01Principles and purposeThe professional or clinical skill and the decisions it supports.
Caustics and foreign bodies injure by different mechanisms. Alkali causes liquefactive necrosis and can penetrate deeply; acids produce coagulation injury but may pool in the stomach. Concentration, volume, contact time and physical form determine harm. Button batteries generate hydroxide at the negative pole, producing local alkaline injury even when the casing does not leak. Sharp objects cause pressure and direct perforation, while complete food impaction threatens aspiration.
Initial actions avoid magnifying exposure. Repeated emesis brings a corrosive substance back across injured mucosa. Neutralisation can generate heat and gas. Activated charcoal neither binds most caustics effectively nor helps endoscopic visualisation. Secure the airway before marked swelling, remove contaminated clothing and irrigate external exposure, and contact the National Poisons Information Service through the clinical route for product-specific advice.
Investigation and timing are anatomy-led. Radiographs locate metal and batteries, but radiolucent food, plastic and thin bone can be missed. CT assesses perforation or transmural caustic necrosis. Endoscopy removes a dangerous object and grades mucosa when appropriate, but insufflation is hazardous if free perforation is suspected. Later care includes nutrition, stricture surveillance, mental-health assessment after deliberate ingestion and pathology for underlying food-bolus disease.
Key points
- Identify the substance or object, time, amount, intent, packaging and co-ingestants while simultaneously assessing airway, breathing, circulation and ability to swallow secretions.
- After caustic ingestion, do not induce vomiting, perform gastric lavage, give activated charcoal routinely, dilute with large fluid volumes or attempt acid-alkali neutralisation.
- Early expert airway control may be safer than waiting for progressive laryngeal oedema to make intubation impossible.
- Plain radiographs locate radiopaque objects and show free air; CT defines perforation, mediastinal contamination and the depth of caustic necrosis more accurately.
- Emergent endoscopy removes oesophageal batteries and sharp objects and relieves complete food-bolus obstruction; less dangerous oesophageal foreign bodies still require urgent removal within 24 hours.
- After food bolus extraction, investigate the underlying stricture, cancer, ring or eosinophilic oesophagitis rather than treating removal as the final diagnosis.
02Situations and prioritiesThe context, relevant information and actions that matter most.
Drooling and inability to swallow saliva indicate complete luminal blockage with aspiration risk.
Hoarseness, stridor, oral swelling, secretion intolerance or respiratory distress warns of worsening laryngeal compromise after caustic exposure and requires early expert airway assessment.
Severe chest or abdominal pain, shock, crepitus, guarding or lactate elevation raises perforation and mediastinal or peritoneal contamination.
A round double-rim radiopaque disc in the oesophagus causes electrical and caustic necrosis before symptoms may become marked.
Previous intermittent dysphagia, atopy or weight loss suggests eosinophilic inflammation, a ring, peptic stricture or cancer beneath impaction.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Airway and flexible nasendoscopic assessment - Why
- Identify laryngeal swelling and need for controlled airway management.
- Interpretation and limitations
- Progressive oedema, stridor or secretion failure favours early expert intubation in a setting ready for surgical airway rescue.
- 02
Plain neck, chest and abdominal radiographs - Why
- Locate radiopaque objects and detect free gas.
- Interpretation and limitations
- Use two views where possible; a button battery may show a double rim, while a negative film does not exclude radiolucent material.
- 03
Contrast-enhanced CT - Why
- Assess perforation, mediastinitis, adjacent structures and depth of caustic injury; absent post-contrast wall enhancement indicates transmural necrosis.
- Interpretation and limitations
- For a stable adult with caustic ingestion, WSES 2019 uses contrast CT of neck, chest and abdomen at three to six hours. Absent wall enhancement indicating transmural necrosis requires emergency surgery. Peritonitis or instability requires urgent surgical action rather than waiting for that imaging interval; endoscopy has selected roles when CT is unavailable, contraindicated or equivocal.
- 04
Therapeutic upper-GI endoscopy - Why
- Remove the object and inspect mucosal injury when safe.
- Interpretation and limitations
- Timing follows object and obstruction severity; use protective devices for sharp extraction and avoid delay for fasting status when a battery is lodged.
- 05
Underlying-disease biopsies - Why
- Diagnose eosinophilic oesophagitis or malignancy after food-bolus relief.
- Interpretation and limitations
- Sample safely after lumen clearance or at planned follow-up if acute trauma makes immediate tissue hazardous.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked case: oesophageal button batteryRemove before symptoms declare the injuryA 29-year-old with learning disability is witnessed swallowing a button battery; radiographs 45 minutes later show a double-rim disc in the mid oesophagus despite normal observations.+
- 1Keep nil by mouth, summon anaesthesia, endoscopy and surgery, review airway and avoid waiting for pain, drooling or routine fasting time.
- 2Classify the oesophageal battery as an emergent-removal object and transfer directly to theatre; endoscopy at 95 minutes retrieves it with a protective device.
- 3The contact site has focal circumferential ulceration despite no visible perforation. Admit for monitored observation because a battery and significant mucosal injury are not an uncomplicated extraction. Contrast CT is reviewed with the upper-GI team for oesophageal-wall integrity and enhancement, surrounding inflammation and airway or vascular complications; it shows preserved wall enhancement without mediastinal collection, fistula or other adjacent-structure injury.
- 4Serial examinations show settling chest discomfort, no fever, crepitus or respiratory deterioration, stable haemoglobin and no further bleeding. After senior reassessment, supervised swallowing and oral intake are tolerated and a nutrition plan is documented. Discharge follows that observed recovery and specialist review, not the absence of free gas alone; carers receive urgent return advice for bleeding, chest pain, breathlessness, fever or new dysphagia and an arranged review for delayed stricture or fistula concerns.
02Caustic ingestionAvoid a second chemical passAn adult deliberately drinks an unknown volume of concentrated drain cleaner and arrives drooling with hoarseness.+
- 1Use protective equipment, remove contaminated clothing, irrigate exposed skin and call anaesthesia and toxicology while assessing airway and circulation.
- 2Do not induce vomiting, perform gastric lavage or attempt acid/alkali neutralisation: WSES 2015 warns of repeat exposure, aspiration and exothermic injury. Avoid routine nasogastric insertion, which that source associates with perforation, reflux and pneumonia. RCEM 2025 advises that charcoal is ineffective for strong acids and alkalis.
- 3Secure the threatened airway early with expert support. Once stabilised, apply the WSES 2019 adult CT approach at three to six hours, assessing post-contrast wall enhancement and adjacent structures. Absent enhancement indicates transmural necrosis and demands emergency surgical management; use endoscopy selectively if CT is unavailable, contraindicated or difficult to interpret. Do not let an imaging timetable postpone surgery for clinical peritonitis or persistent instability.
- 4Integrate nutrition, stricture planning and a mental-health assessment after immediate survival.
03Food bolusTreat the obstruction and its substrateA patient cannot swallow saliva after steak becomes impacted and reports months of intermittent solid-food dysphagia.+
- 1Use suction and airway positioning and classify secretion intolerance as complete obstruction requiring emergent endoscopy.
- 2Remove or gently disimpact the bolus without blind force and inspect for perforation or a fixed lesion.
- 3Assess for ring, peptic stricture, cancer and eosinophilic oesophagitis with appropriate biopsies or planned repeat examination.
- 4Verify saliva and diet tolerance and ensure pathology and dilation follow-up are booked.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- Repeat airway, voice, swallowing, oxygen saturation, chest and abdominal examinations during early evolution.
- After extraction, monitor fever, tachycardia, crepitus, pain and respiratory change for occult perforation.
- Track oral intake, weight and biochemical nutrition during severe caustic injury.
- Arrange contrast or endoscopic follow-up for dysphagia because caustic strictures can evolve after discharge.
- Close mental-health, safeguarding and product-identification actions after deliberate or unexplained ingestion.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
No mouth burn is not clearance
Liquid can pass rapidly through the oropharynx and still produce severe oesophageal or gastric necrosis.
Battery harm is electrochemical
Hydroxide forms at the negative pole, so an intact casing can still create deep tissue injury.
Fasting does not outrank urgency
Waiting six hours for an oesophageal battery or complete obstruction prolongs the mechanism causing necrosis or aspiration.
Impaction reveals disease
Adult food bolus commonly identifies an underlying structural or eosinophilic disorder that needs later treatment.
07Common pitfallsFrequent interpretation and management errors.
- 01
Inducing vomiting or attempting household neutralisation after caustic ingestion.
- 02
Delaying oesophageal battery removal because the patient is asymptomatic or recently ate.
- 03
Passing a nasogastric tube blindly through a caustic or sharp-object injury.
- 04
Discharging after bolus extraction without investigating months of preceding dysphagia.