Toxicology Case Files from the Utah Poison Control Center
Teaching Points
- Ingestion of caustic acid/alkali substances can lead to severe acute esophageal injury as well as long-term complications such as strictures
- All patients with intentional ingestion of caustics require endoscopy
- Unintentional exposures in completely asymptomatic, young children do not require endoscopy
Case
A 2-year-old female was brought to the emergency department a few hours after her mother found her playing with a bottle of toilet bowl cleaner. Mom thought she had a slight cough but had been feeding normally.
In the ED, she was acting normally, had no evidence of oral burns, and continued to feed without issue. There was no stridor or respiratory difficulties.
The product was identified as containing 5-10% hydrochloric acid with a pH < 1.
Though the patient remained asymptomatic, endoscopy was performed given the exposure to a strongly acidic substance.
Fortunately, the endoscopy did not reveal any esophageal injury, and the patient was discharged home.
Diagnostic Evaluation After Caustic Ingestion
Ingestion of strong acid or alkaline substances (pH <3 or pH > 11) may cause immediate tissue damage to the oropharynx, esophagus, or stomach.
Dilution or decontamination is unlikely to be effective unless instituted immediately after exposure. Though the risk of exothermic reaction is likely low, neutralization should not be attempted. Activated charcoal is contraindicated as caustics do not adsorb to charcoal, and the material will obscure attempts at endoscopy or laryngoscopy.
Patients with large, intentional ingestion will be obviously symptomatic and in distress. Endoscopy is useful in these patients to assess degree of injury, facilitate passage of a nasogastric tube, and predict long-term risk of complications. In severe cases, a CT chest may be useful to identify perforation.
Asymptomatic or only mildly symptomatic patients pose a greater challenge. A patient may have minor irritation or burns on the tongue or lip but not have any distal injury as they never swallowed any of the caustic agent. Conversely, a patient who drinks a caustic intentionally may only have esophageal or gastric injury with no obvious oral injury.
Several studies have investigated the relationship between presenting signs and symptoms of caustic ingestion and the outcome of significant findings at endoscopy. Findings are summarized in the table below.
Study |
Notes |
Unintentional |
Intentional |
||
|---|---|---|---|---|---|
| Asymptomatic, +EGD | Symptomatic, +EGD | Asymptomatic, +EGD | Symptomatic, +EGD | ||
| Crain 1984 | Pediatric cases, all received EGD | 0/34, 0% | 7/34, 20.6% | 0/9, 0% | 0/2, 0% |
| Gorman 1992 | Prospective poison center study, all ages. Selective EGD. | 0, % not given |
10/48, 20.8%
|
0, % not given |
8/15, 53%
|
| Gaudreault 1983 | Pediatric, retrospective | 10/80, 12% | 55/298, 18% | - | - |
| Betalli 2008 | Pediatric prospective | 2/70, 2.9% | 17/92,18.5% | - | - |
| Lamireau 2001 | Pediatric prospective | 0/48, 0% | 22/37, 59.4% | - | - |
| Previtera 1990 | Pediatric prospective | 36/96, 37.5% | 30/60, 50% | - | - |
In the Gaudreault study, 12% of asymptomatic children had severe injury on EGD. However, this study was retrospective and relied on documented signs/symptoms at presentation.
In the Betalli study, 2 asymptomatic patients had severe injury on EGD. However, the authors note both of these cases were somewhat older children who intentionally drank the caustic out of a container believing it to be a beverage. Thus these were already higher risk exposures.
In the Previtera study, the 37.5% rate of severe injury was in patients with no visible oral or mucosal injury. The authors did not attempt to assess any symptoms in the patients.
Altogether, the three studies with patients with severe EGD findings had particular limitations that do not apply to a carefully evaluated asymptomatic pediatric patient. Two studies did not assess symptoms at all or only did so retrospectively. The Betalli study identifies the higher risk scenario of the “accidental-intentional” ingestion where a significant quantity was certainly consumed but not done so with self-harm intent.
Generally, patients with multiple signs/symptoms are more likely to have significant injury at endoscopy, but there is no completely sensitive or specific set of criteria that can be used.
In conclusion, an asymptomatic patient with no signs of caustic injury with an accidental, low-risk exposure does not require endoscopy. The high rate of injury in any intentional exposure or any symptomatic exposure mandates endoscopic evaluation. Consultation with a poison center, toxicologist, and/or gastroenterologist is recommended.
References
- Betalli P, Falchetti D, Giuliani S, Pane A, Dall'Oglio L, de'Angelis GL, Caldore M, Romano C, Gamba P, Baldo V, Caustic Ingestion Italian Study Group. Caustic ingestion in children: is endoscopy always indicated? The results of an Italian multicenter observational study. Gastrointestinal endoscopy. 2008 Sep 1;68(3):434-9.
- Crain EF, Gershel JC, Mezey AP. Caustic ingestions: symptoms as predictors of esophageal injury. American Journal of Diseases of Children. 1984 Sep 1;138(9):863-5.
- Gaudreault P, Parent M, McGuigan MA, Chicoine L, Lovejoy Jr FH. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics. 1983 May 1;71(5):767-70.
- Gorman RL, Khin-Maung-Gyi MT, Klein-Schwartz W, Oderda GM, Benson B, Litovitz T, McCormick M, McElwee N, Spiller H, Krenzelok E. Initial symptoms as predictors of esophageal injury in alkaline corrosive ingestions. The American journal of emergency medicine. 1992 May 1;10(3):189-94.
- Lamireau T, Rebouissoux L, Denis D, Lancelin F, Vergnes P, Fayon M. Accidental caustic ingestion in children: is endoscopy always mandatory? Journal of Pediatric Gastroenterology and Nutrition. 2001 Jul 1;33(1):81-4.
- PREVITERA C, GIUSTI F, GUGLIELMI M. Predictive value of visible lesions (cheeks, lips, oropharynx) in suspected caustic ingestion: may endoscopy reasonably be omitted in completely negative pediatric patients?. Pediatric emergency care. 1990 Sep 1;6(3):176-8.