The ingestions of caustic products are relatively rare and can be quickly fatal conditioned by the occurrence of transmural necrosis of the digestive wall. Management has evolved significantly over the past ten years, requiring multidisciplinary management. It is a medico-surgical emergency where computed tomography (CTC) has become the Gold Stand to assess the seriousness of the involvement, and no longer gastric fibroscopy. There Dre Cassandre Follet (Emergency doctor, Rouen University Hospital), during the 2025 emergency congress in Paris, took stock of the new strategies for taking charge of the ingestion of caustic products, according to the recommendations of the Gastroenterology College of 2023.
Preexisting psychiatric disease
A recent analysis of data from the PMSI basis (Information Systems Medicalization Program) in France between 2010-2019 made it possible to identify 3,544 patients admitted in an emergency for ingestion of caustic, or 0.016 % of emergency admissions during this period. This analysis has shown that an extensive digestive necrosis requiring emergency surgery was present in 11 % of patients while 89 % of patients were able to benefit from non-operative treatment. The median age of the population was 49 years with a slight male predominance. Ingestion was voluntary concerned 89 % of them, 72 % of which were carrying a preexisting psychiatric disease.
Identify the exact composition of the ingested product
The identification of the exact composition of the ingested product is essential because in addition to purely local toxicity, some agents may have associated systemic toxicity. To do this, it is essential to contact an anti -poison center from the start of patient care. The lesions vary according to the quantity (mainly), the form and the nature of the ingested product, specifies the Follet DRE. Solid products and gels preferentially cause oropharyngeal lesions and proximal esophagus, explained by their high viscosity and causing liquefaction necrosis quickly all parietal layers. Liquid products, having great fluidity, quickly progress in the digestive sector and cause lesions of the esophagus and stomach through coagulation necrosis with maximum surface lesions. As for volatile forms (strong acids), they can induce tracheo-bronchic lesions. A recent study by the Saint Louis Hospital team showed that in 55% of cases, the substances ingested were strong basis type Destop, 25% of the case of Javel type oxidants and 20% of cases of strong acids.
Short-term evolution (3-6h after ingestion) can be transmural necrosis of the digestive wall, digestive perforation, extension by continuity to neighborhood organs in the mediastin (tracheal or bronchial or tracheo/broncho-esophageal fistula) and abdomen, secondary PNP. Remotely (4 months), a risk of hemorrhage, fistulization, retractile sclerosis (stenosis, chronic GERD), neoplastic degeneration of the scar esophagus are to be feared.
The systematic administration of antacid medication, antibiotic therapy or corticosteroid therapy have not shown their effectiveness to date.
Any attempted neutralization of caustic agents is not recommended
From first aid, it is necessary to proscribe any gesture which exposes to an aggravation of the lesions by “second pass” of the product in the digestive sector, it will then be necessary to proscribe the dorsal decubitus, gastric washes, the installation of a gastric probe, the induced vomiting. Any attempt to neutralize caustic agents is also not recommended, potentially at risk of inhalation and aggravation of burns by exothermic reactions.
Extra- and intra-hospital medical management is symptomatic and aims to maintain homeostasis and fight vital distress. The patient will benefit from a packaging comprising a half-assistance position (45 ° proclive), a removal of his soiled clothing, a rinsing of skin affected by the substance, the implementation of a vascular approach, an effective oxygenation, multimodal analgesia, and primary transport or secondary transfer to a multidisciplinary structure (structure with a technical tray comprising a resuscitation, TDM, digestive).
Note that the systematic administration of antacid medication, antibiotic therapy or corticosteroid therapy have not shown their effectiveness to date.
TDM Thoraco-Abdomino-Pelvienne: Examination of choice
The examination of choice to reliably detect the presence of transmural necrosis of the esophageal wall is now the Thoraco-Abdomino-Pelvic TDM, carried out 3 to 6 hours after the ingestion of the caustic product. Compared to endoscopy, it improves the selection for patients surgery with serious lesions, has helped to significantly reduce the number of un justified esophageal resections, and to improve the survival and quality of life of patients, continues the emergencyist.
A detailed radiological classification of the caustic lesions of the esophagus and abdominal viscera is used, classified into three grades of increasing severity. This classification has a proven predictive value for survival, the risk of developing esophageal stenosis and the functional result of patients, thinking in a fine way the need for surgical management.
High digestive endoscopy realization is reserved for exceptions, such as advanced kidney failure, serious proven allergy to iodized contrast products and children. A tracheo-bronchial fibroscopy is recommended in case of severe lesions with functional respiratory signs and the ENT exam in the event of digestive necrosis, to be carried out within 24 hours of ingestion.
Non -operational treatment
Regarding non -operational treatment, for patients Grade I and II, oral realling must be reintroduced as soon as possible, a psychiatric consultation is systematic before exit and a follow -up consultation with a gastroenterologist is recommended at 4 months from ingestion.
Emergency surgical treatment is indicated in patients with grade III scanographic lesions. Any digestive segment with transparent necrosis must be rescued, not leaving the place in these cases to an initially conservative attitude.
The risk of death of patients who have undergone emergency surgery after caustic ingestion is 19 times higher compared to the general French population. In the work on the PMSI basis, relating to 3,544 patients with caustic ingestion admitted to French hospitals, non-operative treatment was carried out in 3,156 (89 %) patients, 1,047 of which (33 %) had to be admitted to resuscitation, mortality and morbidity associated with non-operative treatment were 6 %and 29 %, respectively. An emergency surgical intervention was made in 388 (11 %) patients, including 156 isolated esophaguectomies, 103 esophagogastrectomies and 9 gastric resections; A therapeutic abstention had been decided in 31 due to extended digestive necrosis. Overall mortality and morbidity after emergency surgery were 25 % and 76 %, respectively.
“Multidiciplinary management in the 6era Hours of caustic lesions of the digestive tract decreases morbidity and mortality in France, concludes the Follet DRE. The realization of an emergency digestive endoscopy must be reserved for exceptions, and even under these circumstances it will be necessary to discuss CT if endoscopy reveals severe digestive lesions ”.
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