Caustic ingestion in adult patients, what you should know, what is debated and what should come next

Caustic ingestion is an uncommon but potentially devastating emergency in which injury arises predominantly from local chemical reaction rather than systemic absorption. In adults, the most severe lesions - up to full-thickness necrosis - result from intentional ingestion of large volumes of strong acids and bases (pH < 2 or > 12). Outcomes depend on early recognition and prompt transfer to an expert center. Initial priorities are securing difficult airways, identifying agents warranting intensive care admission - chiefly caustic soda and hydrochloric acid - and avoiding manoeuvres that aggravate injury (nasogastric tube insertion, induced emesis, activated charcoal). The principal recent shift in practice is the abandonment of early upper gastrointestinal endoscopy in favour of contrast-enhanced cervico-thoraco-abdomino-pelvic computed tomography for severity assessment in the majority of patients and certainly all patients with significant caustic ingestions; a CT-guided selective surgical strategy substantially reduces unnecessary oesophagectomy and is associated with lower mortality and greater eating and breathing autonomy in patients admitted to intensive care units. Transmural (grade 3) injury mandates resection, whereas lower grades, like most admissions, are managed conservatively. Pharmacological prevention of stricture remains poorly supported: only small, conflicting randomized trials of corticosteroids exist, and other adjuvants lack robust evidence. Oesophageal stricture, the commonest late complication, develops in about one quarter of patients and carries a long-term risk of malignant transformation justifying lifelong surveillance. We review the contemporary, CT-centred multidisciplinary management of caustic ingestion in the critically ill adult and outline a research agenda focused on stricture prevention and tissue-engineered oesophageal substitutes.