Evaluation of a patient with suspected ingestion of caustic substances

UGI: upper gastrointestinal; NG: nasogastric; PPI: proton pump inhibitor.
* A substance is caustic if it is capable of burning or corroding organic tissue by chemical action, typically due to strong acid or alkaline properties. Common caustic ingestions are of household cleaning products, including laundry or dishwasher detergents, household bleach, drain cleaners, toilet bowl or oven cleaners, hair relaxer, and swimming pool products.
¶ Substances with low risk for caustic injury include standard liquid household detergents, phosphates, and bleaches. High-risk substances include concentrated forms of laundry or dishwasher detergent, especially single-use packets ("capsules," "gel packs," or "pods"), powdered or granular detergents, and any strong alkali (pH >11.5) or acid (pH <2).
Δ For patients with alkali ingestion, no oral burns, and minimal symptoms (eg, vomiting or drooling alone), it is reasonable to observe overnight and proceed to endoscopy only if symptoms persist.
◊ If significant respiratory symptoms are present, we suggest consultation with a specialist (eg, ear-nose-throat [ENT]) to evaluate the airway.
§ For patients with severe symptoms, it is important to perform endoscopy under general anesthesia. For a description of grading, refer to text of UpToDate topic on caustic esophageal injury in children.
¥ For patients with 2B lesions without signs of esophageal perforation, we suggest a brief course of high-dose corticosteroids. We avoid corticosteroids in patients with grade 3 lesions because they may soften the wound and increase the risk and/or mask symptoms of perforation.
‡ UGI series is optional for grade 2A lesions.
† Antibiotics are given prophylactically to selected patients with severe caustic esophageal injury, but there are no standards to guide patient selection. In our practice, we administer antibiotics to patients with grade 2B or 3 burns (endoscopic evidence of necrosis) and to those with suspicion of perforation on chest radiograph or endoscopy.