Optimizing triage in acute caustic ingestion: Choosing between endoscopy and computed tomography

Table 1 Endoscopic grading of acute caustic injury as per the Zargar’s classification

Endoscopic grading	Findings
Grade 0	Normal findings
Grade 1	Edema and hyperemia of the mucosa
Grade 2a	Superficial localized ulcerations, friability, hemorrhage and blisters
Grade 2b	Deep ulcerations (either discrete or circumferential), in addition to friability, hemorrhage, and superficial ulcerations
Grade 3a	Small, scattered areas of necrosis
Grade 3b	Extensive necrosis

Table 2 Computed tomography grading of acute caustic injury as per the Ryu and Chirica classification

Grade	CT findings	Clinical implication
Ryu classification
Grade 1	No definite swelling of esophagus wall (< 3 mm, within normal limit)	No injury
Grade 2	Edematous wall thickening (> 3 mm) without periesophageal soft tissue infiltration	Usually mild injury; often managed conservatively; low risk of complications
Grade 3	Edematous wall thickening with periesophageal soft tissue infiltration plus well-demarcated tissue interface	Moderate injury; risk of stricture formation; close monitoring required
Grade 4	Edematous wall thickening with periesophageal	Severe injury; high risk of progression; surgical evaluation considered
	Soft tissue infiltration plus blurring of the tissue
	Interface or localized fluid collection around esophagus or descending aorta
Chirica classification
Grade 1	Normal appearing GI tract	No injury
Grade 2	Wall edema, surrounding soft tissue inflammation and increased postcontrast wall enhancement	Mild to moderate risk of injury; moderate to high risk of stricture formation
Grade 3	Transmural necrosis, as shown by the absence of postcontrast wall enhancement with surrounding soft tissue inflammation	Moderate injury; risk of stricture formation; close monitoring required

CT: Computed tomography; GI: Gastrointestinal.

Table 3 Benefits and limitations of esophagogastroduodenoscopy and computed tomography scan in caustic injury

Parameters	EGD	CT scan
Easy availability	-	-
Can be used for Zargar grading for steroid therapy	-	-
Visualization of the entire GIT and other systems	-	-
Easily identifies perforation	-	-
Identifies the candidates for emergency surgery	-	-
Facilitates insertion of the feeding tube	-	-
Risk of radiation	No	Yes
Validity beyond 48-72 hours of ingestion	-	-

CT: Computed tomography; EGD: Esophagogastroduodenoscopy; GIT: Gastrointestinal tract.