Acid ingestion - Revision history

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	**Salicylate, acetaminophen, ethanol levels (if intentional ingestion)		**Salicylate, acetaminophen, ethanol levels (if intentional ingestion)
	**β-hCG in women of reproductive age		**β-hCG in women of reproductive age
	**Extended electrolytes including calcium and magnesium (especially for [[~~hdrofluoric~~ acid]])		**Extended electrolytes including calcium and magnesium (especially for [[hydrofluoric acid]])
	* Imaging:		* Imaging:
	**Chest and abdominal radiograph — assess for pneumomediastinum, pneumoperitoneum, pleural effusion		**Chest and abdominal radiograph — assess for pneumomediastinum, pneumoperitoneum, pleural effusion

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Workup

← Older revision		Revision as of 15:42, 19 March 2026
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	**Salicylate, acetaminophen, ethanol levels (if intentional ingestion)		**Salicylate, acetaminophen, ethanol levels (if intentional ingestion)
	**β-hCG in women of reproductive age		**β-hCG in women of reproductive age
	**Extended electrolytes including calcium and magnesium (especially for [[~~ydrofluoric~~ acid]])		**Extended electrolytes including calcium and magnesium (especially for [[hdrofluoric acid]])
	* Imaging:		* Imaging:
	**Chest and abdominal radiograph — assess for pneumomediastinum, pneumoperitoneum, pleural effusion		**Chest and abdominal radiograph — assess for pneumomediastinum, pneumoperitoneum, pleural effusion

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Ostermayer: Created page with "Acid ingestion is a subcategory of caustic ingestion in which a strong acid (pH <2) causes injury to the upper gastrointestinal tract, predominantly the stomach, through coagulation necrosis.Hoffman RS, Burns MM, Gosselin S. Ingestion of caustic substances. ''N Engl J Med''. 2020;382(18):1739-1748. doi:10.1056/NEJMra1810769 Acid ingestion carries a higher mortality rate than alkali ingestion.Caustic..."

2026-03-17T22:56:59Z

Created page with "Acid ingestion is a subcategory of caustic ingestion in which a strong acid (pH <2) causes injury to the upper gastrointestinal tract, predominantly the stomach, through coagulation necrosis.<ref name="Hoffman2020">Hoffman RS, Burns MM, Gosselin S. Ingestion of caustic substances. ''N Engl J Med''. 2020;382(18):1739-1748. doi:10.1056/NEJMra1810769</ref> Acid ingestion carries a higher mortality rate than alkali ingestion.<ref name="WikEM">Caustic..."

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Acid ingestion is a subcategory of [[Caustic ingestion|caustic ingestion]] in which a strong acid (pH <2) causes injury to the upper gastrointestinal tract, predominantly the stomach, through coagulation necrosis.<ref name="Hoffman2020">Hoffman RS, Burns MM, Gosselin S. Ingestion of caustic substances. ''N Engl J Med''. 2020;382(18):1739-1748. doi:10.1056/NEJMra1810769</ref> Acid ingestion carries a higher mortality rate than alkali ingestion.<ref name="WikEM">[[Caustic ingestion]]</ref>

==Background==
*Acids act as proton donors, causing cell death through protein denaturation and '''coagulation necrosis'''<ref name="Hoffman2020"/>
**Coagulation necrosis forms a protective eschar that classically was thought to limit tissue penetration depth
**However, recent data suggest esophageal perforation rates from acids may be higher than previously believed<ref name="Chen2022">Chen RJ, O'Malley RN, Salzman M. Updates on the Evaluation and Management of Caustic Exposures. ''Emerg Med Clin North Am''. 2022;40(2):343-364. doi:10.1016/j.emc.2022.01.013</ref>
*Acids tend to transit the esophagus rapidly due to low viscosity, causing '''preferential gastric injury'''
**Pylorospasm from acid exposure prolongs gastric contact time (up to 90 minutes), leading to pooling and high-grade gastric burns<ref name="Park2014">Park KS. Evaluation and management of caustic injuries from ingestion of acid or alkaline substances. ''Clin Endosc''. 2014;47(4):301-307. doi:10.5946/ce.2014.47.4.301</ref>
**Gastric antrum and pylorus are most commonly affected
*Acids have a noxious taste that may trigger gagging and choking, predisposing to '''aspiration''' with subsequent airway injury<ref name="Lupa2009">Lupa M, Magne J, Guarisco JL, Amedee R. Update on the Diagnosis and Treatment of Caustic Ingestion. ''Ochsner J''. 2009;9(2):54-59.</ref>
*Certain acids have unique '''systemic toxicity''' beyond local caustic effects (see [[#Special considerations by agent|Special considerations]])
*80% of caustic ingestions worldwide occur in children (usually accidental, small-volume, often benign)<ref name="Merck">Caustic Ingestion. ''Merck Manual Professional Edition''. 2025.</ref>
*In adults, ingestion is more often intentional (self-harm), involves larger volumes, and is more frequently life-threatening<ref name="Chirica2017">Chirica M, Kelly MD, Siboni S, et al. Esophageal emergencies: WSES guidelines. ''World J Emerg Surg''. 2019;14:26. doi:10.1186/s13017-019-0245-2</ref>

===Common acids===
*Hydrochloric acid (HCl) — toilet bowl cleaners, metal cleaners, tile cleaners
*Sulfuric acid (H₂SO₄) — car batteries, drain openers
*Phosphoric acid — rust removers, metal cleaners
*Hydrofluoric acid (HF) — rust removers, glass etching, industrial use
*Oxalic acid — cleaning agents
*Acetic acid (concentrated) — industrial solvent

==Clinical features==
*'''Signs and symptoms are inadequate to predict the presence or severity of esophageal or gastric injury'''<ref name="Previtera1990">Previtera C, Giusti F, Guglielmi M. Predictive value of visible lesions (cheeks, lips, oropharynx) in suspected caustic ingestion: may endoscopy reasonably be omitted in completely negative pediatric patients? ''Pediatr Emerg Care''. 1990;6(3):176-178.</ref>
*'''Absence of oropharyngeal burns does NOT exclude significant esophageal or gastric injury'''

===Oropharyngeal===
*Burns, erythema, or ulceration of lips, tongue, oral mucosa
*Drooling, inability to handle secretions
*Odynophagia, dysphagia

===Airway===
*Stridor, hoarseness, dysphonia (acid ingestion causes upper airway injury more often than alkali due to aspiration from gagging)<ref name="Lupa2009"/>
*Respiratory distress, tachypnea
*Uvular edema

===Gastrointestinal===
*Epigastric or chest pain
*Nausea, vomiting (may be hematemesis)
*Abdominal rigidity, guarding (suggests [[Peritonitis|perforation]])

===Systemic===
*[[Metabolic acidosis]] (from absorbed acid)
**HCl → non-anion gap (hyperchloremic) metabolic acidosis
**H₂SO₄ → anion gap metabolic acidosis (unmeasured sulfate)
*Hemolysis, [[DIC|disseminated intravascular coagulation]]
*[[Acute kidney injury]]
*Shock (hypovolemic from third-spacing/hemorrhage, or distributive from sepsis)

==Differential diagnosis==
===[[Caustic ingestion]]===
*[[Alkali ingestion]]
*[[Button battery ingestion]]
*[[Laundry detergent pod ingestion]]

===Other===
*[[Esophageal perforation]] (other causes)
*[[Peptic ulcer disease]]
*[[Upper GI bleed]]
*Acute gastritis
*[[Anaphylaxis]] (if presenting with oropharyngeal edema and stridor)
*[[Epiglottitis]]
*[[Retropharyngeal abscess]]
*[[Foreign body ingestion]]

==Evaluation==
===Workup===
*'''Identify the specific agent, concentration, estimated volume, time of ingestion, and intent'''
**Obtain product label, MSDS/SDS when possible
**Contact [[Poison control]] for guidance
*'''Labs:'''
**CBC, BMP, hepatic function panel, coagulation studies (PT/INR, fibrinogen), type and screen
**Serum lactate, VBG/ABG (pH, lactate)
**Lipase
**Salicylate, acetaminophen, ethanol levels (if intentional ingestion)
**β-hCG in women of reproductive age
**Extended electrolytes including calcium and magnesium (especially for [[ydrofluoric acid]])
*'''Imaging:'''
**Chest and abdominal radiograph — assess for pneumomediastinum, pneumoperitoneum, pleural effusion
**'''CT chest/abdomen with IV contrast''' — useful adjunct for identifying transmural necrosis, perforation, and peritoneal free fluid; higher specificity than EGD for surgical decision-making but should not replace EGD<ref name="Chirica2015">Chirica M, Resche-Rigon M, Pariente B, et al. Computed tomography evaluation of high-grade esophageal necrosis after corrosive ingestion to avoid unnecessary esophagectomy. ''Surg Endosc''. 2015;29(6):1452-1461. doi:10.1007/s00464-014-3823-0</ref>
*'''Esophagogastroduodenoscopy (EGD):'''
**Gold standard for grading injury severity
**Perform within '''12-24 hours''' of ingestion<ref name="Chirica2017"/>
***Too early (<12 hr) may underestimate injury extent
***Avoid between days 5-15 post-ingestion due to maximal tissue friability and perforation risk<ref name="DeBarros2017">De Barros SG, et al. Management of esophageal caustic injury. ''World J Gastrointest Pharmacol Ther''. 2017;8(2):90-98. doi:10.4292/wjgpt.v8.i2.90</ref>
**Exception: do not delay surgery for EGD if perforation is already evident

===Diagnosis===
*EGD findings graded by the '''Zargar classification:'''<ref name="Zargar1991">Zargar SA, Kochhar R, Mehta S, Mehta SK. The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns. ''Gastrointest Endosc''. 1991;37(2):165-169.</ref>
**'''Grade 0''' — Normal mucosa
**'''Grade I''' — Edema and hyperemia
**'''Grade IIa''' — Superficial ulceration, hemorrhage, erosions, blisters, exudates
**'''Grade IIb''' — Deep, discrete, or circumferential ulceration
**'''Grade IIIa''' — Focal necrosis (small, scattered areas of necrosis)
**'''Grade IIIb''' — Extensive necrosis
**'''Grade IV''' — Perforation (added in some modified classifications)
*Grades 0, I, and IIa generally recover without long-term sequelae
*Grades IIb and above carry significant risk of stricture formation and may require surgical intervention<ref name="Cheng2008">Cheng HT, Cheng CL, Lin CH, et al. Caustic ingestion in adults: the role of endoscopic classification in predicting outcome. ''BMC Gastroenterol''. 2008;8:31. doi:10.1186/1471-230X-8-31</ref>
*'''Lab markers predictive of transmural necrosis:''' severe metabolic acidosis (low pH, elevated lactate), leukocytosis, thrombocytopenia, elevated CRP, deranged LFTs, acute kidney injury<ref name="Chirica2017"/>

==Management==
===Airway===
*Assess airway '''immediately and continuously''' — may deteriorate rapidly over hours as edema progresses
*'''Intubate early''' if stridor, voice changes, drooling, respiratory distress, or uvular edema
**Video laryngoscopy preferred to minimize manipulation
**Blind nasotracheal intubation is '''contraindicated''' (risk of perforation/false passage)
**Have [[Cricothyrotomy|cricothyrotomy]] equipment at bedside
**Consider nebulized [[Racemic epinephrine|racemic epinephrine]] while preparing for intubation if stridor present<ref name="ECBC">Emergency Care BC. Caustic Injuries — Diagnosis and Management. 2024.</ref>

===Resuscitation===
*Large-bore IV access (at least 2 sites); cardiac monitoring
*Aggressive IV fluid resuscitation for hemorrhage, third-spacing, or shock
*Vasopressors if hypotension refractory to fluids
*Transfuse blood products as needed

===Things to avoid===
*'''Do NOT induce emesis''' — re-exposes mucosa to caustic agent, risk of perforation and aspiration
*'''Do NOT perform gastric lavage''' — risk of esophageal perforation
*'''Do NOT attempt to neutralize''' with a base — exothermic reaction compounds chemical injury with thermal injury, may also induce vomiting<ref name="Hoffman2020"/>
*'''Do NOT give activated charcoal''' — ineffective for caustics, obscures endoscopic view, aspiration risk
*'''Dilution with water or milk is generally NOT recommended''' for liquid acid ingestions — may provoke vomiting<ref name="Merck"/>
**Exception: dilution may have limited benefit within the first few minutes after a solid/granular caustic ingestion to remove adherent particles
*'''Do NOT routinely give corticosteroids''' — evidence does not support efficacy in preventing stricture; may increase perforation risk<ref name="Katibe2018">Katibe R, Abdelgadir I, McGrogan P, Akobeng AK. Corticosteroids for preventing caustic esophageal strictures: systematic review and meta-analysis. ''J Pediatr Gastroenterol Nutr''. 2018;66(6):898-902. doi:10.1097/MPG.0000000000001852</ref>
*'''Do NOT routinely insert NGT''' — risk of perforation in severely injured esophagus
**Exception: nasogastric suction may be considered early after large-volume liquid acid ingestion (especially HF, HgCl₂, ZnCl₂) if no signs of perforation, to limit ongoing gastric and distal exposure<ref name="Medscape">Lung D. Caustic Ingestions Treatment & Management. ''Medscape''. 2024.</ref>

===Supportive care===
*NPO until injury severity established
*Proton pump inhibitor or H2-receptor antagonist
*Parenteral nutrition if prolonged NPO anticipated
*Broad-spectrum antibiotics '''only''' if perforation suspected or confirmed
*Pain management

===Surgical consultation===
*'''Emergent surgical consultation''' for:<ref name="Chirica2017"/>
**Clinical signs of perforation (peritonitis, pneumoperitoneum, mediastinal air)
**Hemodynamic instability with evidence of hemorrhage
**Persistent metabolic acidosis or coagulopathy suggesting transmural necrosis
**Grade IIIb injury on EGD or CT findings of transmural necrosis
*Exploratory laparotomy is the standard approach for emergency surgery
*Total gastrectomy may be required for extensive gastric necrosis (partial gastrectomy is not recommended due to risk of progressive necrosis in remnant)<ref name="IJCCMCorrosive">Corrosive Ingestion. ''Indian J Crit Care Med''. 2019.</ref>

===Special considerations by agent===
*'''[[Hydrofluoric acid exposure|Hydrofluoric acid (HF)]]''' — uniquely dangerous due to systemic fluoride toxicity<ref name="Vohra2018">Vohra R, et al. Hydrofluoric Acid: Burns and Systemic Toxicity, Protective Measures, Immediate and Hospital Medical Treatment. ''Curr Pharm Des''. 2018;24(28):3327-3333. doi:10.2174/1381612824666181026150700</ref>
**Causes '''life-threatening hypocalcemia, hypomagnesemia, and hyperkalemia''' → cardiac dysrhythmias, QTc prolongation, cardiac arrest
**Administer empiric IV calcium for any significant HF exposure, QTc prolongation, or dysrhythmia
**Continuous cardiac monitoring mandatory
**Consider early NGT suction to limit absorption
*'''Sulfuric acid (H₂SO₄)''' — highly exothermic upon contact with water; produces high anion gap metabolic acidosis from absorbed sulfate
*'''Hydrochloric acid (HCl)''' — concentrated ingestion >60 mL causes severe gastric and duodenal necrosis with risk of perforation; produces hyperchloremic metabolic acidosis<ref name="LITFL">Corrosive ingestions. ''Life in the Fast Lane (LITFL)''. 2020.</ref>

==Disposition==
*'''Asymptomatic, accidental, small-volume, low-concentration ingestion (child or adult):'''
**Observe 4-6 hours; if tolerating PO, no symptoms, may discharge with GI follow-up and return precautions<ref name="Medscape"/>
*'''Symptomatic patients:'''
**Admit; NPO; arrange EGD within 12-24 hours
**GI consultation
*'''Zargar Grade ≥ IIb:'''
**Admit to ICU or monitored setting
**Surgical consultation
*'''Evidence of perforation, hemodynamic instability, or transmural necrosis:'''
**Emergent surgical consultation and ICU admission
*'''All intentional ingestions:'''
**Psychiatric evaluation mandatory prior to discharge<ref name="Chirica2017"/>
*'''Long-term follow-up considerations:'''
**Stricture formation occurs in up to 70-100% of Grade IIb-IIIa injuries, typically within the first 2 months; endoscopic dilation initiated at 3 weeks post-ingestion<ref name="Park2014"/>
**Upper GI bleeding risk at 2-4 weeks post-ingestion
**Tracheoesophageal fistula may develop months after ingestion
**'''1000-fold increased risk of esophageal carcinoma''' (squamous cell or adenocarcinoma) after high-grade caustic burns; surveillance endoscopy recommended beginning 15-20 years post-injury<ref name="WikEM"/>
**Gastric outlet obstruction from antropyloric stenosis is a common late complication specific to acid ingestion<ref name="Zargar1989">Zargar SA, Kochhar R, Nagi B, Mehta S, Mehta SK. Ingestion of corrosive acids: spectrum of injury to upper gastrointestinal tract and natural history. ''Gastroenterology''. 1989;97(3):702-707.</ref>

==See Also==
*[[Caustic ingestion]]
*[[Alkali ingestion]]
*[[Hydrofluoric acid]]
*[[Esophageal perforation]]
*[[Button battery ingestion]]
*[[Ingested foreign body]]
*[[Upper GI bleed]]

==External Links==
*[https://wikem.org/wiki/Caustic_ingestion WikEM — Caustic ingestion]
*[https://www.ncbi.nlm.nih.gov/books/NBK557442/ StatPearls — Caustic Ingestions]
*[https://pmc.ncbi.nlm.nih.gov/articles/PMC3096249/ Ochsner Journal — Update on the Diagnosis and Treatment of Caustic Ingestion]
*[https://pmc.ncbi.nlm.nih.gov/articles/PMC4130883/ Clin Endoscopy — Evaluation and Management of Caustic Injuries from Ingestion of Acid or Alkaline Substances]
*[https://emergencycarebc.ca/clinical_resource/clinical-summary/caustic-injuries-diagnosis-and-management-2/ Emergency Care BC — Caustic Injuries]

==References==
<references/>

[[Category:Toxicology]]
[[Category:GI]]

← Older revision		Revision as of 09:29, 22 March 2026
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	**Coagulation necrosis forms a protective eschar that classically was thought to limit tissue penetration depth		**Coagulation necrosis forms a protective eschar that classically was thought to limit tissue penetration depth
	**However, recent data suggest esophageal perforation rates from acids may be higher than previously believed<ref name="Chen2022">Chen RJ, O'Malley RN, Salzman M. Updates on the Evaluation and Management of Caustic Exposures. ''Emerg Med Clin North Am''. 2022;40(2):343-364. doi:10.1016/j.emc.2022.01.013</ref>		**However, recent data suggest esophageal perforation rates from acids may be higher than previously believed<ref name="Chen2022">Chen RJ, O'Malley RN, Salzman M. Updates on the Evaluation and Management of Caustic Exposures. ''Emerg Med Clin North Am''. 2022;40(2):343-364. doi:10.1016/j.emc.2022.01.013</ref>
	*Acids tend to transit the esophagus rapidly due to low viscosity, causing ~~'''~~preferential gastric injury~~'''~~		*Acids tend to transit the esophagus rapidly due to low viscosity, causing preferential gastric injury
	**Pylorospasm from acid exposure prolongs gastric contact time (up to 90 minutes), leading to pooling and high-grade gastric burns<ref name="Park2014">Park KS. Evaluation and management of caustic injuries from ingestion of acid or alkaline substances. ''Clin Endosc''. 2014;47(4):301-307. doi:10.5946/ce.2014.47.4.301</ref>		**Pylorospasm from acid exposure prolongs gastric contact time (up to 90 minutes), leading to pooling and high-grade gastric burns<ref name="Park2014">Park KS. Evaluation and management of caustic injuries from ingestion of acid or alkaline substances. ''Clin Endosc''. 2014;47(4):301-307. doi:10.5946/ce.2014.47.4.301</ref>
	**Gastric antrum and pylorus are most commonly affected		**Gastric antrum and pylorus are most commonly affected
	*Acids have a noxious taste that may trigger gagging and choking, predisposing to ~~'''~~aspiration~~'''~~ with subsequent airway injury<ref name="Lupa2009">Lupa M, Magne J, Guarisco JL, Amedee R. Update on the Diagnosis and Treatment of Caustic Ingestion. ''Ochsner J''. 2009;9(2):54-59.</ref>		*Acids have a noxious taste that may trigger gagging and choking, predisposing to aspiration with subsequent airway injury<ref name="Lupa2009">Lupa M, Magne J, Guarisco JL, Amedee R. Update on the Diagnosis and Treatment of Caustic Ingestion. ''Ochsner J''. 2009;9(2):54-59.</ref>
	*Certain acids have unique ~~'''~~systemic toxicity~~'''~~ beyond local caustic effects (see [[#Special considerations by agent\|Special considerations]])		*Certain acids have unique systemic toxicity beyond local caustic effects (see [[#Special considerations by agent\|Special considerations]])
	*80% of caustic ingestions worldwide occur in children (usually accidental, small-volume, often benign)<ref name="Merck">Caustic Ingestion. ''Merck Manual Professional Edition''. 2025.</ref>		*80% of caustic ingestions worldwide occur in children (usually accidental, small-volume, often benign)<ref name="Merck">Caustic Ingestion. ''Merck Manual Professional Edition''. 2025.</ref>
	*In adults, ingestion is more often intentional (self-harm), involves larger volumes, and is more frequently life-threatening<ref name="Chirica2017">Chirica M, Kelly MD, Siboni S, et al. Esophageal emergencies: WSES guidelines. ''World J Emerg Surg''. 2019;14:26. doi:10.1186/s13017-019-0245-2</ref>		*In adults, ingestion is more often intentional (self-harm), involves larger volumes, and is more frequently life-threatening<ref name="Chirica2017">Chirica M, Kelly MD, Siboni S, et al. Esophageal emergencies: WSES guidelines. ''World J Emerg Surg''. 2019;14:26. doi:10.1186/s13017-019-0245-2</ref>
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	* Esophagogastroduodenoscopy (EGD):		* Esophagogastroduodenoscopy (EGD):
	**Gold standard for grading injury severity		**Gold standard for grading injury severity
	**Perform within ~~'''~~12-24 hours~~'''~~ of ingestion<ref name="Chirica2017"/>		**Perform within 12-24 hours of ingestion<ref name="Chirica2017"/>
	***Too early (<12 hr) may underestimate injury extent		***Too early (<12 hr) may underestimate injury extent
	***Avoid between days 5-15 post-ingestion due to maximal tissue friability and perforation risk<ref name="DeBarros2017">De Barros SG, et al. Management of esophageal caustic injury. ''World J Gastrointest Pharmacol Ther''. 2017;8(2):90-98. doi:10.4292/wjgpt.v8.i2.90</ref>		***Avoid between days 5-15 post-ingestion due to maximal tissue friability and perforation risk<ref name="DeBarros2017">De Barros SG, et al. Management of esophageal caustic injury. ''World J Gastrointest Pharmacol Ther''. 2017;8(2):90-98. doi:10.4292/wjgpt.v8.i2.90</ref>
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	===Diagnosis===		===Diagnosis===
	*EGD findings graded by the ~~'''~~Zargar classification:~~'''~~<ref name="Zargar1991">Zargar SA, Kochhar R, Mehta S, Mehta SK. The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns. ''Gastrointest Endosc''. 1991;37(2):165-169.</ref>		*EGD findings graded by the Zargar classification:<ref name="Zargar1991">Zargar SA, Kochhar R, Mehta S, Mehta SK. The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns. ''Gastrointest Endosc''. 1991;37(2):165-169.</ref>
	** Grade 0 — Normal mucosa		** Grade 0 — Normal mucosa
	** Grade I — Edema and hyperemia		** Grade I — Edema and hyperemia
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	*Proton pump inhibitor or H2-receptor antagonist		*Proton pump inhibitor or H2-receptor antagonist
	*Parenteral nutrition if prolonged NPO anticipated		*Parenteral nutrition if prolonged NPO anticipated
	*Broad-spectrum antibiotics ~~'''~~only~~'''~~ if perforation suspected or confirmed		*Broad-spectrum antibiotics only if perforation suspected or confirmed
	*Pain management		*Pain management