A 3-year-old boy presented to the ED after ingesting a liquid in an unmarked bottle. His parents said he vomited a few times before ED arrival. His initial vital signs were a blood pressure of 92/54 mm Hg, heart rate of 114 bpm, respiratory rate of 20 bpm, and pulse oximetry of 98% on room air. The parents reported that he may have ingested a cleaning solution known to contain aluminum hydroxide.
The patient was breathing comfortably, and his airway was monitored closely in the ED. He had no oropharyngeal edema or erythema, and his lung sounds were clear. His mother said she did not think he drank too much of the fluid. The patient was given a PO challenge, and he reported pain with drinking and did not want to drink more.
About 5,000 cases of caustic ingestions are reported annually in the United States, mostly unintentional ingestions in children. Common household corrosive agents may contain ammonia (jewelry or metal cleaners), hydrochloric acid (metal cleaners), sodium hydroxide (detergents, drain and oven cleaners), sodium hypochlorite (bleach), hydrogen peroxide (antiseptic, hair bleach, "food grade" homeopathics), sulfuric acid (drain cleaners), other alkaline substances (hair relaxer), and laundry detergent pods. Reviewing the product's online safety data sheet may be helpful if the ingredients are not listed on the packaging.
Caustics cause a direct chemical injury. The extent of damage depends on the pH, concentration, and volume of the substance ingested and the duration of exposure. Acids cause a coagulation necrosis, and eschar forms, limiting further damage. Acids tend to affect the stomach more than the esophagus. Damage from alkali ingestions occurs due to liquefactive necrosis. There is no eschar formation, so damage continues. This usually affects the esophagus more than the stomach. Other caustic agents work as oxidizing or reducing agents or by defatting and denaturing mechanisms.
Symptoms of a corrosive ingestion include oral pain and burns, drooling, nausea, vomiting, odynophagia, and abdominal pain. The presence or absence of intraoral burns is not reliable about whether damage occurred more distally. Gastrointestinal perforation and sepsis are potentially life-threatening consequences. Symptoms of airway compromise include progressive stridor, voice changes, and respiratory distress.
Some corrosive agents also have systemic effects:
- Hydrofluoric acid and ethylene glycol may cause a profound hypocalcemia.
- Barium salts can be found in some soaps and lubricants, and may cause a severe hypokalemia.
- HCl and formaldehyde may cause a severe metabolic acidosis.
- Concentrated hydrogen peroxide may cause air emboli.
- Boric acid, aside from causing blue-green emesis, may lead to CNS depression and kidney failure.
Gastric decontamination is not recommended in most cases. Activated charcoal will limit the use of endoscopy by interfering with visibility. Induced emesis is contraindicated because it will lead to re-exposure and cause more damage.
Endoscopy is recommended in all patients with intentional ingestions to assess for esophageal injury and provide prognostic information. Also perform an endoscopy for patients with unintentional ingestions if they have stridor and two or more of the following symptoms: vomiting, pain, and drooling.
It is important to remember that endoscopy should be performed within 12 hours of ingestion and no later than 24 hours post-ingestion because the risk of perforation increases after this time. Those patients who are asymptomatic and tolerate liquids after a few hours of observation can safely be discharged with no further intervention.
Our patient was admitted to the hospital, GI was consulted, and an endoscopy was performed, which showed a small grade 1 lesion. No further intervention was needed. The patient tolerated a PO trial, and was able to resume his normal diet.
Zargar Grading of Caustic Esophageal Injury
Grade Description Incidence Stricture Formation
0 No injury evident 11-57% 0
I Edema and erythema 11-88% 0
IIA Superficial non- 7-26% <5%
IIB Deep or circumferential 13.6-28% 71.4%
IIIA Multiple scattered 0.5-12% ~100%
ulcerations with patchy
necrosis (brown, black,
IIIB Extensive necrosis 0-1%