A 24-year-old woman presents to the emergency department 4 hours after suicidal ingestion of 200 mL of liquid drain cleaner (sodium hydroxide, pH > 12). She has severe retrosternal pain, odynophagia, drooling, and hoarseness. After airway intubation for protection, upper endoscopy is performed at 12 hours post-ingestion. The esophageal mucosa shows the finding marked **C** in the diagram. Based on this endoscopic finding and the Zargar grading system, which of the following is the most appropriate next step in management?
A. Observation with IV fluids, NPO status, and reassessment at 48 hours
B. Nasogastric tube placement for feeding and supportive care with antibiotics
C. Urgent emergency esophagogastrectomy with cervical esophagostomy and feeding jejunostomy
D. High-dose proton pump inhibitor therapy with close inpatient monitoring and serial endoscopy
Explanation
Why "Urgent emergency esophagogastrectomy with cervical esophagostomy and feeding jejunostomy" is right
The finding marked C — extensive black eschar with circumferential necrosis — defines Zargar Grade IIIB caustic injury. This represents transmural necrosis with complete loss of viable mucosa and friability, indicating full-thickness esophageal destruction. According to the Zargar grading system and current ESGE guidelines, Grade IIIB injuries carry high mortality (up to 65%) and high perforation risk. Transmural necrosis is an absolute indication for urgent emergency esophagogastrectomy with cervical esophagostomy and feeding jejunostomy, followed by delayed reconstruction. Delaying surgery in Grade IIIB injury risks spontaneous perforation, mediastinitis, and death.
Why each distractor is wrong
High-dose proton pump inhibitor therapy with close inpatient monitoring and serial endoscopy: This is appropriate for Grade 2B injuries (deep discrete or circumferential ulcers), which carry 70–100% stricture risk but do not require surgery. Grade IIIB with transmural necrosis requires definitive surgical management, not medical therapy alone.
Nasogastric tube placement for feeding and supportive care with antibiotics: Blind nasogastric tube placement is contraindicated in caustic ingestion due to perforation risk, especially in Grade IIIB where the esophageal wall is already transmurally necrotic. This approach is inadequate for extensive necrosis and delays necessary surgery.
Observation with IV fluids, NPO status, and reassessment at 48 hours: Observation alone is inappropriate for Grade IIIB. Waiting 48 hours risks spontaneous perforation, sepsis, and death. Transmural necrosis requires urgent surgical intervention within the acute phase (6–24 hours post-ingestion) to prevent catastrophic complications.
High-YieldNEET PG
Zargar Grade IIIB (extensive black eschar with circumferential necrosis) = transmural injury = emergency esophagogastrectomy; Grade 2B (deep ulcers) = high stricture risk = medical management + monitoring.
Zargar SA. Endoscopic grading of caustic injury. Gastrointest Endosc. ESGE 2022 ingestion guideline update.
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