Caustic ingestion

Last updated
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 onsetImmediate
PreventionSafe storage of caustic substances [3]
TreatmentSurgery, medications, observation [1]

Caustic ingestion occurs when someone accidentally or deliberately ingests a caustic or corrosive substance. Depending on the nature of the substance, the duration of exposure and other factors it can lead to varying degrees of damage to the oral mucosa, the esophagus, and the lining of the stomach. [4]

Contents

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, strictures of the oesophagus may form, which may require therapeutic dilatation and insertion of a stent. [4]

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, dyspnea, dysphonia/aphonia, irritation of the eyes and skin. [1] [2] Perforation of the esophagus can lead to mediastinitis or perforation of the stomach or bowel can lead to peritonitis [1] Swelling of the airway or laryngospasm can occur leading to compromised breathing. Injuries affecting the respiratory system include aspiration pneumonia and laryngeal sores. [3] Signs of respiratory compromise include stridor and a change in a person's voice.

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

Acids with a pH of less than 2 or alkalis with a pH above 12 are capable of causing the most extensive injuries in ingestions. [1] Alkalis damage tissue by saponifying fats, leading to liquefaction necrosis which allows the alkalis to reach deeper tissues. Acids denature proteins via coagulation necrosis, this type of necrosis is thought to prevent the acid from reaching deeper tissues. [1] [2] Clinically, the pH, concentration, volume of ingested substance in addition to the duration of time in contact with tissue as well as percentage of body surface area involved determine the severity of the injury. [1]

Diagnosis

Classification

The severity of injuries to the mucosa of the gastrointestinal tract is commonly rated using the Zargar criteria. [5]

CategoryFindings
0Normal examination
1Mucosal edema and erythema
2aSuperficial ulcerations or erosions, friability, blister formation, exudates, hemorrhages
2bDeep ulcerations (either discrete or circumferential) as well as the findings described in 2a
3aMultiple small, scattered areas of necrosis
3bExtensive 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. [1] Due to the greater amount of material usually ingested; injuries are often more severe in the intentional ingestions of adolescents and adults as compared to those of children. [1] Commonly ingested substances include ammonium hydroxide (found in general cleaner and grease remover), sodium hydroxide or potassium hydroxide (found in drain opener or oven cleaner), sodium hypochlorite (bleach), oxalic acid (metal polish) and hydrochloric acid (toilet bowl cleaner). [1] Storage of caustic substances in water or drink containers is a risk factor for accidental ingestion of these materials, particularly in children. [2] Boys of preschool age are at the greatest risk of accidental caustic ingestion. [3]

Prevention

Preventative measures have been recommended that are intended to decrease the risk of accidental ingestion of caustic substances including: [3]

Related Research Articles

<span class="mw-page-title-main">Gastroenterology</span> Branch of medicine focused on the digestive system and its disorders

Gastroenterology is the branch of medicine focused on the digestive system and its disorders. The digestive system consists of the gastrointestinal tract, sometimes referred to as the GI tract, which includes the esophagus, stomach, small intestine and large intestine as well as the accessory organs of digestion which include the pancreas, gallbladder, and liver.

<span class="mw-page-title-main">Esophagus</span> Vertebrate organ through which food passes to the stomach

The esophagus or oesophagus, colloquially known also as the food pipe, food tube, or gullet, is an organ in vertebrates through which food passes, aided by peristaltic contractions, from the pharynx to the stomach. The esophagus is a fibromuscular tube, about 25 cm (10 in) long in adults, that travels behind the trachea and heart, passes through the diaphragm, and empties into the uppermost region of the stomach. During swallowing, the epiglottis tilts backwards to prevent food from going down the larynx and lungs. The word oesophagus is from Ancient Greek οἰσοφάγος (oisophágos), from οἴσω (oísō), future form of φέρω + ἔφαγον.

<span class="mw-page-title-main">Esophagitis</span> Inflammation of the esophagus

Esophagitis, also spelled oesophagitis, is a disease characterized by inflammation of the esophagus. The esophagus is a tube composed of a mucosal lining, and longitudinal and circular smooth muscle fibers. It connects the pharynx to the stomach; swallowed food and liquids normally pass through it.

<span class="mw-page-title-main">Upper gastrointestinal series</span> Radiographs used to examine abnormalities of the digestive system excluding the colon

An upper gastrointestinal series, also called a barium swallow, barium study, or barium meal, is a series of radiographs used to examine the gastrointestinal tract for abnormalities. A contrast medium, usually a radiocontrast agent such as barium sulfate mixed with water, is ingested or instilled into the gastrointestinal tract, and X-rays are used to create radiographs of the regions of interest. The barium enhances the visibility of the relevant parts of the gastrointestinal tract by coating the inside wall of the tract and appearing white on the film. This in combination with other plain radiographs allows for the imaging of parts of the upper gastrointestinal tract such as the pharynx, larynx, esophagus, stomach, and small intestine such that the inside wall lining, size, shape, contour, and patency are visible to the examiner. With fluoroscopy, it is also possible to visualize the functional movement of examined organs such as swallowing, peristalsis, or sphincter closure. Depending on the organs to be examined, barium radiographs can be classified into "barium swallow", "barium meal", "barium follow-through", and "enteroclysis". To further enhance the quality of images, air or gas is sometimes introduced into the gastrointestinal tract in addition to barium, and this procedure is called double-contrast imaging. In this case the gas is referred to as the negative contrast medium. Traditionally the images produced with barium contrast are made with plain-film radiography, but computed tomography is also used in combination with barium contrast, in which case the procedure is called "CT enterography".

<span class="mw-page-title-main">Esophagogastroduodenoscopy</span> Diagnostic endoscopic procedure

Esophagogastroduodenoscopy (EGD) or oesophagogastroduodenoscopy (OGD), also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered a minimally invasive procedure since it does not require an incision into one of the major body cavities and does not require any significant recovery after the procedure. However, a sore throat is common.

<span class="mw-page-title-main">Endoscopic retrograde cholangiopancreatography</span> Use of endoscopy and fluoroscopy to treat and diagnose digestive issues

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. It is primarily performed by highly skilled and specialty trained gastroenterologists. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject a contrast medium into the ducts in the biliary tree and pancreas so they can be seen on radiographs.

<span class="mw-page-title-main">Gastrointestinal perforation</span> Hole in the wall of the gastrointestinal tract

Gastrointestinal perforation, also known as gastrointestinal rupture, is a hole in the wall of the gastrointestinal tract. The gastrointestinal tract is composed of hollow digestive organs leading from the mouth to the anus. Symptoms of gastrointestinal perforation commonly include severe abdominal pain, nausea, and vomiting. Complications include a painful inflammation of the inner lining of the abdominal wall and sepsis.

<span class="mw-page-title-main">Esophageal rupture</span> Tearing of the wall of the esophagus

Esophageal rupture is a rupture of the esophageal wall. Iatrogenic causes account for approximately 56% of esophageal perforations, usually due to medical instrumentation such as an endoscopy or paraesophageal surgery. The 10% of esophageal perforations caused specifically by vomiting are termed Boerhaave syndrome.

<span class="mw-page-title-main">Eosinophilic esophagitis</span> Allergic inflammatory condition of the esophagus

Eosinophilic esophagitis (EoE) is an allergic inflammatory condition of the esophagus that involves eosinophils, a type of white blood cell. In healthy individuals, the esophagus is typically devoid of eosinophils. In EoE, eosinophils migrate to the esophagus in large numbers. When a trigger food is eaten, the eosinophils contribute to tissue damage and inflammation. Symptoms include swallowing difficulty, food impaction, vomiting, and heartburn.

<span class="mw-page-title-main">Ischemic colitis</span> Inflammation of the large intestine due to insufficient blood supply

Ischemic colitis is a medical condition in which inflammation and injury of the large intestine result from inadequate blood supply (ischemia). Although uncommon in the general population, ischemic colitis occurs with greater frequency in the elderly, and is the most common form of bowel ischemia. Causes of the reduced blood flow can include changes in the systemic circulation or local factors such as constriction of blood vessels or a blood clot. In most cases, no specific cause can be identified.

Esophageal dysphagia is a form of dysphagia where the underlying cause arises from the body of the esophagus, lower esophageal sphincter, or cardia of the stomach, usually due to mechanical causes or motility problems.

<span class="mw-page-title-main">Endoscopic foreign body retrieval</span>

Endoscopic foreign body retrieval refers to the removal of ingested objects from the esophagus, stomach and duodenum by endoscopic techniques. It does not involve surgery, but rather encompasses a variety of techniques employed through the gastroscope for grasping foreign bodies, manipulating them, and removing them while protecting the esophagus and trachea. It is of particular importance with children, people with mental illness, and prison inmates as these groups have a high rate of foreign body ingestion.

<span class="mw-page-title-main">Self-expandable metallic stent</span>

A self-expandable metallic stent is a metallic tube, or stent that holds open a structure in the gastrointestinal tract to allow the passage of food, chyme, stool, or other secretions related to digestion. Surgeons insert SEMS by endoscopy, inserting a fibre optic camera—either through the mouth or colon—to reach an area of narrowing. As such, it is termed an endoprosthesis. SEMS can also be inserted using fluoroscopy where the surgeon uses an X-ray image to guide insertion, or as an adjunct to endoscopy.

<span class="mw-page-title-main">Esophageal food bolus obstruction</span> Blockage of the esophagus by an ingested foreign body

An esophageal food bolus obstruction is a medical emergency caused by the obstruction of the esophagus by an ingested foreign body.

<span class="mw-page-title-main">Esophageal stent</span>

An esophageal stent is a stent (tube) placed in the esophagus to keep a blocked area open so the patient can swallow soft food and liquids. They are effective in the treatment of conditions causing intrinsic esophageal obstruction or external esophageal compression. For the palliative treatment of esophageal cancer most esophageal stents are self-expandable metallic stents. For benign esophageal disease such as refractory esophageal strictures, plastic stents are available. Common complications include chest pain, overgrowth of tissue around the stent and stent migration. Esophageal stents may also be used to staunch the bleeding of esophageal varices.

Therapeutic endoscopy is the medical term for an endoscopic procedure during which treatment is carried out via the endoscope. This contrasts with diagnostic endoscopy, where the aim of the procedure is purely to visualize a part of the gastrointestinal, respiratory or urinary tract in order to aid diagnosis. In practice, a procedure which starts as a diagnostic endoscopy may become a therapeutic endoscopy depending on the findings, such as in cases of upper gastrointestinal bleeding, or the finding of polyps during colonoscopy.

Endoscopic mucosal resection is a technique used to remove cancerous or other abnormal lesions found in the digestive tract. It is one method of performing a mucosectomy.

Sulfuric acid poisoning refers to ingestion of sulfuric acid, found in lead-acid batteries and some metal cleaners, pool cleaners, drain cleaners and anti-rust products.

<span class="mw-page-title-main">Lymphocytic esophagitis</span> Medical condition

Lymphocytic esophagitis is a rare and poorly understood medical disorder involving inflammation in the esophagus. The disease is named from the primary inflammatory process, wherein lymphocytes are seen within the esophageal mucosa. Symptoms of the condition include difficulty swallowing, heartburn and food bolus obstruction. The condition was first described in 2006 by Rubio and colleagues. Initial reports questioned whether this was a true medical disorder, or whether the inflammation was secondary to another condition, such as gastroesophageal reflux disease.

Chemical drain cleaners or openers are pure or mixtures of chemicals used to unclog drains that are blocked by hair, food, or other organic materials. They are often accompanied by other mechanical drain cleaners for the optimal effect. Chemical drain cleaners are available through hardware stores, although some may be intended for use by licensed plumbers. They may contain either strong acids or strong alkalis. These cleaners contain chemicals that dissolve at least some of the material causing the clog.

References

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  2. 1 2 3 4 5 6 Hall, Alan H.; Jacquemin, Denise; Henny, Danièlle; Mathieu, Laurence; Josset, Patrice; Meyer, Bernard (3 February 2020). "Corrosive substances ingestion: a review". Critical Reviews in Toxicology. 49 (8): 637–669. doi: 10.1080/10408444.2019.1707773 . PMID   32009535.
  3. 1 2 3 4 5 Rafeey, Mandana; Ghojazadeh, Morteza; Sheikhi, Saeede; Vahedi, Leila (1 September 2016). "Caustic Ingestion in Children: a Systematic Review and Meta-Analysis". Journal of Caring Sciences. 5 (3): 251–265. doi:10.15171/jcs.2016.027. PMC   5045959 . PMID   27757390.
  4. 1 2 3 Chirica, Mircea; Bonavina, Luigi; Kelly, Michael D; Sarfati, Emile; Cattan, Pierre (2017). "Caustic ingestion". The Lancet. 389 (10083): 2041–2052. doi:10.1016/S0140-6736(16)30313-0. PMID   28045663. S2CID   3070364.
  5. Ali Zargar, Showkat; Kochhar, Rakesh; Mehta, Saroj; Kumar Mehta, Satish (March 1991). "The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns". Gastrointestinal Endoscopy. 37 (2): 165–169. doi:10.1016/S0016-5107(91)70678-0. PMID   2032601.