J Clin Gastroenterol 2003;37(2):119–124.

© 2003 Lippincott Williams & Wilkins, Inc.

Clinical Reviews Therapeutic Recommendations

Corrosive Ingestion in Adults
Kovil Ramasamy, MD, and Vivek V. Gumaste, MD, MRCP(I), FACG
Abstract
Ingestion of a corrosive substance can produce severe injury to the gastrointestinal tract and can even result in death. The degree and extent of damage depends on several factors like the type of substance, the morphologic form of the agent, the quantity, and the intent. In the acute stage, perforation and necrosis may occur. Long-term complications include stricture formation in the esophagus, antral stenosis and the development of esophageal carcinoma. Endoscopy should be attempted and can be safely performed in most cases to assess the extent of damage. Procedurerelated perforation is rare. Stricture formation is more common in patients with second and third degree burns. Corticosteroids may help prevent stricture formation. Esophageal carcinoma may develop beginning 30 to 40 years after the time of injury. Key Words: lye ingestion, corrosives, sodium hydroxide

ccording to the annual report of the American Association of Poison Control, there were 206,636 cases of human exposure to cleaning substances (which include acids and alkalis) in 2000. Twenty-seven of these cases (the majority being instances of ingestion) resulted in death.1 Although children account for 80% of accidental ingestion,2 ingestion in adults is more often suicidal in intent and therefore tends to be more serious. Corrosive agents produce extensive damage to the gastrointestinal tract, which may result in perforation and death in the acute phase. Long term complications include stricture formation and the development of esophageal carcinoma.

A

Most commonly used household bleaches contain hydrogen peroxide (3%), sodium hypochlorite or low concentrations of sodium hydroxide (1%), and are mild to moderate irritants with a pH ranging from 10.8 to 11.4.3 Accidental ingestion produces minimal injury to the gastrointestinal tract; long-term damage including stricture formation is rare. However, the ingestion of large quantities of bleach may be associated with serious damage. Unlike bleaches, drain cleaners are more dangerous. Drain cleaners contain sodium hydroxide in concentrations ranging from 4% to 54% and the crystalline variety tends to contain a higher concentration of sodium hydroxide than the liquid form. These agents can produce severe harm to the gastrointestinal tract including perforation. Stricture formation is consistently seen with ingestion of drain cleaners. Automatic dishwasher detergents contain sodium phosphate or tripolyphosphate that are also powerful corrosive agents.1 Clinitest and denture cleaning tablets contain sodium hydroxide and these can cause major esophageal injuries because their solid form prolongs the duration of contact with the mucosa.4 Hair relaxer, a commercially available alkaline product, is another agent implicated in caustic ingestion. Although these products produce extensive facial injury and oral burns, significant esophageal damage has not been reported.5 Acids Acid ingestion tends to occur less frequently in the United States (<5%) but appears to be more common in countries like India where hydrochloric acid and sulfuric acid are easily accessible.6 In the United States, acids are generally available as toilet bowel cleaners (sulfuric, hydrochloric), anti rust compounds (hydrochloric, oxalic, hydrofluoric), battery fluids (sulfuric), and swimming pool cleaners (hydrochloric). PATHOPHYSIOLOGY Solutions with a pH of less than 2 or greater then 12 are highly corrosive. Alkali produces liquefaction necrosis.2 A 22.5% solution of NaOH in contact with the esophagus for 10 seconds and 30% NaOH for 1 second can produce a full thickness injury.2 Thrombosis of small vessels and production of heat exacerbate the initial corrosive injury. Tissue 119

SUBSTANCES Corrosives can be alkaline in nature or acids. Lye is a general term used for alkali found in cleaning agents. Alkalis Alkaline material accounts for most cases of caustic ingestion in western countries.2 Alkalis can be found in a variety of cleaning agents, drain openers, bleaches, toilet bowl cleaners, and detergents (Table 1).

From The Department of Medicine, Mount Sinai Services, City Hospital Center at Elmhurst, New York and the Mount Sinai School of Medicine of the City University of New York, New York. Address correspondence and reprint requests to Dr. Vivek V. Gumaste, Division of Gastroenterology, Mount Sinai Services at Elmhurst, 79-01 Broadway, Elmhurst, New York, NY 11373, USA.

5%) Hydrochloric acid (8. On the other hand. Mucosal sloughing occurs 4 to 7 days after the initial injury. to some extent. 2003 TABLE 1.7 Scar retraction begins by the third week and may continue for several months. The degree of injury correlates directly with stricture formation and mortality. on the physical form of the alkali.9 The degree of injury produced depends.25%) Hydrogen Peroxide (3%) Sodium hypochlorite (5%). any change in the clinical condition of the patient such as worsening of abdominal pain or the appearance of chest pain should be promptly investigated by radiologic studies Studies have tried to ascertain whether the presenting signs and symptoms accurately predict esophageal injury.2 Perforation of the stomach or the esophagus can occur at any time during the first 2 weeks. No. and physical form of the substances. but this does not appear to be a major variable in determining the extent of injury. amount. However.2 Acid induces coagulation necrosis with eschar formation and this may limit tissue penetration.14 Ten to 30 percent of patients with esophageal burns have no oropharyngeal damage. Vol 37.15 Upto16 .120 J Clin Gastroenterol.7 Stricture formation is extremely rare in injuries of the first degree. The pathologic classification of caustic injury to the esophagus is similar to classification of burns to the skin and is elaborated in Table 2.5%) injury progresses rapidly in the first few minutes but can continue for several hours.2 One study reported esophageal injury in 37. Shortening of the esophagus alters the LES pressure leading to increased gastroesophageal reflux. the tensile strength of the healing tissue is low during the first 3 weeks.2 Hence. Sometimes massive hematemesis can occur as a result of an aortoenteric fistula. Asymptomatic children with unintentional caustic ingestion usually do not have significant lesions on endoscopy. In contrast the liquid form transits rapidly through the mouth and pharynx and produces its greatest caustic effect on the esophagus. Many people therefore advocate avoiding endoscopy between 5 to15 days after caustic ingestion. This results in stricture formation and shortening of the involved segment of the gastrointestinal tract. sodium hydroxide (1%) Sodium tripolyphosphates (20%–40%) Phosphates (25%–50%) Trisodium phosphate (14.11 indicated that acid preferentially damages the stomach. being tasteless and odorless. 2. inflammatory response. Because collagen deposition may not begin until the second week. and bacterial invasion. Common household corrosives Product Chlorox Peroxide Tilex mildew remover Electrasol dishwasher detergent Cascade dishwater detergent Comet cleanser Polident powder Drano (liquid) Drano Professional (liquid) Crystal Drano (granular) Liquid Plummer Dow oven cleaner Mister Plumber Lysol toilet cleaner Contents Sodium hypochlorite (5. Solid alkali adheres to the mouth and pharynx producing maximum damage to these areas while relatively sparing the esophagus. and development of granulation tissue ensue.7 CLINICAL PRESENTATION The clinical presentation depends upon the type of the substance.5% of patients without oral damage and twentytwo percent of these were grade 2 or 3 lesions. the absence of pain does not preclude significant gastrointestinal damage. Crystals or solid particles adhere to the mucous membrane making it difficult to swallow and thereby diminishing the injury produced to the esophagus.8 Esophageal injury due to caustic ingestion also produces changes in esophageal motility resulting in low amplitude and nonperistaltic contractions. and is most likely to damage the esophagus and stomach. liquid alkali is easily swallowed. While one study12 claimed that stridor was 100% specific for significant esophageal injury another study13 indicated that no single symptom or group of symptoms could accurately predict esophageal injury. Over 80% of patients with grade 3 burns go on to stricture formation while one-third of those with grade 2 burns may stenose. whereas epigastric pain and hematemesis may be manifestations of stomach involvement. which in turn accelerates stricture formation. Mortality is also more common in grade 3 injury. Symptoms of esophageal involvement include dysphagia and odynophagia.5%–2%) Sodium hypochlorite (5%–10%) Sodium hydroxide (4%) Sulfuric acid (99.5%) Sodium hydroxide (32%) Sodium hydroxide (54%) Sodium hydroxide (0. recent studies6 have reported extensive damage to the esophagus as well.5%) Sodium tripolyphosphate (<15%) Sodium hydroxide (9.2 Hoarseness and stridor may be seen suggesting laryngeal or epiglottic involvement. Although some earlier studies10.

Ramasamy and Gumaste Corrosive Ingestion in Adults 121 TABLE 2. erosions. Milk and water have been used as antidotes but their effectiveness has not been proven. and up to 3% of patients with carcinoma of the esophagus may have history of caustic ingestion.17 This complication may be seen within 5 or 6 weeks or may present for the first time after several years. Gastric outlet obstruction: Symptoms of early satiety and weight loss may suggest gastric outlet obstruction. blisters. There is a 1000. Endoscopic grading of corrosive esophageal injury Grade 0 Grade 1 Grade 2a Grade 2b Grade 3a Grade 3b Normal findings on endoscopy Edema. 1).18 3. Activated charcoal is also contraindicated for the same reason. This tends to occur less frequently than stricture formation. Likewise free air under the diaphragm may indicate gastric perforation. the classic teaching is that a water-soluble agent like hypaque or gastrograffin should be used as they are less of an irritant to the mediastinum and peritoneal cavity compared with barium sulfate. it can also occur with lye injury to the stomach. UGI series showing a long esophageal stricture in a patient with history of lye ingestion. Radiologic Studies In the acute phase.2 Indwelling nasogastric tube may also contribute to the increased formation of long strictures. hyperemia of mucosa Friability. Injuries of the oropharynx are therefore not a reliable index of damage to esophagus.2 4. Most lesions occur at the level of the carina. a plain chest radiograph may reveal air in the mediastinum suggesting esophageal perforation. Late Sequelae 1. 2. hemorrhages.2 MANAGEMENT Pre Hospital Measures Gastric lavage and induced emesis are contraindicated because re-exposure of the esophagus to the corrosive agent tends to produce additional injury. If it is necessary to confirm perforation. Gastric carcinoma is a rare occurrence in patients with a history of caustic injury.2 Although initially thought to be a specific complication of acid ingestion.2 Ingestion of liquid lye is most likely to induce stricture formation than solid crystals. However. Stricture formation may become symptomatic within 3 months or may even manifest a year later. as they tend to be younger and tend to have earlier symptoms. whitish membranes. Patients with carcinoma of the esophagus due to lye ingestion may have a better prognosis than other patients. No one sign or group of signs was 100% accurate in predicting positive or negative endoscopies. Lye induced strictures tend to be long (Fig. Milk may also obscure subsequent endoscopy.2 The latent period between the time of ingestion and the development of carcinoma may be as long as 58 years. Esophageal carcinoma is a well-known sequel of lye ingestion. . being noted in only 4 of 214 patients in 1 study. Furthermore heat generated by the chemical reaction may increase the damage.to 3000-fold increase in the incidence of esophageal carcinoma after lye ingestion. some investigators feel that both FIGURE 1. exudates and superficial ulceration’s Grade 2a plus deep discrete or circumferential ulcerations Small scattered areas of multiple ulcerations and areas of necrosis (brown-black or grayish discoloration) Extensive necrosis 70% of patients with oropharyngeal burns do not have significant damage to the esophagus.

7 Endoscopy should be performed as soon as possible because it serves a dual purpose. A third degree burn of the hypopharynx is a contraindication for endoscopy.2 Secondly. in every patient. stomach. 3.23 Oral Intake Patient whose injuries are graded 1 and 2a are permitted oral intake and discharged within days with antacid therapy. Presence or absence of burns in the esophagus does not always imply extension of the same degree of injury to stomach. 2003 are equally irritants. provides greater radiographic details than water-soluble contrast agents. However it was discovered that perforations were more likely to occur when rigid instruments were used and in children or uncooperative patients. a cupful may be associated with significant injury while a teaspoonful may not. (a) Substance.22 However the need for adequate sedation is emphasized. Persistent symptoms also warrant endoscopic examination. Barium studies may be helpful as a follow-up measure and for the evaluation of complications. (c) Intention. Indications There are no strict guidelines as to who needs endoscopy and who does not. Although it is difficult to exactly quantify the amount. In cases where endoscopy is terminated at the point of esophageal or gastric injury. A complete but careful examination of the esophagus and stomach must be attempted. Extent Every attempt must be made to assess the esophagus. Generally accepted recommendations are that the endoscope should be advanced until a circumferential seconddegree burn or third degree burn is seen. Initial endoscopy should be performed as soon as possible as long as the patient is stable and there is no evidence of perforation.4 Attempts to continue past this point may increase the risk of mechanical perforation. First. and duodenum provided it can be done safely. Endoscopic management 1. provided there are no other complications. 2. . It is radio opaque. Endoscopy can be performed preferably within 12 hours and generally not later than 24 hours alTABLE 3. 6.19 Endoscopy is the diagnostic procedure of choice in the absence of perforation. Therefore it is important to examine the stomach and the first part of duodenum.20 Similarly endoscopy may not be necessary in asymptomatic children who have ingested hair relaxer. Ingestion of larger quantities of corrosives is usually associated with greater damage. safer. Household bleach ingestion in asymptomatic children does not warrant endoscopy.7 Wound softening begins after 2 to 3 days and lasts up to 2 weeks making endoscopy risky during this period. Third degree burns of the hypopharnyx is a contraindication to endoscopy. Prudent to avoid endoscopy between days 5–15 as tissue softening increases the danger of perforation. Endotracheal intubation is required only for patients in respiratory distress. as well. Serious damage is noted when the intent is suicidal and endoscopy is usually indicated in such circumstances. In fact. The use of flexible endoscopy has made this procedure. and small bowel that are not routinely evaluated after caustic ingestion. In more severe cases of damage (grades 2 or 3). in this situation. double contrast CT scan should be performed in stable patients with endoscopic or radiologic evidence of significant duodenal abnormality to inspect those areas of gastrointestinal tract such as the colon. barium sulfate is the preferred contrast agent for an anatomically intact but scarred gastrointestinal tract.21 (b) Quantity. with history of caustic ingestion. patients with no evidence of gastrointestinal injury can be discharged.122 J Clin Gastroenterol. No. Timing Some previous studies have tried to stipulate the timing of endoscopy indicating when it should be done and when it should not be done. more than 50% of patients.7 Other authorities also concur with this finding. (d) Symptoms. the duodenum must then be evaluated by barium studies. and is relatively nonirritant to the pulmonary tissues in case it is aspirated into the lungs. In fact. 2. 4. Risk of procedure related perforation is low. However the following factors may be taken into account when making the decision. though some authors state that endoscopy can be safely performed up to 96 hours post-ingestion. Endoscope can be safely advanced until a circumferential burn is seen. Endoscopy (Table 3) The oropharynx needs to be first examined by laryngoscopy. pancreas. Vol 37. 5. patients with evidence of severe injury can be managed appropriately. No procedure related perforation occurred in series of 381 examinations reported in one study. have no evidence of injury to the gastrointestinal tract. A supraglottic or epiglottic burn with erythema and edema formation may be a harbinger of airway obstruction and should be seen as an indication for early endotracheal intubation or tracheostomy. Since severe duodenal injuries can involve the neighboring structures. Risk of Perforation Early reports advocated general anesthesia and endotracheal intubation prior to upper endoscopy because of the risk of perforation . Endoscopy is usually avoided from 5 to 15 days after corrosive intake. Endoscopic findings may be graded as shown in Table 2. observation in an intensive care unit and nutritional support is required.

Miscellaneous Agents Diverse agents such as heparin.8 In fact it may not be a bad idea to maintain good acid control in all patients with caustic ingestion. Antibiotics With regard to the use of antibiotics. and early dilatation. but the available data is not very convincing. Although in animals.31 Treatment of Strictures Short strictures can be easily treated with endoscopic dilatation. studies in humans have been inconclusive so far. et al. The usual recommended dose of steroids is methyl prednisolone 40 to 60 mg/ day intravenously. However. and coagulation disorders and those who have ingested large amounts of corrosives. necrosis.2 Sucralfate Anecdotal reports suggest that the use of sucralfate may decrease stricture formation. some patients who do not have peritoneal signs on admission go on to develop perforation. and massive bleeding later on with disastrous results. Patients with 3a lesions may not require emergency surgery. REFERENCES 1. White S. in the absence of steroid therapy. 2000 Annual report of the American Association of Poison Control Centers.2 Intraluminal Stent The insertion of specially designed silicone rubber stents may be helpful in preventing stricture formation after caustic ingestion according to some studies. Steroids are usually given for at least 3 weeks.32 In the past.28 Early Dilatation Early dilatation starting after injury results in a high incidence of perforation. Long strictures that are not amenable to endoscopic dilatation may require surgery. surgery may be required to reconstruct the pharynx and esophagus and to treat any gastric outlet obstruction. no controlled trials in humans are available.29 Gastroesophageal Reflux Gastroesophageal reflux has a tendency to worsen the caustic insult to the esophagus probably accelerating stricture formation. Intralesional injection of steroids may decrease the frequency of dilation in these patients. acidosis. epidermal growth factor (EGF). patients with antral stenosis have required surgery. However the use of corticosteroids continues to be a debatable issue. use of indwelling nasogastric tube. Attempts to prevent stricture formation include steroid use. is not advocated.34 Zargar et al7 have suggested that prompt surgical resection may improve the mortality and morbidity in patients with grade 3b injuries. antibiotics have shown to decrease infection in steroid treated esophageal burns. the data is not very clear.27. It may be indicated in patients with third degree burns. SURGERY Surgery has a role to play as an emergency measure and also later in delayed reconstruction. Therefore patients with caustic ingestion should be screened periodically for GERD and treated aggressively. The difference was statistically significant. stenting. . Swartz WK. However. and caffeic acid phenethyl ester (CAPE) have been shown in animal studies to decrease the incidence of stricture formation but studies in humans are awaited. 2001.2 Most investigators would agree that since first degree burns of the esophagus rarely if ever cause strictures. A prophylactic antibiotic. Steroids Although animal studies had shown that the use of steroids after alkali injury decreases the incidence of stricture formation. Am J Emerg Med. Total Parenteral Nutrition Some investigators are of the opinion that total parental nutrition may prevent stricture formation. Early surgical intervention may improve the outcome in this group of patients and certain clinical as well as endoscopic criteria may help in identifying this subset. Retrograde dilation with Tuckers dilators may be attempted in severe strictures.33 The finding of third degree burns on endoscopy also merits surgical exploration according to some surgeons.Ramasamy and Gumaste Corrosive Ingestion in Adults 123 Prevention of Strictures Stricture formation is the most important complication of corrosive damage to the esophagus. The results of a meta analysis25 in 361 subjects from a total of 13 studies produced more encouraging results. corticosteroids are not necessary.19:337–395. Strictures occurred in 40% of patients not receiving corticosteroids and antibiotics compared with 19% in the treated group. usually tend to have severe injury on laparotomy and early surgical intervention may prove beneficial to these patients. Litovitz TL. After recovery. In the acute phase. which invariably cause strictures.26 Nasogastric Tube The insertion of nasogastric tube early in the course of the treatment has been suggested to ensure patency of the esophageal lumen2 but one needs to be cautious because a nasogastric tube itself can contribute to the development of long strictures and routine use is not warranted. it is clear that patients with evidence of perforation require immediate surgery. Patients with shock. either pyloroplasty or gastroenterostomy. This study was severely limited by its small numbers. some cases may be successfully managed with endoscopic dilatation and this may be attempted prior to surgery.30. and is not currently recommended.2 The consensus however appears to be that patients treated with steroids should be treated with antibiotics as well.2 A prospective study24 conducted in 60 children over an 18 year period concluded that there was no benefit from the use of corticosteroids.

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