**4. Pathophysiology**

Caustic substances with pH less than two or more than 12 are especially destructive. Form, concentration, amount of ingestion, and contact duration also affect the results. Acidic substances generate coagulation necrosis which creates eschar formation. Eschar can limit the penetration of injuries [16]. On the other hand, alkaline substances melt the tissue protein and initiate liquefactive necrosis with saponification that can penetrate deeper into the esophageal wall [17].

Perforation occurs in the acute stage of severe esophageal injuries. As a consequence of perforation, stricture follows during the recovery stage. Tissue injuries after corrosive ingestion go through three phases. Phase 1 is characterized by cell necrosis and thrombosis, 48–72 hours after the event. Next, in Phase 2, there is mucosal sloughing with ulceration of the esophageal wall plus fibroblast colonization and granulation. This phase continues for 14 days from the Phase 1, and the esophagus is friable during this phase. Finally, in Phase 3, the healing process starts in the third week and usually continues 3–6 months [3, 20, 21].

#### **5. Management**

When patients arrive at the emergency department, stabilization of the patient is the most important target for this stage [21]. Signs and symptoms that often occur in corrosive ingested patients include burning of the oral cavity, drooling, nausea, and vomiting. Upper gastrointestinal bleeding can be found in severe cases, indicating substance injuries to the alimentary tract. Respiratory trauma can result in hoarseness, difficulty to breathe, stridor, and airway compromise. Esophagus perforation can be expressed as mediastinitis, chest wall emphysema, and pneumothorax, depending on time and severity.

Physicians should first examine the airway, especially for signs of aspiration or laryngeal injury. Physical examination and history taking should be done for details of the corrosive substance, the volume, timing before admission, pre-hospital treatment, and cause of ingestion. The patient should be given nil per os (NPO) and adequate resuscitation. Nasogastric tube intubation, gastric lavage, administration of emetic drugs, and neutralizing agents are not recommended because reflux of these agents into the esophagus could result in further damage [1, 8, 21]. Intravenous broad-spectrum antibiotics may benefit a patient with high-grade esophageal injuries. The investigation by chest and abdominal radiography should be evaluated. In cases of attempted suicide, the patient should be evaluated by the psychiatric department [1, 3, 4, 9, 22, 23].

The initial evaluation of the severity of a caustic injury provides important information. Esophagogastroduodenoscopy (EGD) is recommended for grading esophageal injuries following the Zargar classification (**Table 1**). Zargar classification can assist prognosis and guide clinical management [16]. The EGD should be done as soon as possible within 24–48 hours. Performing endoscopy after 48 hours

#### *Acute Management in Corrosive Ingestion DOI: http://dx.doi.org/10.5772/intechopen.101475*


#### **Table 1.**

*Zargar classification of corrosive esophageal injury.*


#### **Table 2.**

*Endoscopic score and computerized tomography score of corrosive esophageal injury.*

is not recommended because the tissue injuries go through Phase 2 when they should not be subjected to an unwanted event [16, 21]. For patients with Zargar grade 1 and 2a, an oral diet may be given. Patients with Zargar grade 2b and 3a can start an oral diet once they can swallow saliva. Esophagectomy should be performed on patients with Zargar grade 3b injuries.

The method for assessing the degree of esophageal damage by computed tomography (CT) with scoring was recently established as a noninvasive modality [24]. Nowadays, the use of CT scans of the chest and abdomen is increasing. CT can assist prognosis after ingestion, but it is still inconclusive [25–27]. CT also provides extraesophageal information regarding anatomies such as the mediastinum, lung, and pleural cavity, which endoscopies do not (**Table 2**).
