UMEM Educational Pearls

Category: Toxicology

Title: Predictors of esophageal injury in caustic ingestion?

Keywords: caustic ingestion; esophageal injury (PubMed Search)

Posted: 4/17/2014 by Hong Kim, MD, MPH (Updated: 5/16/2022)
Click here to contact Hong Kim, MD, MPH

Caustic ingestion can potentially cause significant esophageal and/or gastric injury that can lead to significant morbidity, including death.

 

Endoscopy is often performed:

·      To determine the presence of caustic injury.

·      To determine the severity of caustic injury (grade: I to III).

 

Grade

Tissue finding

Sequela

I

•  Erythema or edema of mucosa

•  No ulceration

No adverse sequela

IIa

•  Submucosal ulceration and exudates

•  NOT circumferential

No adverse sequela

IIB

•  Submucosal ulceration and exudates

•  Near or circumferential

Stricture > 70%

IIII

•  Deep ulcers/necrosis

•  Periesophageal tissue involvement

Acute

Perforation and death

Chronic

Strictures and increased cancer risk

 

·      Placement of orogastric or nasograstic tube for nutritional support if needed (grade IIb and III)

 

Evidence for predictor of esophageal injury (frequently cited) comes from mostly studies involving pediatric population and unintentional ingestion:

1.     Gaudreault et al. Pediatrics 1983;71:767-770.

o   Studied signs/symptoms: nausea, vomiting, dysphagia, refusal to drink, abdominal pain, drooling or oropharyngeal burn

o   Presence of symptoms: Grade 0/I lesion: 82%; Grade II: 18%

o   Absence of symptoms: Grade 0/I: 88%; Grade II: 12%

2.     Crain et al. Am J Dis Child. 1984;138(9):863-865

o   Presence of 2 or more (vomiting, drooling and stridor) identified all (n=7) grade II and III lesion.

o   Presence of 1 or no symptoms: no grade II/III lesions

o   Stridor alone associated with grade II/III lesions (n=2)

o   10% of patients without oropharyngeal burns had grade II/III lesions.

3.     Gorman et al. Am J Emerge Med 1990;10(3):189-194.

o   Two or more symptoms: vomiting, dysphagia, abdominal pain or oral burns

o   Sensitivity: 94%; specificity 49%

o   Positive predictive value 43% ; negative predictive value: 96%

o   Stridor alone (n=3): grade II or greater lesion

4.     Previtera et al. Pediatric Emerg Care 1990;6(3):176-178.

o   Esopheal injury in 37.5% of patients without oropharyngeal burn

o   Grade II/III injury: 8 patients

 

Available data suggests that there are no “good” or reliable predictors for esophageal injury.

 

However, high suspicion for gastrointestinal injury should be considered with GI consultation for endoscopy in the presence of

·      Stridor alone

·      Two or more sx: vomiting, drooling or stridor (Crain et al)

·      Intentional suicide attempt