Acute Caustic Ingestion: State of Art and New Trends

Abstract

The ingestion of caustic substances, both accidental and voluntary, determines a complex syndrome, characterized by severe, often irreversible, visceral lesions, with still remarkable mortality in highly compromised patients. The most severe esophageal and gastric damage is notoriously related to voluntary and pseudo-voluntary ingestion of high amount or concentration of strong acids or alkali compounds. More recently “liquitabs”, although not always strictly belonging to the caustic category, have been recognized to cause serious damage to the oral cavity and esophagus by rapid osmotic dehydration. Today the ideal approach to caustic ingestion, especially in case of medium or severe damage, should be achieved through the close cooperation of a multidisciplinary team: emergency physician, anaesthetist, toxicologist, endoscopist and surgeon. After the first evaluation of symptoms and clinical signs, the toxicologic assessment and the radiological evaluation, upper digestive endoscopy represents the mainstay of the diagnostic and therapeutic strategy. Despite clinical symptoms, endoscopy is mandatory in all voluntary and pseudo-voluntary ingestions. Endoscopic description of the lesions must be very accurate and possibly referred to an international well known endoscopic classification. Pictures or videos should be encouraged. After endoscopy, eventually including EUS, the team has to decide about the need to perform surgery (laparotomy or thoraco-laparoscopy) or to establish a conservative therapy. In doubtful cases endoscopy can also be short term repeated, under anaestesiological control. Steroid treatment, at least in the majority of cases, is unpredictable and so that kind of therapy should not be in general encouraged, unless in infants and toddlers where high and early dosage of corticosteroids could play a justified role. Early endoscopic esophageal stenting by removable SEMS, or better by biodegradable stents, could play a interesting role in well identified patients.