Caustic (Strong Acid/Alkali) Ingestion — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

🎓 Want to practice? Do a case challenge with this pathway → (get a case, choose management step by step, scored).

Full pathway

1. [Decision] Airway and symptoms
   Caustic ingestion — airway and symptoms? (Strong acid (coagulation necrosis, mostly injures the stomach) vs strong alkali (liquefaction necrosis, penetrates deep, injures the esophagus, e.g. drain cleaner). Management is similar for both. Contraindications (the 'four nos'): no induced emesis, no gastric lavage, no neutralization (acid-base neutralization is exothermic and worsens injury), no activated charcoal (does not adsorb and obscures endoscopy; except with systemic toxicity such as zinc/mercury chloride). Milk/water dilution only in the first few minutes (controversial).)
   • Airway involvement/symptomatic/intentional ingestion → Airway involvement/intentional → airway + early endoscopy
   • Asymptomatic, small accidental ingestion → Asymptomatic · observe
2. [End] Asymptomatic · observe
   Asymptomatic, small accidental ingestion: no emesis/lavage/neutralization/charcoal; observe, keep NPO; after overnight observation, those tolerating oral intake without symptoms may avoid endoscopy; endoscope if unable to tolerate PO or symptoms appear. Contact a poison control center.
3. [End] Airway involvement/intentional → airway + early endoscopy
   Airway involvement (stridor/drooling/voice change)/symptomatic/intentional ingestion: airway first (anticipate swelling/obstruction — intubate under direct bronchoscopic vision, avoid blind intubation, use paralytics cautiously with severe distortion; surgical airway if needed) + hemodynamic stability (fluids/vasopressors); no emesis/lavage/neutralization/charcoal; early endoscopy (EGD) grading at 12–24 h (Zargar, no later than 48 h, stop at severe injury to avoid perforation); CT to assess transmural necrosis/perforation. High-grade/perforation/peritonitis → surgery. Long term: esophageal stricture (dilation), cancer risk.

Source guidelines & references

• Caustic ingestion (Merck Manual; StatPearls; WSES)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

Other pathways