
| 3A | Focal necrosis | High risk for strictures, moderate risk for perforation |
| 3B | Extensive necrosis | High risk for strictures and perforation, moderate risk for fatality |
| 4 | Perforation | High risk of fatality |
