Acute Management in Corrosive Ingestion

Corrosive ingestion is an important health problem and medical emergency worldwide. It occurs by accident or by intention. Acids cause coagulation necrosis, and alkalis cause liquefaction necrosis. In the acute period, stabilization of the patient is most important. Airway assessment and prompt management are a priority for severe cases. Caustic substance reflux into the esophagus resulting in further damage should be prevented. The initial evaluation should be performed by endoscopy and graded according to the Zargar classification. Computed tomography (CT) should be used to assess injury to the esophagus because CT is noninvasive. For Zargar 3b injuries, views from both endoscopy and CT scans should be considered. Post-corrosive esophageal stricture is a complication that responds poorly to treatment. Research and development for stricture prevention are ongo-ing, especially for Zargar 2b and 3a cases. Savary-Gilliard, and Balloon dilator under the endoscopy, fluoroscopy, or both. Alternative


Introduction
Corrosive ingestion is a medical emergency that is especially prevalent in developing countries such as Thailand [1][2][3][4][5][6][7][8][9]. Since 2020, the COVID-19 has had an enormous impact on many sectors worldwide, and it had affected the trend of rising incidence and severity of diseases [10]. However, the actual incidence should not be precise as the tip of the iceberg phenomenon is probably under-report [4,8]. Currently, various studies on this topic are still being developed for medical knowledge to the achievement goal of the best practice. Perforation and stricture are complications of corrosive ingestion which are currently being researched and which are discussed in this chapter.

Pathophysiology
Caustic substances with pH less than two or more than 12 are especially destructive. Form, concentration, amount of ingestion, and contact duration also affect the results. Acidic substances generate coagulation necrosis which creates eschar formation. Eschar can limit the penetration of injuries [16]. On the other hand, alkaline substances melt the tissue protein and initiate liquefactive necrosis with saponification that can penetrate deeper into the esophageal wall [17].
Perforation occurs in the acute stage of severe esophageal injuries. As a consequence of perforation, stricture follows during the recovery stage. Tissue injuries after corrosive ingestion go through three phases. Phase 1 is characterized by cell necrosis and thrombosis, 48-72 hours after the event. Next, in Phase 2, there is mucosal sloughing with ulceration of the esophageal wall plus fibroblast colonization and granulation. This phase continues for 14 days from the Phase 1, and the esophagus is friable during this phase. Finally, in Phase 3, the healing process starts in the third week and usually continues 3-6 months [3, 20, 21].

Management
When patients arrive at the emergency department, stabilization of the patient is the most important target for this stage [21]. Signs and symptoms that often occur in corrosive ingested patients include burning of the oral cavity, drooling, nausea, and vomiting. Upper gastrointestinal bleeding can be found in severe cases, indicating substance injuries to the alimentary tract. Respiratory trauma can result in hoarseness, difficulty to breathe, stridor, and airway compromise. Esophagus perforation can be expressed as mediastinitis, chest wall emphysema, and pneumothorax, depending on time and severity.
Physicians should first examine the airway, especially for signs of aspiration or laryngeal injury. Physical examination and history taking should be done for details of the corrosive substance, the volume, timing before admission, pre-hospital treatment, and cause of ingestion. The patient should be given nil per os (NPO) and adequate resuscitation. Nasogastric tube intubation, gastric lavage, administration of emetic drugs, and neutralizing agents are not recommended because reflux of these agents into the esophagus could result in further damage [1,8,21]. Intravenous broad-spectrum antibiotics may benefit a patient with high-grade esophageal injuries. The investigation by chest and abdominal radiography should be evaluated. In cases of attempted suicide, the patient should be evaluated by the psychiatric department [1,3,4,9,22,23].
The initial evaluation of the severity of a caustic injury provides important information. Esophagogastroduodenoscopy (EGD) is recommended for grading esophageal injuries following the Zargar classification ( is not recommended because the tissue injuries go through Phase 2 when they should not be subjected to an unwanted event [16,21]. For patients with Zargar grade 1 and 2a, an oral diet may be given. Patients with Zargar grade 2b and 3a can start an oral diet once they can swallow saliva. Esophagectomy should be performed on patients with Zargar grade 3b injuries. The method for assessing the degree of esophageal damage by computed tomography (CT) with scoring was recently established as a noninvasive modality [24]. Nowadays, the use of CT scans of the chest and abdomen is increasing. CT can assist prognosis after ingestion, but it is still inconclusive [25][26][27]. CT also provides extraesophageal information regarding anatomies such as the mediastinum, lung, and pleural cavity, which endoscopies do not ( Table 2).

Perforation
Although an endoscopy is an important tool for initial evaluation, contraindications are suspected perforation, oral cavity necrosis, and airway injury with

Zargar classification Description
Grade 0 Normal finding on endoscopic examination  Table 2.
Endoscopic score and computerized tomography score of corrosive esophageal injury.
Post-corrosive esophageal stricture should highly consider inpatient with Zargar grade 2b and 3a [4,5,8,9,16,55]. Although various treatment strategies have been developed, none of them can provide outstanding results. Stricture prevention would be the ideal method. Corticosteroids reduce inflammation, but the benefit is inconclusive. Steroids cause severe adverse side effects such as esophageal candidiasis, gastric ulcer, ethmoiditis, osteomyelitis, and osteoporosis [56][57][58]. Recent studies have demonstrated that omeprazole with proton pump inhibitor activity could enhance healing, reduce stricture, and reduce the short-term risk of developing esophageal stricture in patients with 2b and 3a corrosive injuries [9,[59][60][61]. However, further studies of omeprazole are needed to corroborate these findings (Figure 2).

Conclusion
Corrosive ingestion is a serious medical emergency that is a global problem, especially in several developing countries. When patients arrive at the emergency department, stabilization of the patient is initially the most important target. Airway assessment and prompt management are the priorities for emergency settings, especially in severe cases. Any intervention that might cause substance reflux into the esophagus resulting in further damage is not recommended. Current methods for assessing the degree of esophageal damage are early endoscopy for Zargar classification and CT scan, which focuses on ruling out perforation. Postcorrosive esophageal stricture can be a consequent complication with poor treatment outcomes, and stricture prevention is an interesting idea.

Conflict of interest
The author declares no conflict of interest.

Notes/Thanks/Other declarations
Special thanks to Michael Jan Everts for assistance in editing the English version of this chapter.
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