Review

Caustic ingestion
Mircea Chirica, Luigi Bonavina, Michael D Kelly, Emile Sarfati, Pierre Cattan

Corrosive ingestion is a rare but potentially devastating event and, despite the availability of effective preventive public Lancet 2017; 389: 2041–52
health strategies, injuries continue to occur. Most clinicians have limited personal experience and rely on guidelines; Published Online
however, uncertainty persists about best clinical practice. Ingestions range from mild cases with no injury to severe October 26, 2016
http://dx.doi.org/10.1016/
cases with full thickness necrosis of the oesophagus and stomach. CT scan is superior to traditional endoscopy for
S0140-6736(16)30313-0
stratification of patients to emergency resection or observation. Oesophageal stricture is a common consequence of
Department of Digestive and
ingestion and newer stents show some promise; however, the place of endoscopic stenting for corrosive strictures is Emergency Surgery, University
yet to be defined. We summarise the evidence to provide a plan for managing these potentially life-threatening Hospital of Grenoble, Grenoble
injuries and discuss the areas where further research is required to improve outcomes. Alpes University, Grenoble,
France (M Chirica MD PhD);
University of Milan Medical
Introduction corrosive injuries is increasing, especially in low-income School, Division of General
Corrosive ingestion is a rare but potentially devastating countries because of a lack of effective regulatory Surgery, IRCCS Policlinico
event that induces significant burdens on modern health measures and public health prevention programmes.3 San Donato, Milan, Italy
(Prof L Bonavina MD);
systems worldwide.1,2 Management requires a multi­ Two age groups are most at risk: first, children aged
Acute Surgical Unit, Canberra
disciplinary approach involving a wide range of 2–6 years who unintentionally ingest household cleaning Hospital, Garran, Australian
specialties including emergency care physicians, products and account for up to 80% of caustic ingestion Capital Territory, Australia
surgeons, anaesthesiologists, gastroenterologists, radio­ cases but usually have mild injuries;6–8 and second, adults (M D Kelly MS); and Department
of Digestive and Endocrine
logists, otorhynolaryngologists, and psychiatrists.3 The aged 30–40 years who have usually ingested strong Surgery, Saint-Louis Hospital
low incidence of caustic injuries means that clinicians corrosives with suicidal intent and present with severe, AP-HP, Université Paris Diderot
usually have limited personal experience and in the life-threatening injuries.9,10 Sorbonne Paris Cité, Paris,
absence of evidence-based guidelines, uncertainty The corrosive agents involved include a wide range of France (Prof E Sarfati MD,
Prof P Cattan MD PhD)
persists about best clinical practice. This uncertainty is chemicals that cause damage to and destruction of living
Correspondence to:
mirrored by significant variations in patient management tissue on contact. Strong acids produce a coagulative
Dr Mircea Chirica, Department of
and reported outcomes across the world. The aim of this necrosis that lessens tissue penetration and decreases Digestive and Emergency
Review is to summarise current data and highlight damage.2,3,11,12 Oesophageal eschar formation and Surgery, University Hospital of
existing controversies regarding digestive tract injuries prolonged gastric contact time due to pylorospasm Grenoble, Grenoble Alpes
University, Grenoble, France
resulting from caustic ingestion. explains the preferential stomach involvement of acids. mchirica@chu-grenoble.fr
Worldwide epidemiological data are scarce mainly Alkalis produce liquefactive necrosis, which results in
because of under-reporting of caustic ingestion.2,3 immediately severe injuries at all levels of the
According to the 2013 annual report of the American gastrointestinal tract.2,3,11,12 Acid ingestion is more
Association of Poison Control Centers, there were nearly
60 000 cases of exposure to corrosive agents (48 000 to
bleach, 7500 to acids, 4000 to alkalis), most of which Key messages
occurred by ingestion; 30 fatalities could be undoubtedly • Accidental ingestion by children accounts for 80% of cases worldwide whereas in
related to corrosive ingestion.4 In the UK, 15 000 corrosive adults most ingestions are intentional resulting from underlying psychiatric illness
exposure incidents are recorded every year, but these • Emergency management of caustic ingestion and the treatment of late sequelae
figures also include other exposure routes (dermal, require a multidisciplinary approach
ocular).5 However, the true worldwide incidence of • CT examination is reliable and reproducible in assessing transmural digestive necrosis
ingestion and prevalence of lesions such as strictures, and improves the selection of patients for surgery
including high-incidence countries and regions such as • Surgical resection of organs subject to transmural necrosis is life-saving and should be
France, India, northern Africa, and eastern Europe, is done in first-level hospitals; age, the extent of initial damage, and the derangement of
unknown.3,5 It has been suggested that the incidence of laboratory test results predict survival in these cases
• Treatment of late sequelae of caustic ingestion relies mainly on endoscopy (dilation,
stenting) or complex surgical reconstructive procedures and should be done in expert
Search strategy and selection criteria
referral centres
We searched MEDLINE and Embase for relevant papers • Surgery (emergency or reconstructive) is seldom required in children; on such rare
published in English between Jan 1, 1990, and Feb 1, 2016, occasions, surgical decisions and procedures should be done in expert centres
using the following terms: “caustic ingestion”, “caustic • In low-resource settings, simple solutions such as gastrostomy placement are
lesions”, “corrosive injuries”, “esophagus”, “stomach”, preferable and can be life-saving by addressing vital nutritional issues; complex
“esophageal dilatation”, “gastric outlet obstruction”, endoscopic or surgical procedures in such conditions should be done cautiously
“esophageal reconstruction”, and “coloplasty”. Reports from • Public health programmes to educate the public and establish effective measures
within the past 5 years were selected preferentially together limiting access to strong corrosive agents are paramount to decrease the incidence
with commonly quoted older publications. and severity of caustic ingestion

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 Review

common in Asian countries such as India,13 Taiwan,10 and necrosis of intra-abdominal organs results in perforation,
South Korea,14 whereas alkalis account for most severe peritonitis, and death.22,23 Transoesophageal extension of
caustic injuries in western Europe1 and South America.15 necrosis to the mediastinum might involve adjacent
It is unclear whether the nature of the ingested corrosive structures with dramatic effects (eg, tracheobronchial
(ie, acid or alkali) affects patient outcomes in cases of necrosis,24 aorto-oesophageal fistula25). However, it is
massive ingestion.2,3,11,16 Oxidants (bleach) usually cause unclear whether isolated full-thickness oesophageal
mild injuries by transformation of aminoacids into necrosis is uniformly fatal without surgery.23,26
aldehydes and protein denaturation. Ammonia induces Concomitant airway aspiration of the corrosive agent
superficial haemorrhagic gastritis, which might progress can result in progressive development of caustic
24–48 h after ingestion and requires specific surveillance. pneumonia.27 Along with local effects, caustic ingestion
The physical form of the ingested agent determines the might induce systemic inflammatory response
pattern of damage to the gastrointestinal tract. Solid syndrome, sepsis, and a severe catabolic state, increasing
agents adhere to the mouth and pharynx producing systemic complications and mortality.17
maximum damage to these areas, whereas liquids transit
rapidly and induce burns of the oesophagus and the Management
stomach; concomitant vapour aspiration (of ammonia or The main purpose of emergency management is patient
formaldehyde) may cause airway burns. The ingested survival and then all efforts should focus on treatment of
quantity is a major determinant of outcome (in adults, a early complications, prevention of delayed sequelae,
normal sip is 30–50 mL, a large gulp is 60–90 mL) but preservation of nutritional autonomy, and quality of life.
this information is seldom available.2,3 Early contact of
poison control centres is recommended17 because some Initial approach
corrosives can also cause severe systemic effects such Initial measures aim to avoid aggravation of injuries,
as hypocalcaemia (phosphoric, hydrofluoric acids), control organ failure, and address potential systemic
hyponatraemia (strong acids or alkalis), hypokalaemia, effects. During the pre-hospital phase, it is paramount to
and acidosis. confirm ingestion and identify the corrosive agent,
Significant tissue damage occurs within seconds of evaluate the context (accidental vs intentional) and the time
ingestion of strong corrosive agents.18 Haemorrhage, from ingestion, detect co-ingestion of drugs including
thrombosis, and inflammation with oedema are the alcohol, and identify additional risk factors (pregnancy,
dominant processes during the first 24 h following extreme age, medical comorbidities).17 Manoeuvres liable
ingestion. Severe burns can progress to focal areas of to induce repeat oesophageal passage or risk aspiration of
necrosis with perforation as inflammation extends the corrosive agent (supine position, gastric lavage,
through muscle layers with submucosal thrombosis and ingestion of diluents) as well as attempts at pH
bacterial invasion. On pathological examination, neutralisation should be avoided because they are likely to
transmural necrosis shows specific criteria of coagulation exacerbate existing injuries.2,3,11,12,17,28 Support of vital
necrosis (preservation of the general tissue architecture, functions (securing an airway, intravenous fluid
preservation of the basic outline of the coagulated cells, replacement, pain medication) should be pursued during
presence of marked cytoplasmic eosinophilia) and emergency department management alongside an
nonspecific criteria of advanced necrosis (disruption of evaluation of the extent of damage to the gastrointestinal
oesophageal wall architecture, karyolysis, presence of tract. Laryngeal injuries are associated with severe
anucleate cells, necrotic debris, and leucocytic oesophageal injuries in 40% of patients29 and about 10%
infiltrates).19 Fibroblast colonisation, mucosal sloughing, require intubation and mechanical ventilation on
and granulation tissue appear at the end of the first week; admission. Tracheostomy was eventually done in a third of
oesophageal repair begins 10–15 days after ingestion and patients with severe burns in one study.1 The effectiveness
mucosal re-epithelisation is usually completed by the of nasogastric tubes in preventing vomiting and stricture
sixth week. Scar retraction, starting by the third week and formation is controversial and routine insertion should be
evolving for several months, leads to stricture formation. avoided.17 Systematic administration of antacid medication,
Oesophageal dysmotility due to scarring can be associated corticosteroids, and broad spectrum antibiotics is not
with gastro-oesophageal reflux, which can in turn recommended, because of questionable efficacy.2,11
accelerate scarring.20
If necrosis is transmural, immediate life-threatening Evaluation of gastrointestinal tract injuries
complications can occur. Necrosis initially involves the Specific evaluation of gastrointestinal damage aims to
oesophagus and the stomach but subsequent distinguish patients with severe life-threatening injuries
transpyloric passage of strong corrosives can result in who require emergency surgery from patients with mild
duodenal or more distal small bowel and colonic injuries who are eligible for non-operative management.
necrosis.21 Occasionally, direct extension of gastric Signs of digestive perforation (eg, rebound tenderness,
injuries to the transverse mesocolon causes colon subcutaneous emphysema) and haemodynamic
necrosis. In the absence of appropriate management, instability are rare and should prompt immediate surgery

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after minimal preoperative asssessment.1,30 Otherwise, Kamijo36 proposed an endoscopic ultrasound scoring
symptoms do not correlate reliably with the extent of system suggesting that the destruction of oesophageal
damage; the absence of pain and oral lesions does not muscular layers predicted stricture formation and
rule out significant gastrointestinal injury.2,3,6,8,11,31 Specific response to dilation. However endoscopic ultrasound
symptoms might suggest severe involvement of the failed to improve the accuracy of conventional endoscopy
larynx (hoarseness, stridor), the oesophagus (dysphagia, in predicting early or late complications in another study.37
odynophagia, drooling), or the stomach (epigastric pain, Fibre-optic bronchoscopy is reliable in detecting
haematemesis).3,5 Investigations might be unnecessary tracheobronchial involvement and is mandatory for
in asymptomatic patients following accidental ingestion patients being considered for emergency surgery.24
of a weak corrosive.2,5 Transthoracic oesophagectomy should be done instead of
After massive ingestion, emergency laboratory tests transhiatal stripping oesophagectomy if transmural
should be done, including white blood cell count, tracheobronchial involvement is suspected on
haemoglobin, platelet count, pH and serum lactate, bronchoscopy.
serum concentrations of sodium, potassium, chlorine, CT was the logical choice to alleviate the shortcomings
magnesium, calcium, urea creatinine, aspartate of endoscopy because of its widespread use in the
aminotransferase, alanine aminotransferase, bilirubin, assessment of gastro-oesophageal diseases.38,39 Ryu and
alcohol levels, and measurement of β-HCG in young colleagues14 were the first to propose a CT-based
women.17 Altough initially normal laboratory test results classification of oesophageal corrosive injuries and
do not exclude transmural necrosis, leucocytosis, high showed that it was better than endoscopy in predicting
serum C-reactive protein concentration,3 severe acidosis long-term complications. Lurie40 proposed an emergency
(low pH, high blood lactate concentration),32 renal CT grading system for corrosive injuries but suggested
failure,26 deranged liver function tests,32 and that endoscopy was better than CT in guiding emergency
thrombocytopenia33 can predict transmural necrosis and decisions. The discriminating power of this study was
poor outcome. The pattern of changes in laboratory data limited by the small cohort size and the strict criteria
is useful for monitoring patients and in guiding used to define necrosis (the highest grade category
subsequent management.19,26 included only patients with radiological signs of
Oesophagogastroduodenoscopy has been the mainstay perforation). A review5 based on these data concluded
of emergency management algorithms worldwide for that CT cannot replace early endoscopy for the emergency
decades.2,3,5,12,28 Early (3–48 h) flexible endoscopy assesses assessment of gastrointestinal injuries after caustic
the extent and severity of caustic injuries from the luminal ingestion.
perspective.9,13 In expert hands, endoscopy can be safely These conclusions have been challenged by two studies
repeated up to 3 weeks after ingestion without increasing from a high volume centre.19,33 A first analysis of
risk of perforation.2,3,12 Several endoscopic classifications of 72 patients with grade 3b oesophageal endoscopic
upper digestive corrosive injuries have been proposed.2,13,22,23 necrosis showed that use of CT to select patients for
The Zargar classification13 has gained wide acceptance and emergency oesophagectomy improved patient survival
is used in most centres: grade 0 is normal; grade 1 is and functional outcomes and decreased management
oedema and hyperaemia of the mucosa; grade 2a is costs.19 Subsequent analysis of 120 consecutive cases of
superficial localised ulcerations, friability, and blisters; caustic ingestion showed that CT outperformed
grade 2b is circumferential and deep ulcerations; grade 3a endoscopy in selecting patients for surgery or non-
is multiple and deep ulcerations and small scattered areas operative management.33 Moreover, the high inter-
of necrosis; and grade 3b is extensive necrosis. observer agreement between general and gastrointestinal
Endoscopic grading predicts systemic complications, radiologists when assessing transmural gastro-
respiratory failure, emergency mortality, nutritional oesophageal necrosis suggested that CT assessment of
autonomy, and long term survival.9,34,35 Initial endoscopy caustic injuries was reproducible outside specialised
is reliable in predicting future stricture formation, with centres. In these studies, criteria of transmural gastro-
low grade injuries (grades 1–2a) rarely causing strictures oesophageal necrosis were derived from radiological
but stricture can occur in as many as 80% of patients reports on bowel ischaemia39 and mainly relied on the
with severe burns (grade 3b).9 persistence of anatomical structures and the degree of
The major drawback of endoscopy is its inability to wall enhancement after contrast administration. In 2015,
predict accurately the depth of necrosis, which could lead the World Society of Emergency Surgery consensus
to inappropriate non-operative management jeopardising conference supported the introduction of emergency CT
survival and unnecessary resective surgery with in the management of corrosive ingestion.17
deleterious effects on long-term survival, function, and Based on retrospective analysis of more than 300 CT
management costs.1,22,23 Moreover, endoscopy is observer scans, we propose a simplified radiological classification
dependent and if it is delayed beyond 24–48 h there is the of corrosive injuries (figure 1). Grade 1 is normal
potential disadvantage of misinterpretation due to appearing organs. When present, injuries usually
submucosal haemorrhages and oedema. correspond to low grade (0–2a) endoscopic burns; grade 2

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Grade 1 Grade 2 Grade 3

of caustic peritonitis is high and early identification of
patients with full-thickness digestive necrosis is
paramount as resection of the affected organs can
improve survival by preventing intraperitoneal spillage of
corrosive agents.1,22,23,26,30 Endoscopy-based algorithms
aiming for no deaths among patients under watchful
waiting recommend surgery for grade 3b injuries.22,23,34
Laparotomy23 or laparoscopy41 can assess accurately the
need for intra-abdominal organ resection and can correct
endoscopic misevaluation. Because surgical exploration
of the thoracic oesophagus is not feasible, futile
oesophagectomy remains the major flaw of such
algorithms.1,26 An algorithm based on combined CT and
endoscopy can be used (figure 2).19,33
Difficulties in interpreting CT scans and the ability to
predict accurately the risks of stricture formation9,35
justify early endoscopy in patients with severe radiological
Figure 1: CT grading of corrosive injuries of the oesophagus and the stomach
Grade 1=normal appearance; grade 2=wall and soft tissue oedema, increased wall enhancement (arrow);
injuries. Renal failure and allergy to contrast agents
grade 3=transmural necrosis with absent wall enhancement (arrow). might contraindicate CT. There are no data on CT
assessment of caustic injuries in children and therefore
systematic use of CT assessment cannot be recommended
Corrosive ingestion
in this group because of the scarcity of severe injuries
and lifetime risks of radiation exposure.42 CT might be
CT scan helpful in children with severe clinical, biological, and
endoscopic criteria who are being considered for surgery.

Emergency surgery
Oesophagus Stomach
The decision to perform an emergency operation after
corrosive ingestion can be a heavy burden for the surgeon
and is a life-changing event for the patient.1 Emergency
Grade 1 Grade 2 Grade 3* Grade 3 Grade 2 Grade 1 surgery is required whenever the initial assessment
suggests transmural necrosis of the gastrointestinal
tract. In one study,1 the standard mortality ratio for
patients operated for corrosive injuries was 21·5
Emergency surgery compared with the general French population. In a
population aged 40 years, half of patients died within
10 years of surgery and only half of patients eventually
Non-operative management and endoscopy† regained nutritional and respiratory autonomy.1 Factors
associated with negative effects on long term survival
and functional outcomes included advanced age,
tracheobronchial injuries, emergency oesophageal
No endoscopy resection, need for extended resections, and severe
derangement of laboratory test results. Finally, the overall
Figure 2: Management algorithm for caustic ingestion in adults cost of management of patients who underwent
*Perform endoscopy before surgery in case of difficulties with CT interpretation. †Endoscopy done before emergency surgery was high (€140 000 per patient).1
discharge helps predict stricture risk.
Laparotomy is the standard emergency surgery but
is wall oedema, with surrounding soft tissue successful laparoscopic exploration has been reported.41,43
inflammatory change and increased post-contrast wall All obvious transmural necrotic injuries should be resected
enhancement, which corresponds to more severe during the initial procedure but reoperation should be
endoscopic burns (2b–3b) without transmural necrosis; done whenever ongoing necrosis is suspected.21
and grade 3 is transmural necrosis as shown by the Construction of a feeding jejunostomy at the end of surgery
absence of post-contrast wall enhancement and in this (irrespective of the procedure done) enables early enteral
situation, endoscopy uniformly shows grade 3b necrosis. nutrition in patients with compromised digestive function.17

Management algorithm Surgical procedures

Evidence of perforation after caustic ingestion is rare Oesophagogastrectomy, done through a combined
(0·5%) but should prompt emergency surgery.1 Mortality abdominal and cervical approach using an oesophageal

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Year Whole Emergency Oesophago- Oesophagectomy Gastrectomy Pancreato- Operative Operative Reoperation
cohort resection gastrectomy (n) (n) duodenectomy mortality morbidity (n, %)
(n) N (n, %) (n) (n) (n, %) (n, %)
Wu et al44 1993 ·· 28 22 0 0 6 5 (18%) 10 (36%)
Andreoni et al22 1995 57 11 (19%) 6 0 5 1 3 (27%) ·· ··
Landen et al45 2000 ·· 14 12 0 2 14 7 (50%) 12 (86%) ··
Rigo et al46 2002 210 11 (5%) 6 0 5 0 9 (82%) ·· ··
Ertekin et al47 2004 53 7 (13%) 2 0 3 2 3 (43%) ·· ··
Tohda et al48 2008 92 12 (13%) 0 6 6 0 0 ·· ··
Chou et al32 2010 537 71 (13%) 71 0 0 0 29 (41%) ·· ··
Zerbib et al26 2011 70 24 (34%) 0 0 24 3 4 (17%) ·· 2 (8%)
Javed et al49 2012 209 13 (6%) 12 0 1 1 2 (15%) ··
Chirica et al1 2012 1024 253 (25%) 197 27 11 18 42 (17%) 167 (66%) 51 (20%)
Wu et al50 2015 426 64 (15%) 40 ·· ·· 17 29 (45%) ·· ··

Table 1: Outcomes of emergency surgery for caustic injuries

stripping technique, is the most common emergency A B C

operation done for the treatment of severe caustic burns.1,22,23
Mortality and morbidity are high (table 1) and pulmonary
complications are the most common adverse events.1
If necrosis is confined to the stomach, total gastrectomy
with preservation of the native oesophagus should
be considered.51 Immediate oeso­ phagojejunostomy
reconstruction has been shown to be safe in a high volume
referral centre, with leaks in 5–8%.51 However, for the
occasional surgeon, a damage control procedure such as
exclusion with or without external oesophageal drainage is
likely to be safer and should be considered in this setting.26
Partial gastric resections are usually avoided because
ongoing necrosis might compromise outcomes. The
justification of oesophagectomy with gastric preservation
based on isolated oesophageal necrosis has been Figure 3: Emergency operations for caustic injuries
challenged.26,33 Concomitant necrosis of other abdominal (A) Oesophagogastrectomy, cervical oesophagostomy, feeding jejunostomy. (B) Gastrectomy with
organs (spleen, colon, bowel, duodenum, pancreas) oesophagojejunostomy. (C) Oesophagogastrectomy and pancreatoduodenectomy.
justifies extended resections in 20% of patients who
undergo oesophagogastrectomy.1,21 Pancreato­duo­dene­ grade (endoscopy grade 1–2a, CT grade 1) injuries are
ctomy52 or duo​denal stripping44 can be undertaken in the suitable for early hospital discharge.3,9 Patients with more
small number (6%) of patients who have duodenal necrosis severe injuries (endoscopy grade 2b–3b, CT grade 2)
(pancreatic involvement is uncommon); immediate require close monitoring:9,10 Deterioration of clinical signs
pancreatobiliary reconstruction was recom­ mended after and symptoms (abdominal pain, rebound tenderness, need
pancreatoduodenectomy if the patient’s condition allows.52 for ventilator support, shock, neuropsychiatric deterio­
Pancreatoduodenectomy for caustic injuries has high ration) or laboratory test results (renal failure, leucocytosis,
mortality (39–50%) and morbidity (94–100%), and acidosis, thrombocytopenia) should prompt a repeat of the
functional results are dismal.44,45,52 On rare occasions, direct management algorithm and reconsideration of indications
mediastinal extension of oesophageal necrosis results in for surgery.1,26 In one study,1 18 (2%) of 784 patients managed
tracheobronchial necrosis; pulmonary patch repair through conservatively by endoscopy alone were eventually switched
a right thoracotomy approach might be lifesaving despite to surgery, whereas in a later cohort, none of 143 patients
very high mortality rates (45%).24 The presence of extensive managed by CT-endoscopy were switched.19,33
bowel necrosis warrants discussion of abandoning the The optimal time to resume eating after corrosive
operation on a case-by-case basis because of poor survival ingestion is unknown. Correlations between oral
and compromised nutritional issues.21 Figure 3 shows the re-alimentation and risks of perforation and of delayed
most common emergency operations. sequelae have not been clearly established. Thus, most
clinicians reintroduce oral feeding as soon as patients are
Non-surgical management able to swallow normally,2,3,17 although complex re-
After initial assessment, 70–90% of patients are eligible for alimentation algorithms have also been proposed.34 The
a first-line non-surgical approach.1,6,10 Patients with low role of nutritional support is paramount in the acute

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 Review

phase and subsequently until effective dilatation or human beings. Oesophageal stenting for stricture
oesophageal reconstruction is achieved. When oral prevention has been attempted without gaining wide
alimentation is not feasible, total parenteral nutrition acceptance.3,28,63 Most recommendations on stricture
and early enteral feeding, through nasojejunal tubes or prevention and treatment rely on small retrospective
jejunostomy, is recommended.53 Control of the studies, underscoring the need for well-designed
psychiatric condition and psychological support are research on this topic.
mandatory before hospital discharge, regardless of the Gastric strictures are uncommon because of the large
severity of corrosive injuries.17 Although regular follow- diameter of the stomach and are mostly caused by acids.64
up is recommended for early detection and timely The antrum is most commonly involved (in 75–80% of
treatment of sequelae such as oesophageal stricture, the cases), but hourglass (15%) and diffuse gastric (5%)
frequency of outpatient visits and the best way (clinical strictures have also been described.64,65 Half of patients
examination, endoscopy) to conduct follow-up are still have concomitant oesophageal strictures and gastric
open to debate. outlet obstruction might be unmasked after treatment
of oesophageal involvement. Although successful
Delayed sequelae of corrosive ingestion management of gastric outlet obstruction by endoscopic
Late sequelae of corrosive ingestion occur after variable balloon dilatation has been reported in patients with
periods, are disabling, and can be life-threatening. The short strictures (<15 mm),66 perforation (46%) and failure
most common sequelae include haemorrhage, fistula (55%) are common.67 Evidence supporting the use of
formation (tracheobronchial, aortoenteric), pulmonary stents in the management of gastric outlet obstruction is
complications, stricture development, and malignancy. scarce. Resection or bypass 3–6 months after ingestion
Bleeding is a rare complication, occurring in around has low morbidity (10–15%) and mortality (0–4%) and the
3% of patients, and usually occurs 3–4 weeks after success rate is high.17
ingestion.54 In one study,54 sentinel bleeding preceded by Traditionally, corrosive strictures can involve all
2 days the occurrence of massive gastric or duodenal oesophageal segments, are multiple, long, irregular, and
haemorrhage. Management includes resection or have long stabilisation delays.68 The main treatment goal
embolisation of the bleeding site but mortality (16%) and should be the improvement of symptoms and of the
morbidity (75%) are high.54 nutritional status, rather than the conservation of a large
Fistulisation into adjacent organs can occur at any time oesophageal lumen patency. Endoscopic dilation is the
after massive ingestion of strong corrosive agents. first-line management option.3 Dilation can be started
Chronic tracheo-oesophageal fistula is a rare complication safely after healing of acute injuries, usually between the
(in 3% of patients). Management includes repair of the third and the sixth week; later management might
airway defect and oesophageal reconstruction usually by compromise outcomes because of oesophageal wall
a staged surgical approach.55,56 In one study,25 aorto- fibrosis and collagen deposition.68 CT or endoscopic
oesophageal fistula occurred 5 days to 2 months after ultrasound wall thickness can predict the response to
ingestion in three (0·2%) of 1260 patients and is almost dilatation.68 Savary bougies are preferred to balloon
universally fatal. dilators,69 although studies have shown no clear advantage
In one study,27 aspiration pneumonia was reported in of one method over the other.70 Even for experienced
4·2% of patients after caustic ingestion; risk factors clinicians, perforation rates after dilatation of corrosive
included advanced age, hesitation in swallowing with strictures are higher than other benign strictures (4–17%
prolonged oropharyngeal storage, and emergency vs 0·1–0·4%).3 Oesophageal perforations in this context
nasogastric tube positioning. Small airway obstruction are usually contained and can benefit from non-operative
by sloughing, exudation, ulceration, and granulation management; it is unclear whether perforation should
tissue leads to recurrent atelectasis and pneumonia; preclude further dilation attempts.71 The interval between
treatment is difficult and mortality reaches 60%.27 dilations varies between 1 week and 3 weeks, and three to
Stricture formation is by far the most common, five sessions are expected to provide satisfactory results.3
disabling, and resource-consuming late com­ A cutoff of five to seven failed sessions has been proposed
plication.2,3,11,12,17 Strictures usually develop within for stopping dilatations and considering reconstructive
2 months (3 weeks to 1 year) after ingestion and their surgery.72 Worldwide, such decisions are nevertheless
development is reliably predicted by both emergency influenced by several other factors related to the patient
endoscopy9 and CT.14 Several strategies have been (eg, age, malnutrition, operative risks), the physician’s
proposed for stricture prevention, but the clinical benefits expertise, and the availability of alternative surgical
have not been clearly demonstrated. Studies in human options. Overall, roughly half of dilations for caustic
beings failed to prove the effectiveness of antibiotics3 and strictures are successful, which is significantly lower than
of systemic or intralesional steroid administration57,58 to for other benign strictures (75–80%).3
prevent strictures. The use of intraperitoneal injections The advent of interventional endoscopy has renewed
of fluorouracil,59 antioxidant agents,60 octreotide,61 and the interest of intraluminal stenting to prevent stricture
cytokines62 have been tested in animal models but not in recurrence after dilatation.73–78 Although encouraging

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results have been reported with silicone rubber, polyflex,

A B
and biodegradable stents, their widespread clinical use is
currently hindered by issues such as hyperplastic tissue
growth, removal difficulties, high migration rate (25%),
high recurrence rate (50%), low availability, and high
costs.3,28 Therefore, the place of endoscopic stenting for
corrosive oesophageal strictures is yet to be defined and
controlled studies are needed. Intralesional steroid
injections increase the effects of endoscopic dilation79
and topical mitomycin80 can be effective for the treatment
of complex strictures; such combined approaches
warrant discussion before contemplating surgery.
Pharyngeal strictures have been reported in 0·7–6% of
patients after caustic ingestion and have been attributed
to prolonged contact of the caustic agent with the
superior aerodigestive pathways after massive ingestion,
forced vomiting, hesitation before deglutition, or
ingestion of solid crystal forms.81 Scarring involves the
hypopharynx, the glottis, and the base of the tongue, and
may interfere with the mechanisms of deglutition and
respiration rendering management difficult. Endoscopic Figure 4: Oesophageal reconstruction
treatments are usually ineffective; some patients may The stomach had been preserved initially and digestive continuity subsequently
eventually recover nutritional and respiratory autonomy restored by colonic interposition: (A) right colon, (B) left colon.
after complex surgical repair.81 Corrosive induced
microstomia and glossopalatine synechia are rare, but pharyngeal reconstruction (which requires active patient
can compromise functional outcomes; prevention after participation throughout the re-education process) is
ingestion by daily fatty dressings and regular tongue considered.81 If the use of a colonic substitute is
mobilisation is important. considered, most authors recommend preoperative
Risks of oesophageal malignancy after caustic ingestion colonoscopy to rule out malignancy.72,85 Angiographic
are thought to be 1000–3000 times higher than in the studies of the vascular pedicle before colon interposition
general population.2 Up to 30% of patients with caustic have been advocated,86 but are not used routinely because
injuries develop oesophageal cancer, with a latency they do not replace intraoperative vascular clamping
period of up to 40 years.82 The risk is probably tests.72,83 Angiography might be useful for strategy
overestimated because of several confounding factors planning after failed primary reconstruction.83
such as alcohol misuse and smoking habits.3 Associations Otolaryngological assessment including fibre-optic
between caustic gastric injuries and cancer are less well nasopharyngoscopy, hypopharyngoscopy, and direct
established.2 Although specific screening programmes laryngoscopy under general anaesthetic is necessary.
seem justified after caustic ingestion, there are no Failure to detect pharyngeal strictures before oesophageal
reliable guidelines addressing the topic. reconstruction invariably results in functional failure.72
The choice of the oesophageal substitute after caustic
Oesophageal reconstruction ingestion is a matter of debate. Colon interposition
Oesophageal reconstruction is required to restore (figure 4) is the most common reconstructive procedure.2,3
digestive continuity after emergency oesophageal The issue of which colon segment (right vs left) should be
resection and in patients with strictures that were not preferred has never been addressed by randomised
eligible for or had failed dilation. Although emergency controlled studies. Despite pros and cons for the use of
surgery can be done in admitting facilities, patients that either right or left colon transplants, results of large
require complex reconstruction benefit from early series originating from expert centres show similar
referral to expert centres.83 results.72,84,85,87–91 Operative mortality of colon interposition
One stage reconstruction after emergency oeso­ ranges between 0% and 10% and morbidity ranges
phagectomy is not advisable because subsequent between 19% and 63%. Specific complications include
development of pharyngeal strictures might compromise graft necrosis (0–14%) and cervical anastomosis leakage
outcomes and render reconstruction futile.1 A minimum (6–28%; table 2). Retrosternal oesophagocoloplasty is the
6 months’ delay in reconstruction enables injuries to most common procedure and debate persists as to
stabilise and has been associated with decreased rates of whether to resect96,102 or bypass72,84 the native oesophagus
cervical anastomotic strictures and with improved (if still present) at the time of reconstruction.
functional outcomes.72,84 Control of psychiatric disease Disagreement concerns mainly the risks of malignancy
when present is essential, especially if concomitant and mucocele in the retained bypassed oesophagus and

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 Review

Year Patients Oesophageal Operative Operative Graft Cervical Late Anastomotic Reflux Redundancy Success†
with substitute mortality morbidity necrosis leakage morbidity stricture (n, %) (n, %) (n, %) (n, %)
corrosive (n, %) (n, %) (%) (n, %) (n, %) N (n, %)
injuries (n) (%)
Hong et al92 1963 81 Colon 6 (6%) ·· 7 (9%) 23 (28%) ·· 13 (16%) 12 (15%) ·· 67 (84%)
Chien et al93 1974 60 Colon 1 (2%) 21 (35%) 0 6 (10%) ·· 15 (25%) 6 (10%) 1 (2%) ··
Wu et al94 1992 75 Colon, stomach 0 14 (19%) 0 5 (7%) ·· 3 (4%) ·· 2 (3%) ··
Wain et al91* 1999 20/52 Colon 2 (4%) 27 (52%) 5 (10%) 3 (6%) ·· 24 (46%) 3 (6%) 2 (4%) 57 (90%)
Bassiouny et al95† 2001 100 Colon 3 (3%) ·· 0 8 (8%) ·· 7 (7%) 6 (6%) 95 (95%)
Popovici et al88* 2003 284/347 Colon 16 (5%) ·· 4 (1%) 24 (7%) 12 22 (6%) ·· 2 (4%) 202 (80%)
Gupta et al96 2004 51 Colon, stomach 0 ·· 0 10 (20%) ·· 30 (59%) ·· ·· 51 (100%)
Han et al97 2004 68 Colon, stomach 0 17 (25%) 0 9 (13%) ·· 3 (4%) ·· ·· 65 (96%)
Knezevic et al84 2007 336 Colon 4 89 (27%) 8 (2%) 31 (9%) 47 (14%) 15 (4%) ·· 14 (4%) 233 (82%)
Deng et al98 2008 85 Colon 7 (8%) 39 (47%) 2 (2%) 15 (18%) ·· 7 (8%) ·· ·· ··
Javed et al99 2011 176 Colon, stomach 11 (6%) ·· 8 (5%) 22 (13%) ·· 33 (19%) 25 (15%) ·· 143 (81%)
Boukerrouche et al100* 2013 57/60 Colon 2 (3%) 27 (45%) 2 (3%) 10 (17%) 11 (18%) 5 (8%) 2 (3%) 2 (3%) 58 (97%)
Ezemba et al101 2014 21 Colon 2 (10%) 11 (52%) 3 (14%) 4 (19%) ·· 3 (16%) 4 (19%) ·· 15 (80%)
Chirica et al81 2015 238 Colon 7 (3%) 150 (63%) 12 (5%) 50 (21%) 98 (41%) 49 (21%) 21 (9%) ·· 166 (76%)

*Also included patients with cancer; the ratio corrosive ingestion cases:whole cohort are shown; results of oesophageal reconstruction are provided for the whole series. †In children. ‡Crude data and percentages
as reported by the authors; the denominator can be either the whole cohort or the number of patients available for follow-up.

Table 2: Outcomes after oesophageal reconstruction for caustic injuries

the operative risks of oesophagectomy in the scarred Surgical correction of graft-related complications has
mediastinum. been successful in select patients; in extreme situations
A report comparing colon and stomach interposition redo reconstructions with a novel substitute provide
for corrosive injuries showed that the duration of surgery, similar results to primary reconstruction.83 In one
blood loss, incidence of conduit necrosis, and in-hospital study,81 inability to control the underlying psychiatric
mortality were significantly lower after use of a stomach disease accounted for half of functional failures and
conduit.99 Use of gastric conduits in the setting of 15% of patients attempted suicide again (one third by
corrosive oesophagitis is nevertheless hampered by the caustic reingestion) after reconstruction. These data
presence of concomitant gastric involvement (need for underscore the difficulties in selecting patients for
emergency resection, stricture formation) after caustic reconstruction and the necessity for long-term
ingestion. Length issues and the complexity of the psychological support.
surgical procedure usually limit first-line use of the Most patients (75–100%) regain some degree of
jejunum for oesophageal replacement; salvage utilisation nutritional autonomy after oesophageal reconstruction
has been reported after failure of primary reconstruction.83 for corrosive injuries (table 2). Factors that negatively
Surgical management of pharyngeal strictures is usually affect functional outcomes include old age, severe
recommended as a one-stage procedure at the time of psychiatric disorders, massive ingestion requiring
oesophageal replacement and the difficulty of the emergency tracheotomy and extended visceral
situation is mirrored by the diversity of surgical resections, short delays in reconstruction, and
procedures described (table 3).105,112,113 In one report,81 pharyngeal involvement. The lack of reliable definitions
pharyngeal reconstruction by colo­pharyngoplasty resulted of functional success after oesophageal reconstruction
in similar operative morbidity and mortality as precludes valid comparison between published series
oesophagocoloplasty, although functional outcomes were and calls for an international expert consensus
significantly worse. conference on the topic.
Late complications after oesophageal reconstruction
are common and jeopardise outcomes. In one study,72 Caustic ingestion in children
late morbidity was recorded in half of patients after Caustic injuries in children are most likely caused by
colon interposition and graft-related dysfunction accidental ingestion, with boys more often involved
accounted for half of functional failures. Stenosis of the than girls.28 Injuries are usually mild with emergency
cervical anastomosis is common (4–59%) and usually surgery rarely indicated and the overall mortality is
complicates leakage.72 Complications such as lower than in adults. Endoscopic assessment remains
redundancy, ulceration, reflux, and transplant-specific the gold standard in this population to diagnose severe
disorders (cancer,114 diverticulitis115) are rare but injuries (0·5–14%) and predict risk of stricture
occasionally compromise reconstruction outcomes.116–118 (6–10%).28 Dilation is the cornerstone of treatment of

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 Review

Year Patients Technique Laryn- Simultaneous Operative Operative Cervical Dilation Surgical Median Definitive Success*
(n) gectomy oesophageal mortality morbidity leakage (n, %) revision follow-up trache- (n, %)
(n, %) reconstruction (n, %) (n, %) (n, %) (n, %) (range) otomy
(n, %) (n, %)
Tran Ba Huy103 1988 18 End-to-side 11 18 (100%) 0 ·· 4 (22%) 15 (83%) 13 (72%) ·· (1·5 years 4 (22%) 11 (61%)
ileopharyngeal to 8 years)
anastomosis
Park104 2001 8 Side-to-side 0 8 (100%) 0 2 (25%) 0 1 (13%) ·· ·· (35 months 0 7 (88%)
hypopharyngoileal to
anastomosis 67 months)
Anantha- 2001 4 Island pectoralis major 0 0 0 ·· ·· ·· ·· ·· 0 2 (50%)
krishnan105 myocutaneous flap
Wu106 2001 50 Hypopharyngo- 1 50 (100%) 1 (2%) 8 (16%) 3 (6%) ·· 6 (12%) ·· ·· 42 (84%)
enterostomy
Jianj107 2005 14 End-to-end 1 (7) 14 (100%) 0 - 4 (28%) 2 (14%) 1 (7%) 4 years 1 (7%) 14 (100%)
colopharyngeal (6 months
anastomosis to 10 years)
Anantha- 2007 4 Sternocleidomastoid 0 0 0 2 (50%) 2 (50%) ·· ·· ·· 0 2 (50%)
krishnan108 muscle myocutaneous
inlay flap
Huang109 2009 10 Laryngotracheal- 10 10 (100%) 0 ·· 0 0 0 8 months 10 (100%) 9 (90%)
colocolic anastomosis (3 months
to 3 years)
Radovanovic110 2009 83 End-to-end and side- ·· 83 (100%) 5 (6%) 14 (17%) 4 (5%) 4 (5%) 4 (5%) 16 years ·· 72 (87%)
to-end colopharyngeal (1 year to
anastomosis 30 years)
Vimalraj111 2011 21 Transgastric 0 7 (33%) 0 2 (10%) ·· 10 (48%) 1 (5%) ·· 2 (10%) 11 (52%)
retrograde dilatation
Chirica81 2015 116 End-to-end 29 (25) 116 (100%) 2 (2%) 75 (65%) 20 (17%) 13 (11%) ·· ·· 17 (16%) 61 (57%)
colopharyngeal
anastomosis

*Crude data and percentages as reported by the authors. The denominator can be either the whole cohort or the number of patients available for follow-up.

Table 3: Outcomes of pharyngeal reconstruction for caustic injuries

caustic strictures in children and should be pursued Future directions

for years if surgery can be avoided; a feeding Many questions remain unanswered regarding the optimal
gastrostomy might provide a retrograde approach for management of corrosive ingestion and further research is
dilation of complex strictures.119 Results of oesophageal needed to standardise patient management. An
reconstruction in children done in expert centres are international project is in progress under the auspices of
good but removal of the native oesophagus is the World Society of Emergency Surgery to develop a
recommended to avoid malignancy.95 register that enables collection of clinical data after corrosive
ingestion from many institutions.17 Such a register would
Management of caustic ingestion in enable large scale evaluation of clinical outcomes and of
low-resource settings prognostic factors and alleviate some of the research
In low-income countries, specific issues including difficulties induced by the low incidence of caustic
delays in management, limited access to medical ingestion. Research directed at assessment of quality of life
expertise and technology, and poor follow-up have a after caustic ingestion is scarce,81,120 even though quality of
negative effect on clinical outcomes.119 These factors life is a major concern in modern medicine. This shortage
should be taken into account when planning is of special concern because complex reconstructive
management of caustic injuries in low-resource surgical procedures are done with an exclusively functional
settings. Children are often involved and oesophageal purpose in these patients. Preventive strategies, such as
strictures requiring repeat dilations are the most the introduction of safety bottle tops, crystal rather than
common form of presentation.119 Introduction of liquid forms of corrosive agents, appropriate labelling and
complex endoscopic treatments and surgical procedures packaging, and providing wide publicity in the media have
in the absence of a suitable hospital environment proven effective in several countries.28 Despite these
warrants caution. Under such circumstances, simple convincing data, public health programmes directed at
interventions such as placement of a surgical education and the establishment of effective measures
gastrostomy should be favoured because they might limiting access to strong corrosive agents are lacking in
help avoid malnutrition and prolong survival.119 several low-income and high-income countries.

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 Review

Contributors 22 Andreoni B, Farina ML, Biffi R, Crosta C. Esophageal perforation

MC designed the study, searched the scientific literature, analysed data, and caustic injury: emergency management of caustic ingestion.
and wrote and revised the report. LB designed the study, analysed data, Dis Esophagus 1997; 10: 95–100.
and wrote and revised the report. MDK and ES designed the study, and 23 Estrera A, Taylor W, Mills LJ, Platt MR. Corrosive burns of the
wrote and reviewed the report. PC designed the study, searched the esophagus and stomach: a recommendation for an aggressive
scientific literature, analysed data, and wrote and revised the report. surgical approach. Ann Thorac Surg 1986; 41: 276–83.
24 Benjamin B, Agueb R, Vuarnesson H, et al.
Declaration of interests Tracheobronchial necrosis after caustic ingestion. Ann Surg 2016;
We declare no competing interests. 263: 808–13.
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