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Introduction
Ingestion of a caustic substance in pediatric patients is a frequently observed accident in emergency departments and poses a risk of potentially severe and irreversible injury to the upper gastrointestinal tract. This accidental or intentional ingestion represents a public health problem observed mainly in developing countries due to social, economic, and educational variables1,2. The highest incidence is observed in infants and preschoolers. It is accidental and occurs with substances found at home due to easy access to them because of their location. Additionally, these substances may be mislabeled or placed in inadequate containers3. The following have been identified as risk factors for intake: male gender, attention-deficit/hyperactivity disorder, lower educational level of parents, young maternal age, lack of supervision of children, and rural residence4.
Mortality is rare, but morbidity is devastating and, in some cases, lifelong, with short- and long-term complications, such as prolonged and multiple hospital admissions, esophageal or pyloric stenosis, as well as an increased risk of esophageal cancer in the long term5,6. This study aimed to present the experience of a tertiary pediatric hospital in the care of children with caustic substance ingestion.
Methods
We conducted a descriptive, analytical, retrospective study. We reviewed the biostatistical database of the Hospital Infantil de México Federico Gómez, a national referral center (Mexico City, Mexico). Clinical information was obtained from 336 pediatric patients (age < 18 years) with a diagnosis of admission due to caustic ingestion between 1989 and 2009. We analyzed sociodemographic variables (age and sex), type of substance ingested, signs and symptoms (oral lesions, sialorrhea, vomiting, irritability, nausea, odynophagia, dysphonia, and dysphagia). We also registered those patients who underwent an initial endoscopic study (hospital admission < 72 hours after ingestion) and a control esophagogram. The Zargar esophagitis classification7 was used to establish the degree of esophageal injury at initial endoscopy; in those where the gastric injury was documented, the Sakita-Miwa classification8 was used.
The endoscopic control study was performed in the third week after ingestion to define the finding of esophageal or pyloric stenosis. In addition, those children admitted 72 hours after ingesting the caustic substance, in whom the initial endoscopy was not performed, were registered as late admission.
Results
We included 336 patients with a median age of 1.7 years (range: 6 months to 15 years) at the time of hospital admission; 57% were male. Most patients were admitted to the hospital for accidental ingestion; only three adolescents were admitted for attempted suicide. Alkali ingestion predominated, with 81.5% (n = 274) of patients. Caustic liquid soda was the main substance ingested among other substances (Table 1).
Table 1 Type of ingested caustic substances and initial endoscopic findings in the esophagus and stomach
| n (%) | Grade of esophagitis according to Zargar | Gastric lesion | |||||
|---|---|---|---|---|---|---|---|
| Ingested substance | 0 | 1 | 2A | 2B | 3 | ||
| Liquid soda | 210 (62.5) | 54 | 24 | 34 | 35 | 20 | 44 |
| Solid soda | 25 (7.5) | 12 | 1 | 4 | 3 | 3 | |
| Soda gel | 24 (7.1) | 9 | 5 | 6 | 3 | 1 | |
| Chlorine | 14 (4.1) | 10 | 3 | 1 | 2 | ||
| Hydrochloric acid | 13 (3.8) | 5 | 1 | 3 | 1 | 2 | 3 |
| Salicylic acid | 12 (3.6) | 3 | 2 | 4 | 3 | 1 | |
| Ammonia | 10 (3) | 5 | 2 | 3 | 3 | ||
| Dishwasher | 3 (0.9) | 3 | |||||
| Floor cleaner | 3 (0.9) | 3 | |||||
| Podophyllin | 2 (0.6) | 1 | 1 | ||||
| Disinfectants | 2 (0.6) | 2 | |||||
| Alkaline battery fluid | 2 (0.3) | 1 | |||||
| Merthiolate | 1 (0.3) | 1 | 1 | ||||
| Calcium hydroxide | 1 (0.3) | 1 | |||||
| Thinner | 1 (0.3) | 1 | |||||
| Formaldehyde | 1 (0.3) | 1 | |||||
| Styrene monoxide | 1 (0.3) | 1 | 1 | ||||
| Potassium permanganate | 1 (0.3) | 1 | 1 | ||||
| Not identified | 10 (3) | 4 | 2 | 2 | 2 | ||
| Total | 284 | 114 | 41 | 56 | 48 | 25 | 61 |
After ingestion, 116 children (34.5%) received some liquid or medication intended to neutralize the caustic administered by parents or first contact medical personnel. Gastric lavage was performed in 14 cases (4%). The main clinical examination finding was oral lesions in 222 children (80%). The most frequently observed signs and symptoms are described in Table 2.
Table 2 Signs and symptoms observed on admission to the emergency department in children with caustic ingestion and odds ratios for developing Zargar esophagitis 2B and 3
| Sign or symptom | n (%) | Odds ratio | 95% CI | p-values |
|---|---|---|---|---|
| Oral lesions | 222 (80) | 9.05 | 2.74-29.89 | < 0.001 |
| Sialorrhea | 207 (74) | 4.42 | 2.14-9.09 | < 0.001 |
| Vomiting | 152 (54) | 2.47 | 1.40-4.37 | 0.001 |
| Irritability | 70 (25) | 1.70 | 0.95-3.01 | 0.071 |
| Nausea | 51 (18) | 1.52 | 0.79-2.93 | 0.201 |
| Odynophagia | 47 (17) | 1.63 | 0.83-3.19 | 0.152 |
| Dysphonia | 6 (2) | 2.97 | 0.58-15.06 | 0.169 |
| Dysphagia | 5 (1.8) | 4.47 | 0.73-27.35 | 0.077 |
CI, confidence interval.
Of the 336 patients, 52 were referred late, so they did not undergo endoscopy but only esophagogram in search of complications. In the 284 children who underwent endoscopic evaluation within 72 hours after ingestion, no esophageal lesions were observed in 40% of the patients (n = 114). In turn, esophageal lesions compatible with grade 1 Zargar esophagitis were observed in 14% (n = 41); grade 2A in 20% (n = 56); grade 2B in 17% (n = 48) and grade 3 in 9% (n = 25). Regarding gastric injury, 79% (n = 223) presented normal results, while gastric lesions were found in 21% of the cases, of which 70% (n = 43) were classified as Sakita-Miwa A1 and 30% (n = 18) as Sakita-Miwa A2 ulcers. There were no complications associated with the endoscopic procedure.
A significant association (p < 0.001) was identified between the presence of more than four symptoms at diagnosis (Table 2) with severe esophageal injury (Zargar 2B and 3). Oral lesions, sialorrhea, and vomiting indicated a risk for developing Zargar esophagitis 2B and 3. However, we should consider that most patients had concomitant symptoms. No severe degree of burning was documented in asymptomatic patients.
After treatment with antibiotics, corticosteroids, antisecretory agents, and enteral tube feeding, an esophagogram was performed to look for complications in the third week after ingestion. If stenosis was found, upper gastrointestinal endoscopy was performed to pass an endless string and subsequently perform dilatations with Tucker bougies. Esophageal stricture was documented in 21% of patients with Zargar 2A lesion (n = 12), 75% of patients with Zargar 2B (n = 36), and 88% of patients with Zargar 3 lesion (n = 22).
One patient with a history of ammonia ingestion and grade 2B Zargar esophagitis and three patients with caustic soda ingestion and grade 3 Zargar esophagitis developed pyloric stenosis (Table 3).
Table 3 Initial endoscopic findings in 284 patients and percentage of esophageal stricture and pyloric stenosis development
| Zargar grade | Initial endoscopy n (%) | Esophageal stricture n (%) | Pyloric stenosis n (%) |
|---|---|---|---|
| 0 | 114 (40) | 0 | 0 |
| 1 | 41 (14) | 0 | 0 |
| 2A | 56 (20) | 12 (21) | 0 |
| 2B | 48 (17) | 36 (75) | 1 (2) |
| 3 | 25 (9) | 22 (88) | 3 (10) |
| Total | 284 | 70 | 4 |
Discussion
Accidental ingestion of caustic substances and foreign bodies continues to be a critical medical-social health problem9. This study describes the clinical and endoscopic characteristics and evolution of pediatric patients with caustic ingestion. It has been reported that most ingestions occur in children < 5 years of age4. In Mexico, a previous study reported a mean age of 3.2 years and male predominance10. A meta-analysis that included more than 8,000 children reported that the most frequent age was 2 years11. We observed a mean age of 1.7 years, with a male-to-female ratio of 1.3:1. As previously reported, the vast majority of these ingestions occurred accidentally due to children's curiosity or attempt to obtain food, whereas, in adolescents, it occurs intentionally. In this study, intentional ingestion was documented in < 1% of cases.
After ingesting a caustic substance, the initial clinical manifestations are diverse: vomiting, dysphagia, sialorrhea, abdominal pain, and hematemesis11,12. A multicenter observational study involving 162 children reported that the number of symptoms allowed physicians to predict the presence of severe esophageal injury13. The most useful clinical signs and symptoms to predict the presence of esophageal injury are vomiting, dysphagia, abdominal pain, and the presence of lesions in the oral cavity. If two or more of these signs and symptoms are present, the probability of finding esophageal lesions is higher, with a positive predictive value (PPV) of 43% and a negative predictive value (NPV) of 96%14. However, as a single finding, oral lesions have shown a PPV of only 31% and a relatively low NPV of 79% for detecting esophageal lesions15. Our study found an association between four or more of the symptoms listed in Table 2, the presence of oral lesions and esophageal lesions Zargar 2B and 3, which should be considered when evaluating children with caustic ingestion. Also, we found that if children were asymptomatic, they did not have severe esophageal lesions; only a small proportion of children without oral lesions (n = 3) had severe esophageal lesions. These findings differ from the series published by Temiz et al.16, who reported that 12-26% of asymptomatic children show severe lesions on endoscopic evaluation. Therefore, it is recommended to perform upper endoscopy in patients with a history of caustic ingestion, even if they are asymptomatic1,16.
The ideal time to perform endoscopic evaluation after ingestion of caustic substances in children remains controversial17. Most studies recommend that it be performed in the first 24 to 48 hours after ingestion to assess the extent of the lesions and their severity, establish the prognosis, and guide treatment13,18. Endoscopy is not recommended more than four days after ingestion, as it increases the risk of esophageal perforation19. Currently, the Ibero-Latin American Clinical Practice Guide (Guía de Práctica Clínica Ibero-Latinoamericana) on caustic esophagitis in pediatrics recommends performing this study in the first 24 to 48 hours1,16. Endoscopic evaluation is performed during the first 72 hours in the Endoscopy Service of the Hospital Infantil de México Federico Gómez. In this study, the percentage of stenosis was similar to that published by Zargar et al. and other series19,20: for grade 2A lesions, 21% vs. <15%; for grade 2B lesions, 75% vs. 70-90%; and for grade 3 lesions, 88% vs. 83-100%, respectively, in patients in whom endoscopy was performed in the first 72 hours. All late referral patients already had an esophageal stricture.
In conclusion, the morbidity caused by caustic ingestion indicates that it is necessary to develop more effective prevention measures to avoid this type of accident. Furthermore, any patient with a history of ingestion of a caustic substance, even without symptoms, should undergo an endoscopic procedure within the first 24 to 72 hours since it is not possible to rule out some injuries. If the patient presents with more than four signs/symptoms, or oral lesions, sialorrhea, or vomiting, severe esophageal damage should be suspected.
