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 oral mucosa is the mucous membrane lining the inside of the mouth. It comprises stratified squamous epithelium, termed "oral epithelium", and an underlying connective tissue termed '' lamina propria''. The oral cavity has sometimes been des ...
, the
esophagus
The esophagus (American English), oesophagus (British English), or œsophagus (Œ, archaic spelling) (American and British English spelling differences#ae and oe, see spelling difference) all ; : ((o)e)(œ)sophagi or ((o)e)(œ)sophaguses), c ...
, and the
lining of the stomach.
The severity of the injury can be determined by
endoscopy
An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...
of the upper digestive tract, although
CT scan
A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...
ning may be more useful to determine whether surgery may be required.
[
During the healing process, strictures of the oesophagus may form, which may require therapeutic dilatation and insertion of a ]stent
In medicine, a stent is a tube usually constructed of a metallic alloy or a polymer. It is inserted into the Lumen (anatomy), lumen (hollow space) of an anatomic vessel or duct to keep the passageway open.
Stenting refers to the placement of ...
.[
]
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
Shortness of breath (SOB), known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing discomfort that ...
, dysphonia
A hoarse voice, also known as dysphonia or hoarseness, is when the voice involuntarily sounds breathy, raspy, or strained, or is softer in volume or lower in pitch. A hoarse voice can be associated with a feeling of unease or scratchiness in the ...
/ aphonia, irritation of the eyes and skin. Perforation of the esophagus can lead to mediastinitis
Mediastinitis is inflammation of the tissues in the mid-chest, or mediastinum. It can be either acute or chronic. It is thought to be due to four different etiologies:
* direct contamination
* hematogenous or lymphatic spread
* extension of i ...
or perforation of the stomach or bowel can lead to peritonitis
Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and covering of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One pa ...
Swelling of the airway or laryngospasm
Laryngospasm is an uncontrolled or involuntary muscular contraction ( spasm) of the vocal folds. It may be triggered when the vocal cords or the area of the trachea below the vocal folds detects the entry of water, mucus, blood, or other subst ...
can occur leading to compromised breathing. Injuries affecting the respiratory system include aspiration pneumonia and laryngeal sores. Signs of respiratory compromise include stridor
Stridor () is an extra-thoracic high-pitched breath sound resulting from turbulent air flow in the larynx or lower in the bronchial tree. It is different from a stertor, which is a noise originating in the pharynx.
Stridor is a physical sig ...
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. Esophageal strictures more commonly occur after more severe mucosal injury, occurring in to 71% and 100% of grade 2b and 3 mucosal lesions respectively. 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.
Pathophysiology
Acids
An acid is a molecule or ion capable of either donating a proton (i.e. hydrogen cation, H+), known as a Brønsted–Lowry acid, or forming a covalent bond with an electron pair, known as a Lewis acid.
The first category of acids are the ...
with a pH of less than 2 or alkalis
In chemistry, an alkali (; from the Arabic word , ) is a basic salt of an alkali metal or an alkaline earth metal. An alkali can also be defined as a base that dissolves in water. A solution of a soluble base has a pH greater than 7.0. The a ...
with a pH above 12 are capable of causing the most extensive injuries in ingestions. 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. 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.
Diagnosis
Classification
The severity of injuries to the mucosa of the gastrointestinal tract is commonly rated using the Zargar criteria.
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. Activated charcoal
"Activated" is a song by English singer Cher Lloyd. It was released on 22 July 2016 through Vixen Records. The song was made available to stream exclusively on ''Rolling Stone'' a day before to release (on 21 July 2016).
Background
In an inter ...
does not neutralize caustics and can also obscure endoscopic visualization. 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.
Signs of airway compromise including decreased level of consciousness, stridor, change in voice, inability to control oral secretions necessitate intubation and mechanical ventillation. 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. Endoscopically inserted nasogastric tubes can serve as a stent to prevent esophageal strictures as well as allow tube feedings. A CT scan, often enhanced with contrast, can also be used to evaluate injuries.
The most common surgical methods of treatment in children include esophageal dilation and esophageal replacement as less commonly implantation of an esophageal stent.
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. 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. Commonly ingested substances include ammonium hydroxide
Ammonia solution, also known as ammonia water, ammonium hydroxide, ammoniacal liquor, ammonia liquor, aqua ammonia, aqueous ammonia, or (inaccurately) ammonia, is a solution of ammonia in water. It can be denoted by the symbols NH3(aq). Although ...
(found in general cleaner and grease remover), sodium hydroxide
Sodium hydroxide, also known as lye and caustic soda, is an inorganic compound with the formula . It is a white solid ionic compound consisting of sodium cations and hydroxide anions .
Sodium hydroxide is a highly corrosive base (chemistry), ...
or potassium hydroxide
Potassium hydroxide is an inorganic compound with the formula K OH, and is commonly called caustic potash.
Along with sodium hydroxide (NaOH), KOH is a prototypical strong base. It has many industrial and niche applications, most of which utili ...
(found in drain opener or oven cleaner), sodium hypochlorite
Sodium hypochlorite is an alkaline inorganic chemical compound with the formula (also written as NaClO). It is commonly known in a dilute aqueous solution as bleach or chlorine bleach. It is the sodium salt of hypochlorous acid, consisting of ...
(bleach), oxalic acid
Oxalic acid is an organic acid with the systematic name ethanedioic acid and chemical formula , also written as or or . It is the simplest dicarboxylic acid. It is a white crystalline solid that forms a colorless solution in water. Its name i ...
(metal polish) and hydrochloric acid
Hydrochloric acid, also known as muriatic acid or spirits of salt, is an aqueous solution of hydrogen chloride (HCl). It is a colorless solution with a distinctive pungency, pungent smell. It is classified as a acid strength, strong acid. It is ...
(toilet bowl cleaner). Storage of caustic substances in water or drink containers is a risk factor for accidental ingestion of these materials, particularly in children.[{{cite journal , last1=Hall , first1=Alan H. , last2=Jacquemin , first2=Denise , last3=Henny , first3=Danièlle , last4=Mathieu , first4=Laurence , last5=Josset , first5=Patrice , last6=Meyer , first6=Bernard , title=Corrosive substances ingestion: a review , journal=Critical Reviews in Toxicology , date=3 February 2020 , volume=49 , issue=8 , pages=637–669 , doi=10.1080/10408444.2019.1707773, pmid=32009535 , doi-access=free ] Boys of preschool age are at the greatest risk of accidental caustic ingestion.
Prevention
Preventative measures have been recommended that are intended to decrease the risk of accidental ingestion of caustic substances including:
* Keeping caustic substances in locked cabinets or on upper shelves
* Not storing chemical substances in food or drink containers
* Not keeping large amounts of detergent in the home
* Not mentioning a drug as "candy" when giving it as medication
* Keeping the phone number for poison control in the home
* Keeping caustic substances in labelled containers
References
Gastroenterology
Corrosion
Toxic effects of substances chiefly nonmedicinal as to source