Emergency Medicine Australasia (2019) doi: 10.1111/1742-6723.

13278

PERSPECTIVE

Caustic ingestion: Has the role of the gastroenterologist

burnt out?
Madeleine GILL,1 Derrick TEE1,2 and Mohamed Asif CHINNARATHA 1,2

1
Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, South Australia, Australia, and 2School of Medicine, The
University of Adelaide, Adelaide, South Australia, Australia

Abstract severity of presentations from fatal endoscopy within 6 h is commonly

Caustic ingestion is a frequent pre-
sentation to EDs and encompasses a
wide range of injury to the gastroin-
testinal tract. Endoscopy has long
been considered the gold standard of
investigation, even in patients with
low likelihood of severe injury, and
informs the decision for emergency
surgery. However, recent evidence
suggests that computed tomography
(CT) scan can accurately diagnose
digestive tract necrosis and, more
importantly, guide towards more
judicious use of surgical manage-
ment, with improved mortality and
digestive autonomy. CT scan also
accurately predicts risk of stricture
formation. We propose an algorithm
for the use of CT scan, rather than
endoscopy, as the first-line investiga-
tion in the assessment of caustic
ingestion.
Key words: caustic ingestion, CT
scan, endoscopy, initial investigation.
Introduction
Caustic ingestion is encountered fre-
quently by emergency physicians,
gastroenterologists, surgeons and
psychiatrists. In adults, the majority
of corrosive ingestions are inten-
tional, with an intent to self-harm.
There is great variation in the
Correspondence: Dr Mohamed Asif Chinnaratha, Department of Gastroenterology
and Hepatology, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, SA 5112,
Australia. Email: asif.chinnaratha@sa.gov.au
Madeleine Gill, MBBS, Advanced Trainee in Gastroenterology; Derrick Tee, MBBCh,
MRCP (Gastro), FRACP, MD (Res), Gastroenterologist, Clinical Senior Lecturer;
Mohamed Asif Chinnaratha, MBBS, MRCP (UK), FRACP, PhD, Gastroenterologist,
Clinical Senior Lecturer.
Accepted 24 February 2019
digestive tract necrosis, to asymp-
tomatic patients ingesting small vol-
umes of household cleaning agents.
Gastroenterologists are almost
always involved in the initial phase
to provide endoscopic assessment,
which has long been considered the
gold standard of investigation. How-
ever, with the ever-increasing
demand for inpatient endoscopic ser-
vices, the dogma of urgent endos-
copy for all caustic ingestion should
be questioned. In Australia, currently
there is no nationally agreed path-
way/ algorithm for managing this
common presentation.
Caustic ingestion refers to both
alkalis and acid: alkalis cause pene-
trative, liquefactive necrosis with
deep injury throughout the upper
digestive tract; acids produce a coa-
gulative necrosis with eschar forma-
tion in the oesophagus, which
conveys some protection against
deep tissue penetration, but spasm of
the pylorus increases gastric injury.1
The immediate, life threatening com-
plication of severe caustic injury is
oesophageal or gastric necrosis with
perforation and spillage of the caus-
tic agent into the mediastinum or
peritoneum.
On presentation to the ED, local
poison information centres are often
the first to provide advice, and in
keeping with worldwide practice,
recommended.2 Symptoms do not
always correlate with the extent of
injury,3 so even in the asymptomatic
or mildly symptomatic patient
endoscopy is often considered part
of routine assessment. Based on
expert opinion, the ideal timing of
endoscopy is within 24 h; beyond
24–48 h submucosal haemorrhages
and oedema make interpretation of
the true extent of injury difficult.
In most centres, injuries are graded
according to the Zargar classifica-
tion4 (Table 1). Severe (grade 3b)
oesophagogastric injuries are consid-
ered for surgery, while the 70–90%
of patients with lower grade injuries
(≤ grade 3a) are managed non-
surgically.
Initial diagnosis: endoscopy
versus computed tomography
Endoscopy has the greatest influence
on the decision to proceed to emer-
gency surgery; however, it does not
adequately predict the depth of
injury or necrosis.5 This can poten-
tially misinform surgical manage-
ment because unlike intraabdominal
organs, the thoracic oesophagus can-
not be explored in detail intraopera-
tively, so the decision to proceed to
oesophagectomy relies almost solely
on endoscopy. A futile oesophagect-
omy is disastrous, given the high
mortality rate and loss of digestive
autonomy. With the wide availabil-
ity of computed tomography
(CT) 24 h a day, compared with lim-
ited endoscopic services, the use of
CT to augment, if not supersede,
endoscopic assessment is a reason-
able consideration. In their 2014
review, Bonnici et al.3 offered that
while the current data does not

© 2019 Australasian College for Emergency Medicine

2 M GILL ET AL.
TABLE 1. Zargar classification4
Grade Endoscopic findings
0 Normal
1 Oedema and hyperaemia or the mucosa
2a Superficial localised ulcerations, friability and blisters
2b Circumferential and deep ulcerations
3a Multiple and deep ulcerations and small scattered areas of necrosis
3b Extensive necrosis
support replacing endoscopy with
CT, it is useful as an adjunct. In
2015, the World Society of Emer-
gency Surgery consensus conference2
introduced emergency CT as routine
in assessment of corrosive ingestions.
While Bonnici’s review was based
on small retrospective studies, robust
prospective data has since been pub-
lished. In their 2015 study, Chirica
et al.5 explored the use of CT for the
emergency diagnosis of endoscopic
high-grade corrosive oesophageal
necrosis. This study was performed
in two stages, before and after 2007.
Before 2007, all patients with grade
3b oesophageal necrosis on endos-
copy underwent emergency oesopha-
gectomy. In 2007, CT was added to
routine management of caustic inges-
tions, and subsequently, only
patients with full-thickness necrosis
on CT underwent oesophagectomy,
with the remainder managed non-
operatively under close surveillance.
When the decision was based on
endoscopy alone, 99% (124/125) of
patients with grade 3b injuries
underwent oesophagectomy or oeso-
phagogastrectomy compared with
only 35% (25/72) when endoscopy
and CT were combined. Of the
patients in whom CT findings guided
towards conservative management
(47/72), no patients died or needed
emergency surgery at a later time.
The 90 day mortality was 16% in
the endoscopy only group, compared
with 7% in the CT group; this did
not reach statistical significance.
However, for 1 and 3 year survival,
the use of CT significantly predicted
survival. In the non-operative group,
31 of 45 patients developed oeso-
phageal strictures and over half
underwent oesophageal reconstruc-
tion. Thirty-eight percent of patients
in the CT group had a native func-
tioning oesophagus at the end of
follow up, compared with 1% in the
endoscopy only group. The authors
concluded that in patients with endo-
scopic grade 3b oesophageal necro-
sis, reserving emergency
oesophagectomy for those with CT
evidence of full thickness necrosis
improved survival and avoided
unnecessary oesophagectomy in two-
thirds of patients.
In 2016 the same group published
another prospective study exploring
the utility of CT in all grades of
injury,6 particularly addressing the
possible use of CT as the sole factor
in decision-making, that is, eliminat-
ing the need for urgent endoscopy.
One hundred and twenty patients
underwent endoscopy 3–6 h after
ingestion, as well as CT. Endoscopy
and CT were concordant in 101/120
patients; 24 had endoscopic grade
3b injury and underwent emergency
surgery. The remaining 77 with
endoscopic grade 1–3a were conser-
vatively managed and none required
emergency surgery at a later time. In
the 19 discordant results, the endos-
copy grade was 3b, while the CT
showed no necrosis; these patients
were also successfully managed con-
servatively. On retrospective review
of the decision making process, there
were no cases where CT grade was
higher than endoscopic grade, or
where CT would have led to an
incorrect decision that endoscopy
would have corrected. The use of CT
alone would have resulted in one
unnecessary oesophagectomy and
seven unnecessary exploratory
© 2019 Australasian College for Emergency Medicine
laparotomies. In contrast, using
endoscopy alone would have led to
20 futile oesophageal resections and
23 exploratory laparotomies. A CT-
alone algorithm would have led to
the same decisions as the combined
CT and endoscopy approach.
Using these studies in a 2017 Lan-
cet review,7 Chirica proposes a
radiological classification of caustic
injures (Table 2). Patients with CT
grade 3 require emergency surgery;
CT grade 2 should be assessed by
endoscopy and managed conserva-
tively and CT grade 1 do not require
endoscopy. In the 2016 study, three
radiologists reviewed the CTs: one
senior gastrointestinal radiologist,
one general senior and one resident,
with high inter-observer agreement,
which is reassuring for the reproduc-
tion of these findings outside of spe-
cialist centres. While a formal cost
analysis was not performed, a CT-
based algorithm appears more cost
effective in hospitals that do not
have a 24 h endoscopy service.
While most studies focus on CT in
severe injuries, the mild or absent
injury group is also important. In
Chirica’s 2016 study, 23% of the
overall cohort had no injury on CT
or endoscopy and could have
avoided an unnecessary procedure;
these figures casts doubt on routine
endoscopy in all caustic ingestions.
In their 2014 review, Bonnici et al.
addressed this question, and con-
cluded that it is reasonable to avoid
endoscopy in asymptomatic adults
who have no clinical signs, and that
these patients can be discharged with
confidence after trial of oral intake.
CT is now more convincingly
evidence based and as per Chirica’s
algorithm, a CT grade of 1 would
provide reassurance in the asymp-
tomatic or mildly symptomatic
patient, facilitating early discharge
or psychiatric admission.
Assessment for strictures:
endoscopy versus CT
The other purpose for endoscopic
assessment is in the prediction of
strictures. There is no evidence for
interventions that prevents strictures,
example intralesional steroids or
antibiotics, but if the likelihood of
MANAGEMENT OF CAUSTIC INGESTION 3

algorithm.7 However, given the

TABLE 2. Proposed CT grading system7 reluctance to perform endoscopy in
CT CT features Corresponding Zargar caustic injury beyond 24 h, these
grade grade patients would still require urgent
endoscopy.
Grade 1 Normal appearing organs Grade 0–2a A study by Kocchar et al.9 explored
whether endoscopy performed on
Grade 2 Wall oedema with surrounding soft Grade 2b–3a
Day 1 or Day 5 better predicted the
tissue inflammatory change and
development of oesophageal cicatrisa-
increased post-contrast wall tion. Compared with Day 1, endo-
enhancement without transmural scopic grading of severe injury on
necrosis Day 5 had a higher specificity, posi-
Grade 3 Transmural necrosis as shown by Grade 3b tive predictive value and positive like-
the absence of post-contrast wall lihood ratio for predicting the
enhancement development of oesophageal stricture
or antropyloric stenosis. Of the
62 endoscopies performed on Day
5, 32% with severe injury, there were
strictures can be predicted then ear- 95.6% for CT compared with no complications ie. no perforations.
lier follow up and intervention can 62.8% and 84.8%, respectively for
be planned between 3 and 6 weeks endoscopy. As low-grade injury
before collagen deposition and fibro- rarely causes strictures, a patient Conclusion
sis make therapeutic interventions with CT grade 1 may therefore not
With evidence on CT assessment alone
more difficult. In their retrospective need endoscopy, not for initial
showing a trend towards better out-
observational study of 49 adults, assessment nor prognostication. It
comes, the role for endoscopy in all pre-
Ryu et al.8 found CT to be better seems appropriate that patients with
sentations of caustic ingestion is now
than endoscopy in predicting the risk CT grade 2 injury undergo an endos-
questionable. CT, to guide both deci-
of stricture formation, with a sensi- copy early in their presentation, and
sions about emergency surgery, and
tivity of 81.4% and specificity of this is reflected in Chirica’s proposed
conservative management in asymp-
tomatic patients, should be the first-line
investigation. As there are no current
Australian guidelines for managing
caustic ingestion, based on the above
evidence we propose an algorithm
(Fig. 1) that provides a safe yet prag-
matic approach to the assessment and
initial management of all grades of
caustic injury. This pathway has the
potential for major cost savings and bet-
ter utilisation of endoscopic resources.
However, as the management of these
injuries crosses multiple disciplines,
adopting a new consensus and translat-
ing this into real-world, protocolised
practice may prove challenging.

Competing interests
None declared.

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