Airway first, then what not to do, then CT at 3–6 hours. Follows the WSES 2019 oesophageal emergencies guideline, with its own grades shown.
CT, not endoscopy, is the primary emergency investigation. Emergency management of caustic ingestion can be performed safely relying on computed tomographic evaluation (Grade 2A). Endoscopy is now reserved for the situations in step 4. Most of us were taught the other way round.
Every recommendation on this page carries an evidence tier.Guideline / position paperCohort or seriesCase reports / expert opinion
Corrosive ingestion has a graded guideline behind it. Other poisonings in this suite will not, and we would rather show you the difference than flatten it.
National Poisons and Drug Information Centre, Jinnah Postgraduate Medical Centre (JPMC), Karachi — 0800-77767
WSES recommends contacting a poison control centre to evaluate the systemic toxicity of the ingested agent (Grade 2B). Reported as a round-the-clock toll-free service. Confirm the current number against your own hospital directory before relying on it in an emergency.
Decision-support only. This reproduces published guidance so you can apply it quickly. It does not replace clinical judgement, your hospital protocol, or the guideline itself. Where the guideline is silent — steroids, prophylactic antibiotics, early dilution — this tool says so rather than inventing an answer.
✓ Clinically reviewed by Dr Syed Usama Hussain, MBBS, BSc · 05 Aug 2026.
Step 1 · Airway first
WSES 2019
Guideline / position paper
Stridor, hoarseness, voice change, drooling or respiratory distress mean the airway is already involved. Oedema progresses — intubate early and electively rather than late and in extremis.
Vapour aspiration (ammonia, formaldehyde) may cause airway burns in addition to the ingestion injury.
Preoperative tracheobronchial endoscopy is mandatory before surgery to detect tracheobronchial necrosis extending from the oesophagus.
Harpic is hydrochloric acid.
Harpic Power Plus is formulated at approximately 10.5% w/v hydrochloric acid. It is a strong acid ingestion, not a "detergent" ingestion, and it should be triaged as such. Drain and oven cleaners are usually the opposite — strong alkalis — and injure by liquefactive necrosis, but the emergency pathway below is the same for both. Cohort or series
Manufacturer safety data sheet (Reckitt Benckiser)
Step 2 · What was swallowed, and how much
WSES 2019
A normal mouth does not mean a normal gut. It is commonly accepted that clinical symptoms do not correlate reliably with the extent of gastrointestinal damage; the absence of pain and of oral lesions does not rule out life-threatening gastrointestinal injuries. Guideline / position paper
What to establish
Why it changes management
Deliberate or accidental
The ingestion pattern determines the quantity swallowed. WSES calls quantity "the most important prognostic factor", while noting that reliable information is usually lacking. A deliberate adult ingestion is a different problem from a child's accidental sip.
Nature of the agent
Strong acids and alkalis cause most severe injuries. Oxidants such as bleach usually cause mild injury, though severe damage requiring emergency resection has occasionally been reported. Ammonia causes superficial haemorrhagic gastritis that may progress over the first 24–48 hours.
Physical form
Solids produce maximum damage to the mouth and pharynx. Liquids transit rapidly and burn the oesophagus and the stomach — so a liquid like Harpic can leave an unremarkable mouth and a destroyed stomach.
Systemic effects
Specific corrosives cause hypocalcaemia (phosphoric, hydrofluoric acids), hyponatraemia (strong acids and alkalis), hypokalaemia and acidosis. These are separate from the burn itself.
Step 3 · What never to do
AACT/EAPCCT position papers · WSES 2019
Every item here is something commonly done in casualty that either has no evidence behind it or actively harms.
Do not attempt to neutralise the acid or alkali Case reports / expert opinion
Acid–base neutralisation is exothermic. Giving an alkali after an acid adds a thermal burn to a chemical one, and the reaction generates gas in an already-injured stomach.
Standard clinical toxicology teaching; WSES does not address neutralisation directly.
Do not pass a nasogastric tube blindly Case reports / expert opinion
A freshly burned oesophagus is friable and perforates. WSES does recommend nasogastric feeding in patients unable to eat, and endoscopic placement of a nasogastric tube in other oesophageal emergencies — placement should be under direct vision, not blind.
Extrapolated from WSES 2019 practice; not a graded WSES recommendation.
Do not give activated charcoal Guideline / position paper
Corrosives are not adsorbed to charcoal, so there is nothing to gain, and charcoal coats the mucosa and obscures the endoscopic assessment you may need.
AACT/EAPCCT single-dose activated charcoal position paper — charcoal is for poisons known to adsorb to it.
Do not induce vomiting Guideline / position paper
Named explicitly in the ipecac position paper: never after ingestion of a corrosive substance such as an acid or alkali.
AACT/EAPCCT ipecac syrup position paper, 2013
Do not perform gastric lavage Guideline / position paper
Against the position paper in general, and specifically hazardous here — passing a tube and instilling fluid into a burned, friable stomach risks perforation and re-exposes the oesophagus.
AACT/EAPCCT gastric lavage position paper, 2013
The position papers, in their own words
Gastric lavage — Not routinely — if at allGuideline / position paper
At present there is no evidence showing that gastric lavage should be used routinely in the management of poisonings. Further, the evidence supporting gastric lavage as a beneficial treatment in special situations is weak, as is the evidence to exclude benefit in all cases. Gastric lavage should not be performed routinely, if at all, for the treatment of poisoned patients. In the rare instances in which gastric lavage is indicated, it should only be performed by individuals with proper training and expertise.
Contraindicated outright if the airway is unprotected — for example a patient with a depressed level of consciousness who has not been intubated.
AACT/EAPCCT Position Paper Update: gastric lavage for gastrointestinal decontamination, 2013
Single-dose activated charcoal — Not routinelyGuideline / position paper
Single-dose activated charcoal should not be administered routinely in the management of poisoned patients. Based on volunteer studies, the administration of activated charcoal may be considered if a patient has ingested a potentially toxic amount of a poison (which is known to be adsorbed to charcoal) up to one hour previously. ... There is no evidence that the administration of activated charcoal improves clinical outcome. Unless a patient has an intact or protected airway, the administration of charcoal is contraindicated.
Two conditions are easy to miss: the poison must actually adsorb to charcoal, and the airway must be intact or protected.
AACT/EAPCCT Position Paper: single-dose activated charcoal
Induced emesis (ipecac) — No — and specifically never after a corrosiveGuideline / position paper
Ipecac should not be administered following ingestion of hydrocarbons with high aspiration potential, after the ingestion of a corrosive substance such as an acid or alkali, in debilitated, elderly patients, or those with medical conditions that could be further compromised by the induction of emesis.
Vomiting a corrosive drags it back across the oesophagus and larynx, burning both a second time.
AACT/EAPCCT Position Paper Update: ipecac syrup for gastrointestinal decontamination, 2013
Step 4 · Bloods and imaging
WSES 2019
Laboratory evaluation Guideline / position paper
Initial laboratory evaluation of caustic injuries should include CBC, serum concentrations of sodium, potassium, chlorine, magnesium, calcium, urea creatinine, liver tests (bilirubin, alanine aminotransferase, aspartate aminotransferase), pH and serum lactate, blood alcohol levels, and measurement of β-HCG in young women (Grade 2A).
Normal bloods do not reassure. Initial normal laboratory values do not rule out transmural necrosis. It is the kinetics — the trend on repeat testing — that is useful in monitoring.
Predictive of transmural necrosis and poor outcome:
Severe acidosis — low pH, high blood lactate
Deranged liver function tests
Leucocytosis
Elevated CRP
Renal failure
Thrombocytopenia
CT first — not endoscopy Guideline / position paper
Emergency management of caustic ingestion can be performed safely relying on computed tomographic evaluation (Grade 2A).
Contrast-enhanced CT outperformed endoscopy in detecting transmural injuries and in predicting stricture formation. WSES states that a CT-based algorithm to select patients for emergency surgery significantly improved outcomes compared with endoscopy-based management, and that endoscopy's major drawback is its inability to predict transmural necrosis accurately — exposing patients either to futile surgery or to inappropriate watch-and-wait and risk of death.
Protocol. CT of the neck, thorax and abdomen 3–6 hours after ingestion, before and after intravenous injection (2–3 mL/s) of a non-ionic contrast agent (2 mL/kg), with an 18–25 s acquisition time and a 90 s scan delay.
The finding that decides surgery. The main sign of transmural digestive necrosis is the absence of post-contrast wall enhancement, and its presence at any level — oesophagus, stomach, duodenum, bowel, colon — is an indication for emergency surgery.
When endoscopy is still the right call Guideline / position paper
Emergency endoscopy should be performed if (1) CT is unavailable, (2) CT with contrast administration is contraindicated (renal failure, iodine allergy, etc.), (3) CT suggests transmural esophageal necrosis but interpretation is difficult/uncertain, or (4) in the pediatric population (Grade 2A).
Endoscopy remains the upfront examination in children, because severe injuries are rare and the long-term effects of radiation exposure matter.
The Zargar endoscopic classification is the one most commonly used, but WSES notes its ability to predict stricture formation remains controversial and is outperformed by CT.
Endoscopy remains the main diagnostic and therapeutic tool for caustic strictures later on — this is about the emergency assessment only.
Step 5 · CT grade → disposition
WSES 2019 — four-stage CT classification
Select the CT grade reported for the oesophagus.
Non-operative management Guideline / position paper
Patients who do not have full-thickness necrosis of digestive organs should undergo non-operative management (Grade 1C).
What to watch for. Non-operative patients need close clinical and biological monitoring. Any deterioration should prompt repeat CT and consideration for surgery (Grade 2A). Rebound tenderness, increasing abdominal pain, shock, a need for ventilatory support, or worsening renal failure, acidosis or leucocytosis suggest evolution to transmural necrosis — which happens in about 5% of patients.
Step 6 · Strictures, follow-up and discharge
WSES 2019
Strictures Guideline / position paper
Stricture is the most common and disabling long-term complication. Strictures involve the oesophagus more often than the stomach and usually occur within 4 months of ingestion. Dysphagia and regurgitation should prompt immediate upper gastrointestinal evaluation.
Dilation. Endoscopic dilation is the first-line treatment and should be attempted 3–6 weeks after ingestion in patients with few (fewer than 3) short (under 5 cm) oesophageal strictures (Grade 2A). Intervals between dilations are 1–3 weeks, and 3 to 5 sessions are expected to give satisfactory results.
Reconstructive oesophageal surgery should be considered after recurrent failure of endoscopic dilation (Grade 2A) — after 5 to 7 failed attempts. Corrosive strictures are often multiple, long and irregular, with long stabilisation delays. Evidence for intraluminal stenting is still lacking.
Almost all of these ingestions are deliberate self-harm.
Psychiatric evaluation is mandatory in all patients prior to hospital discharge (Grade 2C). Long-term control of the psychiatric disease is important to avoid recurrence.
A patient who is medically fit for discharge is not therefore fit for discharge. The guideline makes the psychiatric assessment a requirement, not a courtesy — and the ingestion pattern (deliberate versus accidental) is itself among the strongest predictors of how bad the injury will be.
WSES Esophageal Emergencies guidelines, 2019
What this guideline does not settle
Corticosteroids — WSES does not make a recommendation on steroids for caustic injury. They remain contentious and are not endorsed here either way.
Prophylactic antibiotics — not addressed for caustic ingestion in this guideline.
Early dilution with water or milk — not addressed. It is widely described but not graded, and it must never delay airway assessment or transfer.
Where the guideline is silent, this tool says so rather than filling the gap with something that sounds authoritative.
Common questions
Should I do endoscopy or CT first after a corrosive ingestion?
CT. WSES 2019 states that emergency management of caustic ingestion can be performed safely relying on computed tomographic evaluation (Grade 2A). Contrast-enhanced CT outperformed endoscopy in detecting transmural injury and in predicting stricture. Endoscopy is now reserved for when CT is unavailable, when contrast is contraindicated, when CT interpretation is uncertain, or in children.
What is in Harpic?
Harpic Power Plus is formulated at approximately 10.5% w/v hydrochloric acid. It is a strong acid ingestion and should be triaged as one, not treated as a detergent ingestion.
The patient has no mouth burns and no pain. Can I discharge them?
No. WSES states that clinical symptoms do not correlate reliably with the extent of gastrointestinal damage, and that the absence of pain and of oral lesions does not rule out life-threatening gastrointestinal injuries. Liquids in particular transit quickly and can leave an unremarkable mouth with a destroyed stomach.
Should I neutralise the acid with something alkaline?
No. Acid–base neutralisation is exothermic, so it adds a thermal burn to the chemical one and generates gas in an already-injured stomach.
Should I do gastric lavage or give activated charcoal?
Neither. The AACT/EAPCCT position paper states gastric lavage should not be performed routinely, if at all. Activated charcoal is for poisons known to adsorb to charcoal — corrosives are not — and it coats the mucosa, obscuring the endoscopic assessment you may need. Inducing vomiting is named explicitly as contraindicated after a corrosive.
When should the CT be done?
CT of the neck, thorax and abdomen 3–6 hours after ingestion, before and after intravenous non-ionic contrast at 2–3 mL/s, 2 mL/kg, with an 18–25 second acquisition and a 90 second scan delay.
What CT finding means the patient needs emergency surgery?
Absence of post-contrast wall enhancement. WSES states this is the main sign of transmural digestive necrosis, and its presence at any level — oesophagus, stomach, duodenum, bowel or colon — is an indication for emergency surgery.
When should stricture dilation be started?
Endoscopic dilation should be attempted 3–6 weeks after ingestion in patients with fewer than 3 short strictures under 5 cm (Grade 2A), at intervals of 1–3 weeks. Three to five sessions are expected to give satisfactory results, and reconstruction is considered after 5–7 failed attempts.
Do corticosteroids help?
WSES does not make a recommendation on steroids for caustic injury, and this tool does not either. Where the guideline is silent we say so rather than filling the gap.
Clinically reviewed by Dr Syed Usama Hussain, MBBS, BSc
MBBS, BSc — active medical practitioner in Pakistan. Graduated from Federal Medical & Dental College, Islamabad (2021) and completed a one-year clinical internship at the Pakistan Institute of Medical Sciences (PIMS), Islamabad (2022).
Sources
Chirica M, Kelly MD, Siboni S, et al. Esophageal emergencies: WSES guidelines. World Journal of Emergency Surgery 2019;14:26. — the source of every "Grade" cited on this page.
AACT/EAPCCT Position Paper Update 2013: gastric lavage for gastrointestinal decontamination.
AACT/EAPCCT Position Paper: single-dose activated charcoal.
AACT/EAPCCT Position Paper Update 2013: ipecac syrup for gastrointestinal decontamination.
Harpic Power Plus composition (approximately 10.5% w/v hydrochloric acid) from the manufacturer safety data sheet — verify against the product actually ingested where possible.
Background reading — why CT replaced endoscopy, what a normal-looking mouth does not tell you, and the five things never to do: Harpic and corrosive ingestion.