Do Asymptomatic Patients Need Endoscopy after Caustic Ingestion?

We applaud Levine and colleagues for addressing the question of whether esophagogastroduodenoscopy (EGD) is universally indicated in asymptomatic self-harm caustic and unintentional acidic ingestions [1]. Given the sometimes low pretest probability for clinically relevant injury in these populations, as well as potential for iatrogenic harm and unnecessary resource expenditure, we similarly question whether EGD should be performed without exception [2]. In our experience endoscopic evaluation (which may necessitate interhospital transfer) of asymptomatic patients is often unrevealing. Nonetheless, it is de rigueur that suicidal patients ingesting a caustic are at elevated risk of gastrointestinal injury, and thus require EGD irrespective of symptoms and signs [3]. Crain et al’s landmark study supported a symptoms-based management strategy in unintentional alkaline ingestions, which due to liquefactive necrosis are theoretically at higher injury risk than unintentional acidic ingestions. Though, until further data to the contrary emerges, it may be premature to apply the findings of the Crain study to acidic exploratory ingestions [4, 5]. Levine et al., however, report an absence of significant esophageal injury (defined as Zargar IIB or greater, perforation on computed tomography, death, or need for follow-up esophageal procedure) in both self-harm and unintentional caustic ingestions without symptoms or signs. Symptoms and signs were defined as: dysphagia, dysphonia, persistent vomiting or inability to tolerate oral intake six hours after caustic exposure, and oropharyngeal lesions. Data included 40 exploratory acidic ingestions, adding to the sparse research describing best management of this sub-group [6, 7].

The authors’ valuable contribution to the literature does raise certain questions. Will suicidal patients minimize symptoms of dysphagia to the examining clinician, resulting in missed cases of significant injury? At our institutions, we have observed such patients sometimes deny difficulty with swallowing after caustic ingestion, despite clear signs of dysphagia to the examiner. Such an oversight may alter not only acute outcomes, but also preclude interventions such as steroid therapy of Zargar IIB lesions and appropriate outpatient follow-up, potentially resulting in the already tenuous mental health of suicidal patients being further burdened by long-term dysphagia [8, 9]. More objective measures of oropharyngeal and esophageal dysphagia than patient report are themselves prone to operator error, invasive, and resource-intensive [10, 11]. Likewise, in young children who struggle to articulate symptoms, rapid dysphagia assessment without invasive diagnostic modalities may prove difficult. Though dysphonia is more easily assessed in adults or verbal children, the pre-verbal child may pose a diagnostic dilemma, as dysphonia can be less apparent than frank stridor. Findings of oropharyngeal burns, vomiting, and inability to tolerate oral intake are presumably not subject to the same sensitivity concerns.

In this study, the authors report no statistically significant difference between acidic and basic ingestions in rates of esophageal injury. We would caution, however, that statistical significance, or lack thereof, does not always equate with clinical significance. For example, despite no significant difference in injury rates between acidic and basic ingestions, do patients with acidic ingestion experience a greater degree of long-term dysphagia? Finally, the authors make note of six missing EGD reports and 29% of patients not receiving EGD or 30-day follow up, precluding definitive assessment for significant esophageal injury in these cases. It is indeed challenging in retrospective medical toxicology research to avoid some degree of loss to follow-up; however, this missing patient subset limits clinical application of the study findings at this time.

We look forward to future research that will address these points in a prospective manner. Such investigation is needed to determine whether the proposed management framework can be safely applied to asymptomatic patients after acidic and alkaline exposures. In the meantime, we thank the authors for their efforts in advancing our knowledge of how to best utilize EGD in cases of caustic ingestion.

Author contributions

All authors contributed to this editorial’s creation. The draft of the manuscript was written by James Whitledge and Michele Burns, both of whom have read, revised, and approved the final manuscript.

Funding

This work has no source of funding.

Declarations

Conflicts of interests

James Whitledge reports no conflicts of interest. Michele Burns is the Pediatric Toxicology Section Editor for UpToDate.