Synopsis
Protect the airway, prevent repeat caustic exposure, locate and remove dangerous oesophageal objects on time, identify transmural injury and plan surveillance for strictures or underlying disease.
- 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.
Key red flags
Absence of visible oral burns does not exclude deep oesophageal or gastric caustic injury, particularly after a liquid ingestion.
An oesophageal battery, sharp-pointed object or complete obstruction needs emergent endoscopy, preferably within two hours and at the latest within six hours under ESGE 2016. WSES 2019 includes oesophageal magnets in that emergency group; this is not permission to wait until six hours. Gastric batteries, magnets and sharp objects have a different ESGE urgent within-24-hour recommendation.
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.
Reasoning priorities
Identify laryngeal swelling and need for controlled airway management.
Progressive oedema, stridor or secretion failure favours early expert intubation in a setting ready for surgical airway rescue.
Worked reasoning
A 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.
- Keep nil by mouth, summon anaesthesia, endoscopy and surgery, review airway and avoid waiting for pain, drooling or routine fasting time.
- Classify the oesophageal battery as an emergent-removal object and transfer directly to theatre; endoscopy at 95 minutes retrieves it with a protective device.
- The 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.
- Serial 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.