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INTRODUCTION

Caustics are substances that cause both functional and histologic damage on contact with body surfaces. Many household and industrial chemicals have caustic potential. Caustics are broadly classified as alkalis (pH >7) or acids (pH <7). In developed nations, increased education and product regulation (especially of acids) have decreased morbidity and mortality from caustic exposures in both adults and children. However, in underdeveloped parts of the world, exposure to caustics remains a significant problem.1-3 Alkaline ingestions predominate in the developed world,4 whereas acid ingestions are more common in developing countries.5

Caustic exposures tend to fall into three distinct groups: (1) intentional adolescent or adult ingestions with suicidal ideation; (2) unintentional ingestions (the majority of which are by curious children in the toddler age group); and (3) other incidental, often occupational or industrial contact exposures. The majority of reported exposures are unintentional or accidental, but intentional ingestions account for the majority of serious injuries.1 The geographic variation in caustic ingestion circumstances, such as involved substances, intention, age of the patient, and extent of evaluation, make it important to base treatment decisions on each particular patient’s presentation.

Many chemicals used in industry have caustic potential (Table 200-1). Household caustics are often less concentrated forms of industrial-strength cleansers.

TABLE 200-1Common Caustic Compounds

PATHOPHYSIOLOGY

The degree to which a caustic substance produces tissue injury is determined by a number of factors: pH, concentration, duration of contact, volume, and titratable acid or alkaline reserve. Acids tend to cause significant injuries at a pH <3 and alkalis at a pH >11. The physical properties of the product formulation (i.e., liquid, gel, granular, or solid) can influence the nature of the contact with tissue. Following ingestion, solid or granular caustics often injure the oropharynx and proximal esophagus, whereas liquid alkali ingestions are characterized by more extensive esophageal and gastric injuries. Titratable acid or alkaline reserve refers to the amount of acid or base required to neutralize the agent; the greater this value, the greater is the potential for tissue injury.

Esophageal mucosal burns from caustic ingestions are classified by a visual endoscopic grading system, which correlates with risk of future complications: Grade 1 burns involve tissue edema and hyperemia; grade 2 burns include ulcerations, blisters, and whitish exudates, which are subdivided into ...

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