Emergency General Surgery

Like Vampires Drinking Holy Water – Part 2

The devil loves no holy water.

Romanian Proverb

Here we are again, as promised… To continue our journey on caustic ingestion

In this post, you are going to see how to grade a caustic injury and how this allows for determining its best treatment if needed…

Well… Let’s not lose time, and proceed with what waits for us…


After this initial management, the following step may be either gastroscopy or contrast-enhanced thoracoabdominal CT scan. These exams determine the grading of injury and, consequently, titrate the management.

1. Gastroscopy

Its main role is to determine the grade and extension of the injury. Moreover, it guides the correct placement of the NGT.

The indication to perform an early endoscopic exam should be made on a case-by-case basis. A possible rule to determine if a patient needs an endoscopy is the following:

  • Acid ingestion – always endoscopy;
  • Adults with suicidal alkali ingestion – always endoscopy;
  • Children with no symptoms, or only vomiting or drooling, or who refuse to drink after alkali ingestion – overnight observation and, if symptoms persist, perform endoscopy (low risk of injuries more severe than grade 1, even though 12% of asymptomatic children have a Zargar 2 at the EGDS);
  • Children with both vomiting and drooling or with stridor – always have an endoscopy (high risk of grade 2 or higher injury).

The endoscopic exam should be performed between 12 and 48 hours from the index event. Earlier it may underestimate the grade of injury, where after 48-96 hours there is a higher risk of perforation.

Contraindications to its execution are glottic/supraglottic burns with edema and suspected perforation.

The endoscopic grading of caustic injuries is sorted by the so-called Zargar’s classification:

Grade Features
Grade 0Normal
Grade 1Superficial mucosal edema and erythema
Grade 2
– Grade 2A
– Grade 2B
Mucosal and submucosal ulcerations
– Superficial ulcerations, erosions, exudates
– Deep discrete or circumferential ulcerations
Grade 3
– Grade 3A
– Grade 3B
Transmural ulcerations with necrosis
– Focal necrosis
– Extensive necrosis
Grade 4Perforations

This classification allows for planning of the subsequent management and prognosis.

2. CT Scan

The contrast-enhanced thoracoabdominal CT scan has 75% sensitivity and 90% specificity to determine the grade of injuries. It is particularly useful in patients who are too sick to undergo endoscopy.

CT scan has reliable criteria for esophageal transmural necrosis: before contrast, the “blurring” of the esophageal wall and the periesophageal fat can be recognized, while after its administration the accentuation of the gastric and esophageal wall is not recognizable anymore.

Grade 1No definite swelling of the esophageal wall
Grade 2Edematous wall thickening without periesophageal soft tissue involvement
Grade 3Edematous wall thickening with paraesophageal soft tissue infiltration plus well-demarcated tissue interface
Grade 4Edematous wall thickening with periesophageal soft tissue infiltration plus blurring of tissue interface or localized fluid collection around the esophagus or descending aorta
Image by Contini S, et al.

3. Endoscopic Ultrasound (EUS)

It may be taken into account only if a mini-probe is available. Regular EUS probes are too broad and it does not seem safe.

EUS allows determining the presence of damage to muscular layers that appear a reliable sign of potential stricture formation.

Further Management & Early Surgery

Patients with Zargar’s grade 0 injuries can be safely discharged home with anti-acid therapy after observation of at least 6 hours and successful drinking.

Patients with grade 1-2A should be admitted to be monitored for a couple of days. These patients may eat and can be discharged within days with anti-acid therapy.

Patients with grade 2B-3 need observation in an intensive care unit and adequate nutritional support that may be administered through the NGT positioned during the endoscopic examination.

Urgent surgery should be reserved for patients with evidence, either clinical or radiological, of abdominal perforation that may happen any time during the first 2 weeks from the index event. The preferred surgical approach is laparotomic because it allows for a better exploration of the hollow viscus involved. However, laparoscopy may be performed in selected patients, provided the surgeon has adequate skills.

The surgical operation usually requires esophagectomy, cervical esophagostomy, gastrectomy, and, sometimes, more extensive resections. All organs involved and injured must be resected during the first operation. The damage may indeed spread even afterward, but the main goal of surgery is to remove all the injured tissues as soon as possible. Further surgical exploration should be performed when in doubt or when clinical conditions require it.

To correctly assess the extension of the caustic damages, a gastrostomy may be performed in order to accurately evaluate the state of the mucosa: the spread of destruction may be more extensive than what it seems from the outside (i.e. serosal side).

When early surgery is required, do not forget to create a feeding jejunostomy: it is life-saving.

Upper gastrointestinal bleeding following caustic ingestion is usually self-limiting and, usually, does not require surgery.

Flowchart by Hoffman RS, et al.

Complications of caustic ingestion are divided into early and late, depending on the timing of the presentation. Early complications are quite rare and they include tracheobronchial, gastrocolic, or entero-aortic fistula. Late complications are more common and comprise gastroesophageal reflux disease, gastric outlet syndrome, achlorhydria, intractable pain, strictures, protein-losing gastropathy, and cancerization.

1. Strictures

Strictures develop in 70% and 100% of patients following grade 2B and grade 3 esophageal injury, respectively. They usually appear after about 8 weeks from the index event, but they may occur any time between 3 weeks and 1 year.

Many methods have been studied to prevent stricture formation after caustic ingestion:

  • Steroids – no clear evidence supporting their systemic use was found, even if a study reported good results in preventing strictures administering 3 days of methylprednisolone (1 g per 1.73 m2 of body-surface area per day) along with 1 week of ceftriaxone and ranitidine in patients with grade 2B injuries (meaning a high risk of stricture, low risk of perforation);
  • Antibiotics – no indication exists supporting their use to decrease stricture formation;
  • NGT – it guarantees esophageal patency and allows enteral nutrition, but the routinary use cannot be recommended only to decrease stricture rate;
  • Sucralfate – it seems associated with rapid healing, but more studies are needed to confirm this effect;
  • Mitomycin C – it may be useful to prevent stricture formation, but it carries potential adverse events, such as the risk of secondary malignancy;
  • Intraluminal stents – silicone rubber or polyflex stents may decrease the development of stricture, but their efficacy is less than 50, and they have a high migration rate (25%).

Once a stricture has developed, it may be treated with endoscopic dilatation using a balloon or a bougie. This procedure should be avoided between 7 and 21 days after the caustic ingestion because of the increased risk of perforation (0.4-32%). The time interval between each dilatation is variable and it goes from a little less than one week to 2-3 weeks. Usually, 3-4 cycles are adequate to ensure durable results. Remember that a good nutritional state is critical for a productive effect.

2. Cancerization

In patients with grade 2B-3 injuries, the risk of esophageal cancer, both adenocarcinoma, and squamous cell carcinoma, is increased by 1000-3000 times compared to patients of similar age. The incidence is reported to be between 2% and 30%, and its development may be any time between 10 and 30 years after the index event.

Because of this increased risk of esophageal cancerization, these patients should be followed-up with a gastroscopy yearly.

Late Surgery

Late surgery may be necessary in the case of esophageal strictures non-responding to endoscopic dilatation, gastric outlet syndrome, and emergency esophagectomy.

In the first case, esophagectomy followed by a right colon or gastric interposition can be performed. In the case of gastric outlet syndrome, possible surgical techniques are pyloroplasty or gastrojejunostomy. Lastly, after emergency esophagectomy, reconstruction should be planned after about 6 months, when the scarring process is terminated, and its functional success rate has been reported as high as 77% at 5 years.

Luckily, caustic ingestion is a rare event, and it is even rarer that it needs to be treated by a surgeon… However, since the consequences may require an operational approach, the surgeon is often called to evaluate the situation.

We hope we have given you a comprehensive overview of how to manage these patients…

See you next time.


  1. Contini S, et al. Caustic injury of the upper gastrointestinal tract: a comprehensive review. World J Gastroenterol 2013;19:3918-30.
  2. Bonavina L, et al. Foregut caustic injuries: results of the world society of emergency surgery consensus conference. World J Emerg Surg 2015;10:44.
  3. Kluger Y, et al. Caustic ingestion management: world society of emergency surgery preliminary survey of expert opinion. World J Emerg Surg 2015;10:48.
  4. Katz A, et al. Caustic material ingestion injuries – Paradigm shift in diagnosis and treatment. Health Care Current Reviews 2015;3:2.
  5. Hoffman RS, et al. Ingestion of caustic substances. NEJM 2020;382:1739-48.
  6. Zargar SA, et al. The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns. Gastrointest Endosc 1991;37:165-9.
  7. Ryu HH, et al. Caustic injury: can CT grading system enable prediction of esophageal stricture? Clin Toxicol (Phila) 2010;48:137-42.
How to Cite This Post

Bellio G, Bacchion M, Ricci G, Marrano E. Like Vampires Drinking Holy Water – Part 2. Surgical Pizza. Published on December 3, 2022. Accessed on May 27, 2023. Available at [https://surgicalpizza.org/emergency-surgery/like-vampires- drinking-holy-water-part-2/].

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