Clinical Toxicology (2014), 52, 911–925

Copyright © 2014 Informa Healthcare USA, Inc.

ISSN: 1556-3650 print / 1556-9519 online
DOI: 10.3109/15563650.2014.957310

REVIEW ARTICLE

Should computerised tomography replace endoscopy in the

evaluation of symptomatic ingestion of corrosive substances?
K. S. BONNICI,1,2 D. M. WOOD,2,3 and P. I. DARGAN2,3

1Department of Acute Medicine, Chelsea & Westminster Hospital NHS Trust, London, UK
2ClinicalToxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, London, UK
3King’s College London, London, UK
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Introduction. Corrosive ingestions are common, although most ingestions do not result in clinically significant effects. Limited guidance is
available on the role of endoscopy and/or computerised tomography (CT) in the investigation of individuals with corrosive ingestion, and
the present data regarding predictors of poor outcome are confusing. Furthermore, whilst there are many case series describing the use of
endoscopy in corrosive ingestions, no clear ideal time frame has been established as to when it should be undertaken. More recently, CT has
been used to grade injuries, but there are few studies on its role in managing corrosive injuries, and those studies that have been reported
are conflicting in their results. Methods. A Medline search was performed with the terms ‘Caustic ingestion’ and ‘Corrosive ingestion’ and
a second search by adding the words ‘Endoscopy’, ‘CT’, and ‘Computerised tomography’ as a subject term or keyword. These searches
revealed a total of 277 reviews and papers, of which 33 original papers were relevant for analysis. Three further papers were identified
during the analysis of these papers and a PubMed search of the same terms added one further paper, bringing the total to 37. There have
been no prospective, randomised controlled trials directly comparing endoscopy and CT. Only two retrospective studies compared the use
For personal use only.

of CT and that of endoscopy. Thirty-five studies examined whether an endoscopy is always needed, and if so, within what time frame this
should be done: CT or endoscopy? A review of these studies suggests that the data regarding the use of CT in these circumstances are not
yet of sufficient weight to replace endoscopy as the first-line investigation in corrosive ingestion–related injury. Who needs investigation
after corrosive ingestion? We believe that signs and symptoms indicate the likelihood of clinically significant injury in adults. Specifically,
any evidence of oropharyngeal burns, drooling, vomiting, pain or dysphagia clearly indicates the need for an endoscopy. In children,
it appears that an even greater degree of caution is needed. How soon after ingestion should investigation be performed? For whom
an endoscopy is required, it is prudent to enable surgery and other specifics regarding management of corrosives to be decided quickly
(⬍ 12 h). There are many incidences where endoscopy has been done safely beyond 48 h although this is not needed frequently. Management
recommendations Asymptomatic patients, particularly adults with a normal clinical examination and who can eat and drink normally, can
be discharged safely without endoscopy. Endoscopy is preferred over CT in the assessment of risk in symptomatic patients with corrosive
ingestion. If patients have any oropharyngeal injury and in particular symptoms of drooling, vomiting, dysphagia or pain (retrosternal or
otherwise), the risk of having a high-grade injury is higher, and urgent endoscopy should be performed to grade the injury and determine
whether surgical intervention is required. Patients who have non-specific symptoms, such as cough, should also undergo endoscopy, but
this is less urgent. Conclusions Despite the lack of high-quality clinical trial data, the available evidence and clinical experience support the
use of early endoscopy (⬍ 12 h) in patients who are symptomatic after ingestion of a corrosive substance. We propose a clinical guideline
that can be used to help plan management of corrosives.

Keywords Caustic ingestion; Corrosive ingestion; Endoscopy; Computerised tomography

Introduction
Acids and alkalis are found in a number of household and
industrial products. It is widely accepted that the most seri-
ous injuries occur when the solution consumed has a pH of
Received 10 April 2014; accepted 17 August 2014.
Address correspondence to Dr. Paul I. Dargan, Medical Toxicology Of-
fice, 3rd Floor, Block C, South Wing, St Thomas’ Hospital, Westminster
Bridge Road, London SE1 7EH, UK. Tel: ⫹ 020 7188 5848. Fax: ⫹ 020
7188 4292. E-mail: Paul.Dargan@gstt.nhs.uk
less than 2 or greater than 12.1 Acids cause injury through
coagulation necrosis on contact with tissue, whilst alkalis
cause liquefaction necrosis that can affect deeper tissues and
are therefore typically more serious.2 Corrosive or caustic
agents (throughout this review we shall regard ‘corrosive’
and ‘caustic’ as synonyms) are available in both industrial
products and consumer products intended for household
use. Industrial agents typically have higher concentrations
and more extreme pH values, and they generally cause more
severe injury than their domestic counterparts.2,3 In addition

911
 912 K. S. Bonnici et al.
to localised injury, hydrofluoric acid can cause significant
hypocalcaemia which can result in complications including
tetany and arrhythmias.4 It is important to identify the sub-
stance involved (in particular, pH and concentration) when
possible, as well as to estimate the volume ingested. Previ-
ous studies have suggested that both clinician’s and patient’s
estimates of volume ingested are poor; therefore, one should
estimate the ingested volume based on the volume left in the
container.5
There are no data available on the prevalence of corrosive
ingestion. In England and Wales, there are approximately
15,000 corrosive incidents (this includes other routes of
exposure such as dermal and ocular injury) every year.6 Data
from the US National Poison Data System show that in 2012
there were 193,802 substance exposures relating to clean-
ing substances (7.2% of all exposures) and 39,729 chemical
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exposures (1.4%).7 Specific data are not provided on cor-
rosive ingestions, but it is likely that a proportion of these
exposures involve corrosives.
The demographics of corrosive ingestion are dependent
on local accessibility, and the age of presentation typically
follows two peaks: children, aged 2–5 years, who consume
household products unintentionally and generally have
milder symptoms but account for a high caseload, and adults
who more commonly ingest products intentionally to cause
themselves harm.8,9
For personal use only.
On the basis of the limited data available, it is likely
that corrosive ingestion is more common in the developing
world.10 There are many case series reporting high incidents
of ingestion around industrial plants such as rubber manu-
facturers (using acetic and formic acids). The high availabil-
ity of automotive battery acid makes this another common
agent.11–13 Furthermore, there is some evidence to suggest
that corrosive ingestions in the developing world are typically
more severe than those in the developed world in part due to
late presentation at hospital, ingestion of more concentrated
products with greater extremes of pH, and/or because inges-
tions are treated at home by traditional healers.14
Many aspects of the management of corrosives are already
well established and not controversial, such as early intuba-
tion in those with severe injury airway compromise, and
the avoidance of the use of agents to neutralise the ingested
substance.15 Gastric emptying by induced emesis or gastric
lavage are not recommended, and activated charcoal is not
effective.16,17 Endoscopy has long been considered the gold-
standard investigation. In the 1970s–1980s, it was common-
place to wait 12–24 h before performing endoscopy as it was
thought that this time was needed for the injury to ‘mature’
and for the scarred areas of oesophagus and stomach to
demarcate.18
In this paper, we shall assess whether the literature sup-
ports this practice of delayed endoscopy. Given that we
know that the tensile strength of the oesophageal wall weak-
ens substantially after day 4 of corrosive injury, it is of little
surprise that many current guidelines, such as those from
the UK National Poisons Information Service, advocate that
the risk of perforation is too high for endoscopy to be
performed during days 5–15.19,20 Zargar et al.21 proposed a
classification system (Table 1) of oesophageal injury based
on a series of 381 endoscopies performed in 81 patients after
ingestion of corrosives.
More recently, computerised tomography (CT) has been
introduced in the assessment of corrosive ingestion.22,23
With the more widespread availability of CT, it is not clear
whether CT could be used in the place of endoscopy and, if
so, whether there are particular groups of patients in whom
this may be more appropriate. CT has potential advantages
for use as a means of stratifying these patients based on risk,
given its non-invasive nature and widespread availability. In
addition, it is now used successfully to grade and assess a
number of other oesophageal diseases, both malignant and
non-malignant.24
The three aims of this review are to establish whether CT
or endoscopy is best used in the initial assessment of indi-
viduals with corrosive ingestion; whether all patients with
corrosive ingestion require investigation; and how soon after
ingestion investigation(s) should be undertaken.
Methods
A Medline search was performed with the terms ‘Caustic
ingestion’ and ‘Corrosive ingestion’ followed by a second
search by adding the words ‘Endoscopy’, ‘Computerised
tomography’ and ‘CT’ as a subject term or keyword. These
searches revealed a total of 277 reviews and papers, of which
33 original papers were relevant for analysis. Three further
papers were identified during the analysis of these papers,
and a PubMed search of the same terms added one further
paper, bringing the total to 37.
Each paper was analysed for mention of symptoms and
signs on arrival, proportion of intentional and unintentional
ingestions, time to investigation, severity of injury found,
complications relating to any procedure and any prognostic
analysis that was done. Tables 2 and 3 summarise the data
that were extracted from the 37 papers identified.
CT or endoscopy after corrosive ingestion?
Whilst CT has been used for many years to assess malignant
disease of the oesophagus,24 there is more limited evidence for
its use in corrosive ingestions. As summarised in Table 2, only
two retrospective studies have compared CT and endoscopy
in patients following corrosive ingestion. Ryu et al.22 looked
at their ability to predict the longer-term complications of
corrosives including likelihood of stricture formation, whilst
Lurie et al.23 examined their shorter-term value in predicting
Table 1. Zargar’s Criteria for assessment of corrosive injuries.17
Grade Endoscopic Findings
0 Normal Examination
1 Oedema and Hyperaemia of mucosa
2a Friability, erosions, haemorrhages, blisters, whitish
membranes, exudates and superficial ulceration.
2b Grade 2a plus deep discrete or circumferential ulceration
3a Small scattered areas of necrosis
3b Extensive necrosis
Clinical Toxicology vol. 52 no. 9 2014

Table 2. Is endoscopy or CT best as the initial investigation?
Number in
Author Year Study type study
Lurie et al.23 2013 Retrospective observational 23 adults
study
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Ryu et al.22 2010 Retrospective observational 49 adults
study
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mortality and the need for emergency laparotomy. Ryu et al.22
found that CT was better than endoscopy in predicting the
risk of stricture formation. They found that sensitivity and
specificity of CT (81.4% and 95.6%, respectively) were both
greater than those of endoscopy (sensitivity of 62.8% and
specificity of 84.8%). In contrast, Lurie et al.23 found CT to
be less sensitive than endoscopy in predicting mortality and
in determining the need for surgery. The presence of grade-2b
or grade-3 injury at endoscopy had sensitivities of 1 for mor-
tality and 0.8 for emergency laparotomy compared with the
sensitivities of 0.4 and 0.28, respectively, for CT.
In a subsequent letter, Lurie’s group25 commented that the
machines used were all of the third generation, and so it was
unlikely that poor resolution explained poorer performance
of CT. However, this study was limited by the blinding of the
radiologist but not the endoscopist to the clinical details, and
the numbers involved were very small (23 adults). There-
fore, whilst there are instances in which CT will provide
valuable information such as when endoscopy is unsafe, for
example in the case of airway oedema, or the expertise is not
available on site, we do not believe that the current data sup-
port replacing endoscopy with CT as the gold standard in the
assessment of corrosive ingestion.22,23 However, the study by
Lurie et al.23 demonstrated some of the potential advantages
of CT such as the finding of pulmonary infiltrates on CT in
three patients who were not present for chest X-ray. Given
its use in assessing soft tissues such as the thyroid, MRI may
have a place in the investigation of corrosive ingestions in
the future.26
Copyright © Informa Healthcare USA, Inc. 2014
Corrosive ingestion management 913
Key results
• 78% of intentional and 22% of unintentional ingestions
• Substances: acid, 52.2%; alkali, 26.1%; bleach, 13%; and unspecified, 8.7%
• All had both CT and endoscopy within 48 h of admission
• Endoscopy grading was higher than CT grading in 14 patients (66%)
• The sensitivities of endoscopy grades 2b and 3 to predict mortality and
emergency laparotomy were 1 and 0.8, respectively; the specificities were
0.38 and 0.37, respectively
• The sensitivity of CT grade 3 to predict mortality and emergency lapa-
rotomy was 0.4 and 0.28, respectively; specificity was 0.94 and 0.93,
respectively
• Radiologists but not endoscopists were blinded to clinical details
• Three patients had pulmonary infiltrates shown on CT that were not present
on chest x-ray (CXR)
• 65% of intentional and 35% of unintentional ingestions
• Substances: acid, 71.4%; alkali, 28.6%; bleach, 8.2%; lye, 16.3%; and
calcium hydroxide, 4.1%
• All patients had a CT done within 72 h and had an oesophagoscopy prior to
discharge
• The CT grading system for oesophageal stricture resulted in a slightly
larger area under the receiver-operating characteristic curve (0.90) com-
pared with endoscopic grading system (0.79)
• The sensitivity and specificity of CT grading system were moderately high-
er than those of endoscopic grading system particularly when comparing
grades I–III with grade IV injuries (CT sensitivity, 81.4% and specificity,
95.6% compared with endoscopy sensitivity, 62.8% and specificity, 84.8%)
Endoscopy is now known to be a safe and economically
sound procedure, and the use of a flexible rather than rigid
endoscope has decreased the risk of perforation that might
occur with rigid instruments.27,28 The British Society of
Gastroenterology recommends that unless immediate surgery
is likely, endoscopy should, where possible, be a planned
procedure with experienced staff in endoscopy units rather
than in the main theatres out of hours with less experienced
staff.29 Clearly, local expertise and availability of 24-h endo-
scopic and radiological services will impact on the clinical
decision-making in each individual case. However, given the
small amount of literature on the accuracy of CT in these
instances, we believe that endoscopy remains the preferred
investigation of choice.
Who needs investigation after corrosive ingestion?
The 35 papers that address this question are summarised
in Table 3; all of these are observational case series. When
included, we recorded the proportions of different substances
to see if there is any evidence for treating certain groups dif-
ferently. Studies that contained high proportions of alkaline
ingestions consistently had a high proportion of low-grade
injuries.31,34–36,44,49 Conversely, those with a high proportion
of acid ingestions had a higher overall proportion of high-
grade injuries.22,57
Analysis of patients categorised as ‘severe’ found that 14%
of the group who had ingested acid developed high-grade
injuries, whilst only 2.9% of the alkaline group had severe
 914 K. S. Bonnici et al.

Table 3. Does everyone need an endoscopy and in what time frame?

Author Year Study Type Number in study Key results

Temiz et al.30 2012 Retrospective 206 children • Substances: acids, 34.9%; alkali, 27.2%; bleach, 30.1%; and
observational study unknown substance, 7.8%
• There was no significant difference in the development of stricture,
but there was a difference in the percentage of who had a ‘severe’
gastric injury (14% of acid group, 2.9% of alkaline group, 1% of
bleach group and 0.5% of unknowns)
• Endoscopy was performed within 48 h in 89.8% (range, 1–10 days).
Of these, 10.2% were done after 48 h owing to late presentation to
hospital. There were no endoscopy-related complications
• Endoscopy was not performed in those who had a ‘questionable’
history (undefined), were asymptomatic and had no oropharyngeal
signs or injury
• Endoscopic findings: Grade-0 or grade-1 injury (65.5%), grade-2b or
grade-3 injury (14.1%)
• 19.3% of those with severe oesophageal injury had no signs or
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symptoms
• 59.7% of those with clinical symptoms had grade-0 or grade-1 injury
• The sensitivity of all clinical findings regarding severe (undefined)
oesophageal or gastric injury was high at 80.6% and 75.7%, respec-
tively, but the specificity was low at 32.8% and 29%, respectively
Arici et al.31 2012 Retrospective 83 adults and 99 • 87% of unintentional and 13% of intentional ingestions
observational study children
• Substances: alkali, 58.3%; acids, 25.8%; and detergents, 15.4%
• Endoscopy was carried out only in 27% of cases (46) of the
exposures. Most (58.7%) showed grade-1 injury
• Endoscopy was required according to the substance (more often in
case of acids and intentional ingestion) but the exact criteria used
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were unclear
• Of those who had endoscopy, 38 (38.3%) cases were symptomatic
and 8 (10.6%) cases were asymptomatic. Within the asymptomatic
group, 7 of the 8 (93%) cases had findings less than third degree
Chang et al.32 2011 Retrospective 389 adults • 27.5% of unintentional and 72.5% of intentional ingestions.
observational study
• Substances: acids, 63%; alkali, 31.9%; and unknown, 5.1%
• All patients underwent endoscopy (time frame not recorded): Grade
1, 14.7%; Grade 2a/2b, 39.3%; Grade 3a, 15.7%; and Grade 3b,
26.7%
• Symptoms and signs at presentation were not recorded.
• Found that clinical outcome of adults who ingest caustic substances
is related to age, with those ⬎ 65 years having a poorer outcome
(p ⬍ 0.001)
Pramod et al.33 2011 Retrospective 16 adults • 6.25% of unintentional and 93.75% of intentional ingestions
observational study
• Substances: acid, 62.5%; and alkali, 18.5%
• Endoscopy was ‘usually done’ within 12–48 h in 9 selected cases
(no information on criteria used or exact timing)
• 12.5% had grade-1 injury and 12.5% had grade-3 injury
• Symptoms: pain, 93.75%; haematemesis, 50%; retching, 50%;
dysphagia, 75%; and others, 37.5%
• Two patients had minimal symptoms but endoscopically grade-2
injuries. No other correlation was made between symptoms and
OGD findings
Kaya et al. 34 2010 Retrospective 134 children • Substances: alkali, 85%; and acids, 15%
observational study
• Endoscopy was done in all cases. No time frame was mentioned
• 57% of the cases had grade-0 or grade-1 injury; 2% of the cases had
grade-3 injury
• Further the cases were divided into low grade (grades 0, 1, and 2a),
87%; and high grade (grades 2b and 3), 13%
• In the patients with low-grade injury: vomiting, 9%; drooling saliva,
3.5%; respiratory symptoms, 2%; oral lesion, 24%; and mean WBC,
10.9 ⫾ 3.0
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Clinical Toxicology vol. 52 no. 9 2014

 Corrosive ingestion management 915

Table 3. (Continued )

Author Year Study Type Number in study Key results

• The patients with high-grade injury had the following symptoms:

vomiting, 24%; drooling saliva, 47%; 6% respiratory symptoms;
oral lesions, 65%; and mean WBC, 17.0 ⫾ 3.9
• 70% patients were asymptomatic. The absence of clinical signs
correlated with no or low-grade injury (specificity for vomiting:
0.91, drooling saliva: 0.96, respiratory symptoms: 0.98, oral lesions:
0.76, and NPV: 0.89, 0.92, 0.87 and 0.93, respectively)
• Drooling saliva and oral lesions were indicative of a high-grade
injury (p ⬍ 0.05). WBC above 10.5 ⫻ 103/μL was highly sensitive for
severe lesions (0.93), but PPV was low (0.18). It is unclear whether
any patients with high-grade injury had signs or symptoms
Riffat and 2009 Retrospective 50 children • 98% of unintentional and 2% of intentional ingestions
Cheng35 observational study
• Substances: alkali, 74%; acids, 6%; and others (including bleach,
remaining 20%)
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• All patients had oesophagoscopy at 48–72 h

Betalli et al.36 2008
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• Six (12%) cases had oesophageal injury but no oral injury. So it is
unclear whether they were in groups that had other symptoms, for
example, drooling (56%), vomiting (48%) and refusal of oral intake
(78%). None of the patients had grade-3 or grade-4 injury
Multicentre 162 children • 100% of unintentional ingestions
observational study
• Substance: alkali, 82.1%; and acid, 17.9%
• Endoscopy was performed between 12 and 24 h in all patients
• The majority (88.3%) had grade 2 or less than grade-2 findings on
endoscopy, 11.7% had grade-3 injury
• Predictive values of signs and symptoms with relation to a

third-degree injury:
• No symptoms, 2/70; PPV, 0.03; NPV, 0.82; sensitivity, 0.11;
1-specificity, 0.48
• ⬎ 3 symptoms 9/19: PPV, 0.47; NPV, 0.93; sensitivity, 0.47;
1-specificity, 0.07
• Vomiting 8/35: PPV, 0.23; NPV, 0.91; sensitivity, 0.42; 1-specificity,
0.19
• Drooling 12/42: PPV, 0.29; NPV, 0.94; sensitivity, 0.63; 1-specificity,
0.21
• Haematemesis 3/6: PPV, 0.50; NPV, 0.90; sensitivity, 0.16;
1-specificity, 0.02
• Dyspnoea 2/3: PPV, 0.67; NPV, 0.89, sensitivity, 0.11; 1-specificity,
0.01
• Oral lesions 14/69: PPV, 0.20; NPV, 0.95; sensitivity, 0.74;
1-specificity, 0.38
• The risk of severe damage increased proportionally with the number
of signs and symptoms
• Multivariate analysis showed that the presence of symptoms was
the strongest predictor of severe oesophageal lesions: symptoms
(no vs. yes)-adjusted OR, 2.308; 95% CI, 0.57–3.38; p ⫽ 0.001
Cheng et al. 37 2008 Retrospective 273 adults • 71% of intentional and 29% of unintentional ingestions
observational study
• Substances: alkali, 35.16%; and acid, 34.43%
• Endoscopy was done within 24 h in all patients
• Grade 3b was the commonest injury (30%)
• Data on signs and symptoms were not recorded
Tohda et al. 38 2008 Retrospective 95 adults • 51.6% of intentional and 48.4% of unintentional ingestions
observational study
• Substances: acid, 18%; alkali, 33%; bleach, 26%; detergent, 14%;
ammonia, 4.2%; and unknown, 4.8%
• Endoscopy performed within 24 h of admission
• 10 patients had no mucosal damage, 47 had grade-1, 25 had grade-2
and 13 had grade-3 injuries
• How many patients had symptoms or signs on admission in each
classified grade is unclear
(Continued )

Copyright © Informa Healthcare USA, Inc. 2014

 916 K. S. Bonnici et al.

Table 3. (Continued )

Author Year Study Type Number in study Key results

Havanond and 2007 Prospective 148 adults • 92% of intentional and 8% of unintentional ingestions
Havanond39 observational study
• Substances: acid, 62%; alkali, 3%; household cleaner, 15%;
dishwasher detergent, 12%; bleach, 7%; and unknown, 1%
• All patients had endoscopy within 24 h
• Most (82.4%) had low-grade (type 1–type 2a) injury
• Presenting symptoms: nausea and vomiting 84%; drooling 24%;
abdominal pain 34%; hoarseness 14%; oral lesions: lip 33%, buccal
43%, tongue 44%, palate 49%; abdominal pain 34%
• Drooling saliva, buccal mucosal burn and white cell count were the
significant independent predictors of GI injury (stepwise logistic
regression OR: 112.4, 5.0 and 28.3, respectively)
Gün et al.40 2007 Retrospective 296 children • 100% of unintentional ingestion
observational study
• Substances: 76% of sodium hydroxide (it is unclear what remainder
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were)
• All had endoscopy (rigid) at 24–48 h
• 20 (7%) cases had grade-3 injury
• Data on signs and symptoms were not recorded
• All were treated conservatively (grades 2b and 3 had a week of a
nasogastric tube and oesophageal rest, and then had oesophageal
dilatation after 3 weeks as needed)
Arevalo-Silva 2006 Retrospective 25 children and • 23% of intentional and 77% of unintentional ingestions
et al.41 observational study 25 adults
• Substances ingested: acidic, 32%; alkaline, 42%; and bleach, 26%
• Rigid oesophagoscopy performed 6–48 h under general anaesthetic
to grade injury in 84% (selection is unclear). Most had grade-1
For personal use only.

injuries (44/50)
• More serious injuries were recorded in 33% who were ‘suicidal’
(64.5% of grade 3 or grade 4) than in the ‘accidental’ group
(10% of grade 3 or grade 4)
• Proportion of second degree (27%), third degree (27%) and fourth
degree (27%) was higher than that in the alkaline group (12%, 23%
and 12%, respectively)
• Signs and symptoms were not recorded
Doğan et al.42 2006 Retrospective 473 children • Substances most commonly encountered: concentrated bleach
observational study (36.6%) and oven cleaner (23%)
• Endoscopy done within 48 h in all children
• Endoscopy results: No damage in 20%, mild injury (grade 1 or
grade 2a) in 48% and severe injury (grade 2b or grade 3) in 32%
• Oesophageal lesions seen in 61% who had no oral cavity burns
• No record of symptoms or signs apart from 208 patients who had
vomited. No correlation was made of these on endoscopy compared
to the other children
Turner and 2005 Retrospective 32 children • 9% of intentional and 91% of unintentional ingestions
Robinson43 observational study
• Commonest substances: dishwasher powder (31%), bleach (18%)
and caustic soda granules (15.6%)
• All but one patient underwent oesophagoscopy within 24 h
• Results of oesophagoscopy stated to alter the therapy (not stated
exactly how) in 2 cases (6%)
• Twenty patients were drooling on arrival and twenty patients had
oropharyngeal ulceration
• Grade found at endoscopy was not recorded and therefore symptoms
could not be linked to grade
Satar et al.44 2004 Retrospective 37 adults • 86.5% of unintentional and 13.5% intentional ingestions
observational study • 65% had ingested alkali (sodium hypochlorite) and 35% had ingested
acid (hydrochloric acid)
• Endoscopy was attempted in all patients (and completed in a mean
time of 7.8 h after admission). Majority had grade-0 or grade-1
injury (67.5%) and none had grade-3 injury
• No data on symptoms or signs were collected
(Continued )

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 Corrosive ingestion management 917

Table 3. (Continued )

Author Year Study Type Number in study Key results

Poley et al.45 2004 Retrospective 179 adults • 85% of intentional and 15% of unintentional ingestions
observational study
• Substance ingested: acid, 47.5%; and alkali, 52.5%
• All patients had an endoscopy within 8 h of admission. 40% of cases
were grade 0 or grade 1, 30% of cases were grade 2 and 30% of
cases were grade 3. Patients who ingested acid were more likely to
go to ICU
• No complications from endoscopy
• Data on signs and symptoms were not collected
Mamede and 2002 Retrospective 239 adults • 60% of intentional and 37.2% of unintentional ingestions
De Mello observational study
Filho15
• All had consumed caustic soda
• No data on the timing of endoscopy
• Recorded number of spoons of caustic soda was compared to
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tablespoons of sugar
• Among those who consumed trace amounts, 47% developed a steno-
sis but among those who consumed one or more tablespoons, 90%
developed stenosis
• No data on symptoms were collected
Rigo et al.46 2002 Retrospective 210 adults • 60% of intentional and 40% of unintentional ingestions
observational study
• Substances: acids, 28%; alkali, 17%; bleach, 31%; ammonia, 6.7%;
others, 11.9%; and unknown, 5.2%
• All patients were admitted within 12 h and had endoscopy within
24 h
• Results: 13 patients (6.2%) underwent emergency surgery and
For personal use only.

25 patients (11.9%) died

• Endoscopy findings: no oesophageal injury, 49%; grade-1 injury,
32%; grade-2 injury, 13%; and grade-3 injury, 6%
• Multivariate analysis identified the following as independent
predictors of death: age (10-year intervals; OR: 2.4; 95% CI:
1.4–4.1), ingestion of ‘strong acids’ (OR: 7.9; 1.8–35.3), white
blood cell count at admission ⬎ or ⫽ 20 000 units/mm3 (OR 6.0;
1.3–28), deep gastric ulcers (OR: 9.7; 1.4–66.8) and gastric
necrosis (OR: 20.9; 4.7–91.8)
de Jong et al.47 2001 Retrospective 80 children • Oesophagoscopy was performed in 35 cases (selection criteria were
observational study unspecified). Within 24 h in 7 cases, between 1 and 3 days in 15
cases, between 4 and 7 days in 8 cases and 5 cases had oesophagos-
copy performed ⬎ 7 days after the initial injury
• There was no description of symptoms and signs
• 58% had first- or second-degree burns shown orally or on endoscopy,
and 16% had third-degree burns
Gupta et al.48 2001 Retrospective 28 children • A variety of substances were ingested: lye-containing cleaning
observational study agents, bleach, hair relaxant and hair dye were the most common
• All the 3 patients with grade-3 injuries had taken lye-containing
cleaning agents
• All the 4 asymptomatic patients had normal findings on endoscopy
• All the 8 patients with abnormal findings on endoscopy were
symptomatic (grade 1 in 3/28, grade 2 in 2/28 and grade 3 in 3/28)
• No single symptom or combination of symptoms could identify all
patients with oesophageal injury
Lamireau 2001 Prospective study 85 children • 100% of unintentional ingestion
et al.49
• Substances: alkali, 61%; acid, 19%; and other, 17%
• Endoscopy results: Normal mucosa 47%, ‘minimal’ oesophageal
injury 27% and ‘severe’ injury 26%
• The presence of 3 symptoms of vomiting, drooling, haematemesis,
respiratory distress or oral lesions was strongly associated with
severe lesions. Predictive value of symptoms for severe injury – a)
vomiting: PPV, 0.45; NPV, 0.80; sensitivity, 0.40; specificity, 0.82.
b) Drooling: 0.12, 0.72, 0.04, 0.88; c) Oral lesions: 0.71, 0.81, 0.43,
0.93; d) Respiratory Distress, 1, 0.78, 0.22, 1; and e) Haematemesis:
1, 0.75, 0.20, 1
(Continued )
Copyright © Informa Healthcare USA, Inc. 2014
 918 K. S. Bonnici et al.

Table 3. (Continued )

Author Year Study Type Number in study Key results

• The absence of symptoms was always associated with no or minimal

lesions. Predictive value of no symptoms:
a) PPV 0, NPV 1, sensitivity 0 and specificity 0.31; ⬎ 3 symptoms
b) PPV 1, NPV 0.75, sensitivity 0.20 and specificity 1
Christesen50 1995 Retrospective 115 children • Substances: strong alkali, 63%; weak alkali, 21%; and acids, 16%
observational study
• All patients who had complications had taken strong alkalis
• All endoscopies were done 6 h to 4 days post ingestion. The number
of each grade was not listed
• Results: Predictive values of symptoms and signs relating to
oesophageal complications (commonly stricture):
• Oral Injury: PPV, 0.31; NPV, 1; sensitivity, 1; specificity, 0.47.
• Vomiting: 0.38, 0.93, 0.75, 0.25. Drooling: 0.40, 0.90, 0.30, 0.10.
Dyspnoea: 0.78, 0.88, 0.35, 0.02
• All children with complications had at least one sign or symptom:
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• ⬎ 1 symptoms/signs: 0.26, 1, 1, 0.62; ⬎ 3 symptoms/signs 0.91, 0.90,

0.50, 0.01
Andreoni 1995 Retrospective 57 adults • 26% of unintentional and 26% of intentional ingestions
et al.51 observational study
• All patients had an endoscopy between 6 and 12 h if there was no
evidence of perforation
• Substances ingested: bleach, 52%; acids, 15%; alkalis, 18%; ammo-
nia, 6%; and others, 9%
• Patients fell into 3 categories based on their protocol: Requiring
immediate surgery (4 patients) or early surgery (9 patients) in case
of perforation or grade-3 and grade-4 injuries or second-degree
symptoms, or conservative treatment in case of grade-2 findings and
For personal use only.

negative examination or grade-1 findings on endoscopy (37 patients)

• Endoscopic findings: grade 1, 52%; grade 2, 22%; grade 3 or 4, 26%.
The proportion with symptoms in each category was not mentioned
Gorman et al.8 1992 Prospective 7 poison centres • 85.4% of unintentional, 9.8% of intentional (but accounted for 44%
observational study (336 children of the positive oesophagoscopies), 0.9% of occupational, 1.8% of
and adults) accidental misuse, 0.3% of intentional misuse and 1.8% of unknown
ingestions
• Substances: Cleaners of varying types, 72%; ammonia, 8.3%; hair
care products, 8.3%; lye, 4%; and others, 7.7%
• Eighty-eight (26%) patients had an oesophagoscopy. 53% had posi-
tive oesophagoscopy reports in intentional ingestions compared with
20.8% who had positive findings within the unintentional group
• Symptom reports were available in 63 of 88 patients undergoing
endoscopy
• 45 (71%) had no or grade-1 injury and 18 (29%) had grade-2 or
grade-3 injury
• 87% of oesophagoscopies were performed in 24 h or less
• Analysis of initial symptoms as predictors of significant oesophageal
injury was performed in these 63 cases
• Oral burns: PPV, 0.31; NPV, 0.79; sensitivity, 0.83; specificity, 0.24.
Vomiting: 0.52, 0.87, 0.72, 0.73; Abdominal Pain: 0.36, 0.83, 0.71,
0.53; Dysphagia: 0.67, 0.88, 0.71, 0.86; Drooling: 0.37, 0.78, 0.61,
0.57; Refused to swallow: 0.38, 0.79, 0.54, 0.67; Cough: 0.40, 0.73,
0.22, 0.86; Nausea: 0.38, 0.71, 0.18, 0.87; Stridor: 1, 0.75, 0.17, 1
• All patients with positive oesophagoscopies (grade 2 or grade 3)
were symptomatic but no particular symptom group was completely
predictive
• The presence of 2 or more of oral burns, vomiting, pain and dys-
phagia had excellent sensitivity (0.94) and NPV (0.96)
• Suicidal patients were more likely to suffer significant injury: 53% of
positive oesophagoscopy reports in intentional overdose compared
with 20.8% of those in accidental overdose
Zargar et al.52 1992 Prospective 31 patients • 26% of unintentional and 74% of intentional ingestions
observational study
• Substance ingested: Alkali, 100%
• Endoscopy done within 36 h in all patients
(Continued )
Clinical Toxicology vol. 52 no. 9 2014
 Corrosive ingestion management 919

Table 3. (Continued )

Author Year Study Type Number in study Key results

• None of the patients had grade-0 or grade-1 injury and 17 patients

Zargar et al.21 1991
Clinical Toxicology Downloaded from informahealthcare.com by University of Ottawa on 11/23/14
had grade-3 injury
• Oropharyngeal pain and dysphagia (24 patients), salivation (20
patients), retrosternal pain (12 patients), epigastric pain (17 patients)
and vomiting and retching (14 patients); 23 patients had oropharyn-
geal burns, but 8 had abnormality of the GI tract without these burns
(although it is unknown whether any of these were asymptomatic)
• There is no statistically significant relationship between the presence
and severity of oropharyngeal symptoms and upper GI tract injury
Prospective observa- 81 children and • 88 endoscopies done up to 96 h, 108 between third and ninth week
tional study adults but total and others done later for follow-up
381 endoscopic
examinations
• 67% had ingested acid and 33% had ingested alkali
• The commonest grades found were grade 2 (40.7%) and grade 3

(38.3%)
Ferguson 1989 Retrospective observa- 41 children and • 95% had unintentional ingestions and 5% (2 adults) had ingested
et al.53 tional study adults caustics intentionally
• Thirty-one patients had an oesophagoscopy and this was done within
36 h
• Sodium hydroxide or potassium hydride, 59%; drain cleaner, 17%;
ammonia 7.3%; bleach, 2.4%; and others, unspecified
• 13 patients had a barium swallow, but this was normal in 11 cases
when there was an abnormal oesophagoscopy
• Reasons for why the other patients did not have an oesophagoscopy
are unclear
• The physical signs on admission were listed, which included 35 with
For personal use only.

burns in the lip or tongue, but no correlation to injury found in the

oesophagus was presented
• All those who had grade-1 injury at initial endoscopy did not develop
strictures but all with grade-2 or grade-3 injury developed severe
strictures
Sarfati et al.54 1987 Retrospective observa- 484 adults • Substances: sodium hydroxide, 34%; chlorine bleach, 60%; acid,
tional study 24%; and ammonia, 2%. No comment on the outcome of each group
• All patients had an endoscopy as part of the initial assessment: no
data on timing
• Patients were assigned to group 1: superficial injury and no surgery
• (250 patients), group 2: patients who required emergency surgery
(44 patients), or group 3: patients who had oesophageal and gastric
ulceration, but no necrosis and so did not require surgery (190
patients)
• There was no mention of symptoms of patients on arrival
Thompson55 1987 Case series 9 adults • 100% of unintentional ingestions of sodium hydroxide
• All the patients were taken into operating room for rigid oesophagos-
copy within 6 h of presentation
• All the patients had odynophagia and 4 also had chest and abdominal
pain. All of them also had burns of varying degree in the mouth
• Endoscopy: 1 had oesophageal third-degree and 5 had second-degree
burns, and 3 had normal findings.
• In the series, 6/9 patients needed some intervention immediately or
as a delayed procedure
Schild56 1985 Retrospective observa- 16 adults • 10 were intentional (62.5%), 4 were unintentional (25%) and 2
tional study (12.5%) were questionably unintentional ingestions. Morbidity and
mortality were higher in those with intentional ingestion
• All patients but one had an endoscopy that was done within 48 h
• 75% ingested alkaline materials and 25% ingested acidic substances
• 2 patients had evidence of a perforated viscus on admission and 14
had oesophagoscopy under GA and 1 under topical anaesthesia. All
the patients had evidence of burn injuries at some point from the
mouth to the oesophagus
• All the patients had mouth injury at initial assessment but 11 also had
injury to the oesophagus
(Continued )

Copyright © Informa Healthcare USA, Inc. 2014

 920 K. S. Bonnici et al.

Table 3. (Continued )

Author Year Study Type Number in study Key results

Dilawari 1984 Prospective 16 adults • 69% of unintentional and 31% of intentional ingestions
et al.57 observational study
• Substances: All patients had taken acids of varying types
• 13 patients had endoscopy within 9–32 h of ingestion (mean: 21 h)
• Grade-1 findings were not found in any patient. 5 had grade-2 and
10 had grade-3 injuries
• Symptoms: epigastric pain, 94%; vomiting, 88%; haematemesis,
• 75%; and oral injury, 75%. No correlation between symptoms and
endoscopy findings was reported
Crain et al.58 1984 Retrospective 79 patients • 85% of unintentional, 3% of intentional and 12% of unknown inges-
observational study (all under tions
age 20) • Substances: lye, 76%; ammonia, 9%; oven cleaner, 9%; clinitest
tablet, 5%; and cresylic acid, 1%
• Endoscopic results: no or mild (grade 1) injury, 91%; and serious
injury 9% (grade 2 or 3)
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• Normal endoscopy findings in the 65 with none or one of 3 symp-

toms (vomiting, drooling and stridor)
• 66 (90%) of the 73 patients who had symptoms had no injury
(p ⫽ ⬍ 0.001)
• All 6 who had no symptoms also had normal endoscopy (p ⫽ ⬎ 0.40)
• All 7 patients who had positive endoscopic findings had 2 or more
symptoms
• The presence of 2 signs or symptoms had a sensitivity of 100% for
submucosal injury
Gaudreault 1983 Retrospective 378 children • Substances: alkali, 86%; and acids, 14%
et al.59 observational study
• All patients had an oesophagoscopy within 48 h
For personal use only.

• Of the 298 children who demonstrated signs or symptoms, 243

(82%) had a grade-0 or grade-1 lesion and 55 (18%) had a grade-2
lesion and there were no grade-3 lesions
• Among the 80 patients who had no signs or symptoms, none had a
grade-3 lesion (but one went on to have an oesophageal stricture and
10 had grade-2 lesions)
• Frequency of a positive endoscopy result with symptoms
(grade-2 lesion or above): vomiting, 33%; dysphagia, 25%;
excessive salivation, 24%; abdominal pain, 24%; refusal to drink,
20%; and oral burn, 18%
Cello et al. 18 1980 Retrospective 17 adults • Substances: sodium hydroxide, 53%; ammonia, 12%; and others,
observational study 35%
• Endoscopy was performed in 16 subjects (time was not given) and
one was taken straight to theatre
• All patients had either some signs or symptoms: dysphagia, 35%;
abdominal pain, 47%; haematemesis, 35%; oral burns, 88%; and
abdominal pain, 29%. There was no correlation between these and
the endoscopy findings
• Endoscopy findings: normal, 6%; mild oesophageal disease, 35%;
moderate, 24%; and severe, 35%
Hawkins 1980 4-year retrospective 214 (96 children • Aimed to do an oesophagoscopy using a rigid scope within 36 h in all
et al.9 Study and 3-year and 118 adults) cases but in cases of severe airway oedema, it was postponed by up
prospective Study to 7 days to allow it to settle. The procedure was also not performed
in those who had perforated
• One patient died as a result of mediastinitis secondary to an oesopha-
goscopy done 36 h before. The patient was diabetic and had evidence
of perforation post scope but it was unclear how severe pre-scope the
patient was or at what hour post ingestion this was performed

oesophageal injury.30 A further study also found that those
who had ingested acid were more likely to go on to have a
higher grade of injury (grade 2 vs. grade 1, p ⫽ 0.013), a lon-
ger hospital stay (9.9 vs. 7.2 days, p ⫽ 0.01), and were more
likely to be admitted to the intensive care unit (44% vs. 22%,
p ⫽ 0.002) and to have a higher rate of complications (24%
vs. 3%, p ⫽ ⬍ 0.001) and death (14% vs. 2%, p ⫽ 0.003).45
Ingestion of a ‘strong acid’ has been identified as one of the
independent predictors of death in multivariate analysis (odds
ratio (OR): 7.9, 95% CI: 1.8–35.3).46
However, products that contain strong alkalis can also
be associated with severe, potentially devastating, injury as
Clinical Toxicology vol. 52 no. 9 2014

explained by Gupta et al.48 (3/3 patients who had grade-3
injuries had consumed lye) and Christesen et al.50 (36.8% of
lye ingestions led to complications) have shown.
We examined the proportions of intentional and uninten-
tional ingestions within each of the studies when recorded in
order to find out whether this should be included within our
protocol as a discerning feature. Three studies37,38,45 found
that intentional ingestions correlated with a higher inci-
dence of positive findings on endoscopy. As expected, the
four studies31,35,36,40 in which the cases were mainly unin-
tentional had a high proportion of low-grade injuries found
on endoscopy. The potentially confounding factor is that the
majority of unintentional ingestions were in children who
tend to ingest smaller volumes upon tasting the substance.
Arevalo-Silva et al.41 retrospectively reviewed the oeso-
phageal injuries in a cohort of 50 patients (25 adults and
Clinical Toxicology Downloaded from informahealthcare.com by University of Ottawa on 11/23/14
25 children); Forty-two patients underwent rigid endoscopy,
of which fourteen cases were intentional ingestions and
twenty-eight cases were unintentional ingestions. Nine of
the fourteen patients who had ingested a corrosive intention-
ally had grade-3 or grade-4 injuries whilst only 10% (3 of
28 patients) of the accidental group had such severe injuries.
Gorman et al.8 found similar results within their prospective
observational study that included 7 poison centres and 336
children and adults; there were 53% positive oesophagos-
copy reports in the intentional ingestion group compared
For personal use only.
with 20.8% positive findings within the unintentional group.
Mamede et al.15 related the risk of stenosis to the reported
quantity of ingested sodium hydroxide. Stenosis occurred in
47% of those who had ingested ‘trace’ amounts of sodium
hydroxide, whilst it occurred in 90% of those who had
reportedly consumed one or more tablespoons.
Eleven of the 35 studies specifically mention that the
symptoms of drooling, dysphagia, vomiting and pain are a
marker of high-grade injury.8,18,33–36,39,49,50,58,59 Several also
comment on oral lesions being another marker, although
none of these have been shown to be perfect indicators. Kaya
et al.34 found that 65% of those with high-grade injury had
oral lesions. In a cohort of 85 children with corrosive inges-
tion, Lamireau et al.49 calculated the predictive value for oral
lesions to be as follows: positive predictive value (PPV) of
0.71, negative predictive value (NPV) of 0.81, sensitivity of
0.43 and specificity of 0.93 for severe oesophageal injury.
Several studies suggest that the severity of the lesions
found on endoscopy increased with the number and sever-
ity of the presenting signs and symptoms.36,39,46,49,49,60 In
the multivariate analysis done within a multicentre obser-
vational study, which included 162 children, Betalli et al.36
found that the presence of symptoms was the strongest pre-
dictor of severe oesophageal lesions. The predictive value
of the presence of more than three symptoms with relation
to a third-degree injury was as follows: PPV of 0.47, NPV
of 0.93, sensitivity of 0.47 and 1-specificity of 0.07. An
observational study of 210 adults, focussing on predictors
of death rather than oesophageal injury, found leucocytosis
(WBC ⱖ 20 ⫻ 109/L) to be correlated to adverse outcome
(OR: 6.0 and 95% CI: 1.3–28).46 Some studies also dem-
onstrated that the absence of clinical signs or symptoms on
Copyright © Informa Healthcare USA, Inc. 2014
Corrosive ingestion management 921
admission correlated with no or low-grade injury found on
endoscopy.49,58 Lamireau et al.49 found that PPV and NPV
for severe oesophageal injury were 0 and 1, respectively, for
zero symptoms; 0.54 and 0.92, respectively, for one and two
symptoms; and 1 and 0.75, respectively, for three and more
symptoms. Among their cohort of 85 children, the absence
of symptoms was always associated with no or minimal
lesions. All of the 6 patients without symptoms in the study
by Crain et al.58 had a normal endoscopy.
Kaya et al.34 reviewed their experience with 134 children
and concluded that ‘all patients with corrosive ingestion
should have an endoscopy because no system is completely
fail-safe and overtreatment is better than undertreatment’.
However, within this study, 70% of patients were asymp-
tomatic and the absence of clinical signs correlated with no
or low-grade injury on endoscopy. In addition, significant
clinical features (drooling saliva and oral lesions, along with
leucocytosis (WBC ⬎ 10.5 ⫻ 109/L)) were associated with
high-grade injury on endoscopy.
Temiz et al.30 also concluded that every patient should
have endoscopy given that 19.3% of children in this study
with severe injuries had no signs or symptoms. However,
their findings are limited because in this study, some form
of rationalisation took place prior to consideration of endos-
copy. Patients did not undergo endoscopy if it was felt that
they had a ‘questionable history’ and were asymptomatic
with no clinical signs. This study took place in Sierra Leone
and, as might be expected, studies done there and in India
have a higher incidence of high-grade injury compared to the
developed world studies that were reviewed.25,47,52,60
Both the study by Kaya et al.34 and that by Temiz et al.30
were entirely in children (mean age of 3.4 years and 38.1
months, respectively); often the history and the circum-
stances surrounding ingestions are less clear, and symptoms/
signs can be harder to elicit.
Based on these observational studies, it seems reasonable
to avoid endoscopy in adults who are asymptomatic and who
have no clinical signs. However, it seems reasonable to have
a more cautious approach in managing children after corro-
sive ingestion and an extended period of observation would
be prudent if the decision was made to avoid endoscopy in
an asymptomatic child.
The reason often given for undertaking endoscopy in all
patients is that a grade-3 injury might be missed otherwise.
In the vast majority of studies reviewed here, asymptomatic
patients with a normal examination had either no or mild
injuries found on endoscopy. Only two studies reported find-
ing severe injuries in patients such as these. Temiz et al.30
documented 6 of 206 children while Arici et al.31 docu-
mented 1 of 182 children and adults having severe injury
despite having no symptoms and signs. In light of the data
from the literature review suggesting that patients, particu-
larly adults, who are asymptomatic at presentation, rarely
have clinically significant/high-grade endoscopy findings,
it seems reasonable to recommend that these patients do
not require an endoscopy. However, patients with clinically
significant symptoms, in particular drooling, dysphagia,
vomiting or pain or the presence of oral lesions should have
 922 K. S. Bonnici et al.
an early endoscopy as a number of observational case series
have suggested a good correlation between these features
and high-grade findings at endoscopy; other severe outcomes
including the need for surgery and mortality are also likely
to be higher in these patients.
In summary, we suggest that any patient, who reports no
symptoms or signs after the ingestion of a commercial agent
containing a corrosive and continues to be asymptomatic
after being given oral fluids and food, can be discharged with
confidence without the need for an endoscopy. We recom-
mend that these patients be advised to return in the event of
developing dysphagia. A higher level of caution should be
exercised in treating children in whom symptoms and signs
might be harder to elicit; a longer observation period may be
appropriate, although there are no data available to recom-
mend the duration of the longer observation period.
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How soon after ingestion should investigation
be performed?
In terms of the timing of investigation, the studies listed in
Table 3 demonstrate a large variation in the protocols used
across the world currently, and it is difficult in view of the
variable endoscopy findings in these observational studies
to be definitive in this regard. However, it appears that early
endoscopy is safe and without complications.44,45 Further-
For personal use only.
more, endoscopy as early as 6 h from presentation has also
been shown to be useful in planning early surgical proce-
dures that can be life-saving.55
We did not find any evidence to support the claim that
endoscopy is especially risky beyond 48 h; in fact, there
are many instances of endoscopy being done later safely.
Riffat and Cheng35 describe a series of 50 children in
whom they undertook endoscopy safely at 48–72 h as they
wanted the effects of injury to be fully established with
the view to making grading more reliable. de Jong et al.47
described 8 cases of corrosive ingestion that underwent
endoscopy on days 4–7 without any complications. In the
original study by Zargar et al.21 in 1991, which proposed
the grading criteria, 381 endoscopic examinations were
performed among 81 patients who underwent endoscopy
after corrosive ingestion; 88 endoscopies were carried
out within 96 h of ingestion (mean, 21 ⫾ 11.5 h), and 108
endoscopies occurred between the third and ninth weeks,
and 185 examinations occurred after nine weeks for the
follow-up of strictures treated with bougie dilation. There
were no complications reported as a result of the procedure
at any of these times.
Management recommendations
Based on the above information, we have developed an algo-
rithm that can be used to guide the investigation and man-
agement of patients with corrosive ingestion (Fig. 1).
Patients with severe clinical features, in particular stridor
or other signs of airway compromise, may require early intu-
bation as per ACLS/ATLS guidelines. An erect chest X-ray
is required in these cases to rule out perforation as well as to
assess whether aspiration has occurred. Steroids have now
been found to have no place in the management of patients
with corrosive ingestion and thus have not been included in
this guideline.61–63
Empiric use of histamine H2-receptor antagonists,
and more recently of proton pump inhibitors (PPIs), has
been common. Although the rationale for using either an
H2-receptor antagonist or a PPI intuitively seems reason-
able, no controlled study has confirmed whether H2-receptor
antagonists or PPIs improve outcomes or whether one is
superior to the other. Further, no study has determined the
optimum dose of either H2-receptor antagonists or PPIs in
either adults or children. A small case series of 13 adult
patients published by Cakal et al.64 in 2013 suggested the
benefit of a high-dose bolus of IV omeprazole (80 mg) fol-
lowed by a 72-h omeprazole infusion at a rate of 8 mg/h.
They described findings of repeat endoscopy after 72 h of
treatment and reported that nine patients had healed com-
pletely, three improved to grade one, and one patient still
had grade-three injury. Based upon this limited evidence, we
suggest that patients with any signs or symptoms should be
treated initially with a high-dose proton pump inhibitor.
We make no recommendation about estimating the vol-
ume or substance strength given the known problems of
reliability in such estimates from the history.5 Although the
available data suggest that intentional ingestions and those
of acidic substances were more likely to be serious, there
were enough unintentional and alkaline ingestions with poor
outcome for these to still require investigation if associated
with signs or symptoms.
If adult patients remain asymptomatic 4 h after ingestion
and are able to eat and drink normally then, based on the lit-
erature reviewed here, the risk of clinically significant injury
is low and they can be discharged. In older children who
can reliably give a history and confirm an absence of symp-
toms, the 4-h observation may be reasonable, but in younger
children in whom we do not know their exact symptoms, it
seems reasonable that we be more cautious and consider a
longer observation period. In the following 4–8 weeks, we
advise that if atients develop pain on swallowing; pain in the
throat, neck or upper abdomen; or experience the sensation
of food getting stuck in the gullet, they should present to
their GP (primary care physician) or to an emergency depart-
ment as they may need further investigation.
If patients have any oropharyngeal injury and in particular
symptoms of drooling, vomiting, dysphagia or pain (retros-
ternal or otherwise), the risk of having a high-grade injury
is higher and endoscopy should be performed as a matter of
urgency in order to grade the injury and determine whether
surgical intervention may be required. Patients who have
non-specific symptoms, such as cough, should also undergo
endoscopy but this is less urgent and could wait until the
next working day.
Conclusions
Despite a lack of quality clinical trial data, the available
evidence and clinical experience support the use of early
Clinical Toxicology vol. 52 no. 9 2014
 Corrosive ingestion management 923
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For personal use only.

Fig. 1. Algorithm for the initial management of corrosive injuries in adults.

endoscopy (⬍ 12 h) as the initial investigation of choice in in the first instance, a ‘normal’ result may not exclude
symptomatic patients with corrosive ingestion. Endoscopy significant risk of evolving injury. We propose a clinical
is preferred over CT in the assessment of risk in symp- guideline that can be used to help plan management of
tomatic patients with corrosive ingestion. If CT is used corrosives.

Copyright © Informa Healthcare USA, Inc. 2014

 924 K. S. Bonnici et al.
Declaration of interest
The authors report no declarations of interest. The authors
alone are responsible for the content and wirting of the
paper.
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