Caustics (strong acids and alkalis), when ingested, burn upper GI tract tissues, sometimes resulting in esophageal or gastric perforation. Symptoms may include drooling, dysphagia, and pain in the mouth, chest, or stomach; strictures may develop later. Diagnostic endoscopy may be required. Treatment is supportive. Gastric emptying and activated charcoal are contraindicated. Perforation is treated surgically.

Common sources of caustics include solid and liquid drain and toilet bowl cleaners. Industrial products are usually more concentrated than household products and thus tend to be more damaging.

Pathophysiology

Acids cause coagulation necrosis; an eschar forms, limiting further damage. Acids tend to affect the stomach more than the esophagus. Alkalis cause rapid liquefaction necrosis; no eschar forms, and damage continues until the alkali is neutralized or diluted. Alkalis tend to affect the esophagus more than the stomach, but ingestion of large quantities severely affects both.

Solid products tend to leave particles that stick to and burn tissues, discouraging further ingestion and causing localized damage. Because liquid preparations do not stick, larger quantities are easily ingested, and damage may be widespread. Liquids may also be aspirated, leading to upper airway injury.

Symptoms and Signs

Initial symptoms include drooling and dysphagia. In severe cases, pain, vomiting, and sometimes bleeding develop immediately in the mouth, throat, chest, or abdomen. Airway burns may cause coughing, tachypnea, or stridor.

Swollen, erythematous tissue may be visible intraorally; however, caustic liquids may cause no intraoral burns despite serious injury farther down the GI tract. Esophageal perforation may result in mediastinitis, with severe chest pain, tachycardia, fever, tachypnea, and shock. Gastric perforation may result in peritonitis. Esophageal or gastric perforation may occur within hours, after weeks, or any time in between.

Esophageal strictures can develop over weeks, even if initial symptoms had been mild and treatment had been adequate.

Diagnosis

• Endoscopy

Because the presence or absence of intraoral burns does not reliably indicate whether the esophagus and stomach are burned, meticulous endoscopy is indicated to check for the presence and severity of esophageal and gastric burns when symptoms or history suggests more than trivial ingestion.

Treatment

• Avoidance of gastric emptying
• Oral fluids

Treatment is supportive. (Caution: Gastric emptying by emesis or lavage is contraindicated because it can reexpose the upper GI tract to the caustic. Attempts to neutralize a caustic acid by correcting pH with an alkaline substance [and vice versa] are contraindicated because severe exothermic reactions may result. Activated charcoal is contraindicated because it may infiltrate burned tissue and interfere with endoscopic evaluation.)

Pearls & Pitfalls Do not do gastric emptying by emesis or lavage with a caustic ingestion because it reexposes the upper GI tract to the caustic. Do not attempt to neutralize a caustic acid with an alkaline substance (and vice versa) because it will produce heat that may worsen tissue damage.

Oral fluids are started when they can be tolerated. Esophageal or gastric perforation is treated with antibiotics and surgery (see Acute Abdomen and Surgical Gastroenterology: Acute Perforation). IV corticosteroids and prophylactic antibiotics are not recommended. Strictures are treated with bougienage or, if they are severe or unresponsive, with esophageal bypass by colonic interposition.

Key Points

• Suspect severe consequences if a large volume of a caustic or an industrial-strength caustic product is ingested.
• Alkalis, by causing liquefaction, can perpetuate damage until neutralized.
• Consider esophageal and stomach burns (and arranging endoscopy) even if intraoral burns are absent.
• Treat acute ingestion with oral fluids as tolerated and perforation with antibiotics and surgery.

Last full review/revision February 2013 by Gerald F. O'Malley, DO; Rika O'Malley, MD

Content last modified March 2013