Abstract
Accidental caustic ingestions are uncommon but can lead to serious esophageal injury. Clinicians may lack experience grading mucosal findings, creating circumstances for treatment misalignment because management recommendations depend on severity. Regardless of treatment, access to pediatric gastroenterology is essential for severe injuries but is often limited by geography and can be further impacted by poor social determinants of health (SDOH). This report describes the case of a simultaneous accidental caustic ingestion in two previously healthy siblings with severe esophageal injuries. Amidst divergent care plans derived from their initial grading, their outcomes were complicated by the intersection of complex initial assessment, escalating treatment recommendations based on esophageal injury severity, and poor SDOH impeding follow‐up. Grading accuracy can be supported with adjunct computed tomography to assess transmural injury. Assessment of a family's SDOH is key to addressing barriers to follow‐up and creating a multidisciplinary approach in collaboration with the medical home.
Keywords: corticosteroids, esophageal injury, social determinants of health, X‐ray computed tomography
1. INTRODUCTION
Accidental caustic ingestions in young children result in 1000 hospitalizations per year in the United States and cost $22 million. 1 Strictures occur in 20% of children and can lead to chronic pain and malnutrition. 1 The Zargar classification, portrayed by Singh et al., 2 dictates severity grading for esophageal injury and guides management recommendations. 1 , 3 , 4 Mild injuries can receive supportive care while deeper injuries require advanced therapies and repeat endoscopy. 1 , 4 Although endoscopy remains the gold standard, computed tomography (CT) better assesses transmural injury to predict stricture formation and should be employed when stricture risk is high. 5 Initial endoscopy should occur 12–24 h after ingestion, 1 , 4 but access to pediatric gastroenterology is limited in many rural communities, which delays time‐sensitive subspecialty management in underserved communities. 6
Stricture formation typically develops within the first month after ingestion and appropriate follow‐up begins with collaborative family education to understand the diagnosis and need for longitudinal care. 1 , 4 Successful transition to outpatient care requires a high‐quality medical home to provide care that is “accessible, family‐centered, continuous, comprehensive, coordinated, compassionate, and culturally effective.” 7 Social determinants of health (SDOH) influence both access to and quality of healthcare, and when unfavorable, they contribute to health disparities. 8 Children with health inequities and substandard medical homes have poorer health outcomes. 7 This case describes the intersection between the management of caustic ingestion and health inequities.
2. CASE REPORTS
Two previously healthy pre‐school‐aged siblings presented to their local hospital with rust‐colored oral secretions an hour after ingesting an alkali cleaning detergent (pH 13.5). Table 1 details their clinical course. They were transferred 90 miles to a tertiary hospital 6 h after ingestion, were admitted to the pediatric intensive care unit (PICU), and underwent initial endoscopy 16 h post‐ingestion which demonstrated comparably significant esophageal injuries (Figure 1).
Table 1.
Chronologic care timeline of siblings with simultaneous accidental ingestion of an alkali cleaning detergent.
| Younger sibling | Postingestion day | Older sibling |
|---|---|---|
| Ingestion of caustic substance (pH 13.5) | 0 | Ingestion of caustic substance (pH 13.5) |
| Presentation to community ED with rust‐colored emesis | Presentation to community ED with rust‐colored emesis | |
| Transfer to tertiary care center 90 miles from home | Transfer to tertiary care center 90 miles from home | |
| Endoscopy reveals Zargar IIb grading; NGT placed, NPO; admit to PICU | Endoscopy reveals Zargar IIa grading; admit to inpatient floor | |
| Begin treatment: IVC (3‐day course), high dose PPI, sucralfate (5‐day course), ceftriaxone (5‐day course) | 1 | Begin treatment: high dose PPI |
| Transfer to pediatric floor | 2 | |
| Vital sign instability; IVC discontinued | 3 | Transfer to pediatric floor |
| 4 | ||
| 5 | Poor oral intake; failure to advance diet | |
| UGI study reveals narrowing of esophagus | ||
| Discussion with caregiver shows preference for endoscopy over UGI; UGI cancelled | 6 | |
| Repeat endoscopy: Ongoing tissue healing | 7 | Repeat endoscopy: 8 mm diameter × 5 cm length stricture dilated to 11 mm |
| … | ||
| 14 | Discharge home on purees/soft foods | |
| Discharge home on formula, advance as tolerated | 15 | |
| … | ||
| Presentation to community ED with dysphagia | 41 | Presentation to community ED for inability to tolerate food by mouth |
| Barium swallow: Known stricture progressed to >95% stenosis | ||
| Barium swallow: 2 discrete strictures (50% stenosis each) | Surgical consult for gastrostomy tube |
Abbreviations: cm, centimeter; ED, emergency department; IVC, intravenous corticosteroids; mm, millimeter; NGT, nasogastric tube; NPO, nothing per os; PICU, pediatric intensive care unit; PPI, proton pump inhibitor; UGI, upper gastrointestinal.
Figure 1.
Endoscopic evaluation at presentation and 1 week post injury. Endoscopic esophageal images of initial injuries post‐ingestion of a commercial‐grade alkali detergent. From left to right: The younger sibling's (Zargar IIb) upper and lower esophagus at presentation, then again at 1 week, followed by the older sibling's (Zargar IIa) upper and lower esophagus at presentation, then again at 1 week. Both initial endoscopies were accomplished with Olympus GIF‐XP190N (outer diameter of 5.8 mm). Both follow up endoscopies were initiated with Olympus GIF‐H190 (outer diameter of 9.2 mm). Due to stricture development/progression in the upper esophagus of the Zargar IIa sibling, the endoscopy was completed with an Olympus GIF‐XP190 N.
The older sibling was graded as Zargar IIa (Z‐IIa) and was recommended a clear liquid diet and high‐dose proton pump inhibitor (PPI) before transferring to the pediatric floor the next day. Subsequent decreased oral intake and failure to advance the diet led to an upper gastrointestinal (UGI) series that demonstrated an irregular, narrowed proximal esophageal lumen. Repeat endoscopy showed a severe proximal esophageal stricture which was successfully dilated. The diet was advanced to soft foods and purees at discharge.
The younger sibling was graded higher as Zargar‐IIb (Z‐IIb), received a bridled nasogastric tube, and was ordered nothing by mouth with high‐dose methylprednisolone (3 days), sucralfate and ceftriaxone (5 days), and high‐dose PPI. Persistent stridor prolonged the PICU admission. Repeat endoscopy demonstrated ongoing tissue healing without discrete stricture. At discharge, the younger sibling tolerated a liquid diet with instructions to advance to purees as tolerated.
A mandated report to Child Protective Services and the siblings' divergent care plans and settings led to tension between the inpatient care team and family. Social work consultation revealed that the family lived in an economically distressed county. There were eight children under 8 years old living in the multigenerational household with food insecurity, transportation difficulties, limited financial resources, and limited social support. Social work assisted the family with meals and transportation during hospitalization. Endoscopy and care management follow‐up were recommended 1 week after discharge, but were not scheduled, communicated to the medical home, or reviewed with the family. Therefore, the children missed these appointments, which were never rescheduled despite multiple care coordination attempts. The children re‐presented to their local hospital within 4 weeks of discharge with dysphagia and were transferred to a second tertiary hospital 73 miles from home. The Z‐IIb sibling had developed two strictures (50% stenosis each) but tolerated food by mouth. The Z‐IIa sibling's esophageal stricture worsened to >95% stenosis. Since oral intake was not tolerated, a gastrostomy tube was placed. All subsequent care was transferred to the second tertiary hospital.
3. DISCUSSION
Caustic ingestions require timely and accurate injury grading, evidence‐based therapies, and longitudinal care coordination. Differentiation of tissue injury depth and clinical grading is more complex than visual inspection allows, 1 , 5 and the initial assessment of both siblings' injuries could have been under graded. Both siblings developed strictures independent of treatment regimen, likely due to lack of surveillance. Strained relationships between care teams and families may hinder therapeutic communication on the importance of ongoing outpatient surveillance, particularly in contexts shaped by SDOH. 8 Such challenging circumstances underscore the need for transparency, compassion, and patience to build trust and mitigate health inequities.
Once rapport and trust are established or repaired, the inpatient multidisciplinary team should systematically appraise the family's knowledge, skills, and barriers to navigating the healthcare system, then empower competency building and resource access while supplementing remaining gaps through coordinated support. Limited health literacy amidst other poor SDOH heightens the risk for disparities as demonstrated by the family's post‐discharge challenges that could have been anticipated and mitigated. 8 Prior to discharge, families should receive a comprehensive short‐ and long‐term care plan focusing on nutrition, medications, appointments, and objective return criteria. Reviewing symptoms of stricture development in small children—throat clearing, choking, and dietary changes—extends clinical oversight at home. Furthermore, an initial virtual care meeting between the inpatient team and medical home ensures closed‐loop communication necessary for surveillance and follow‐up, including UGI and/or endoscopy. Transportation logistics should be coordinated collaboratively and supported by the medical home. 8 The care team should highlight access points to social networks and community resources that can bolster resilience and provide support in outpatient settings. 8 Care escalation to pediatric gastroenterology should occur when the child's recovery deviates from the expected trajectory.
4. CONCLUSIONS
This case describes the convergence of pediatric accidental caustic ingestion, health inequities, and complex care coordination. Providers should consider CT as an adjunct to endoscopy for evaluating transmural injury. After assessing a child's SDOH, multidisciplinary coordination with the medical home should use closed‐loop communication to create short‐ and long‐term care plans that address barriers to care. Strategic use of symptom appraisal and contrast imaging can temporarily offset limited access to pediatric gastroenterology, though repeat endoscopy remains essential for longitudinal evaluation of stricture formation. More research is needed to define optimal pathways for patients in resource‐limited settings.
CONFLICT OF INTEREST STATEMENT
John L. Lyles is a consultant for EvoEndo. Rebecca A. Carson declare no conflicts of interest.
ETHICS STATEMENT
Written consents for publication of the case details were given by the patients’ parents.
REFERENCES
- 1. Hoffman RS, Burns MM, Gosselin S. Ingestion of caustic substances. N Engl J Med. 2020;382(18):1739‐1748. 10.1056/NEJMra1810769 [DOI] [PubMed] [Google Scholar]
- 2. Singh AK, Gunjan D, Dash NR, et al. Short‐term and long‐term management of caustic‐induced gastrointestinal injury: an evidence‐based practice guidelines. Indian J Gastroenterol. 2025;44(5):646‐674. 10.1007/s12664-024-01692-1 [DOI] [PubMed] [Google Scholar]
- 3. Usta M, Erkan T, Cokugras FC, et al. High doses of methylprednisolone in the management of caustic esophageal burns. Pediatrics. 2014;133(6):e1518‐e1524. 10.1542/peds.2013-3331 [DOI] [PubMed] [Google Scholar]
- 4. Bonavina L, Chirica M, Skrobic O, et al. Foregut caustic injuries: results of the world society of emergency surgery consensus conference. World J Emerg Surg. 2015;10(1):44. 10.1186/s13017-015-0039-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Bruzzi M, Chirica M, Resche‐Rigon M, et al. Emergency computed tomography predicts caustic esophageal stricture formation. Ann Surg. 2019;270(1):109‐114. 10.1097/SLA.0000000000002732 [DOI] [PubMed] [Google Scholar]
- 6. Sauer CG, Barnard JA, Vinci RJ, Strople JA. Child health needs and the pediatric gastroenterology workforce: 2020–2040. Pediatrics. 2024;153(suppl 2):e2023063678K. 10.1542/peds.2023-063678K [DOI] [PubMed] [Google Scholar]
- 7. Arthur NSM, Blewett LA. Contributions of key components of a medical home on child health outcomes. Matern Child Health J. 2023;27(3):476‐486. 10.1007/s10995-022-03539-7 [DOI] [PubMed] [Google Scholar]
- 8. Vrtikapa K, Hoque Urmy F, Hoque F. Social determinants of health: the impact of this overlooked vital sign. J Brown Hosp Med. 2025;4(3):138072. 10.56305/001c.138072 [DOI] [PMC free article] [PubMed] [Google Scholar]