# Caustic Oesophageal Strictures: Management > Caustic oesophageal strictures for NEET-PG Surgery: acid versus alkali injury, Zargar grading, endoscopy timing, dilatation protocol and surgery options. - Canonical URL: https://prepelephant.com/topics/neet-pg/surgery/caustic-strictures-management - Exam / course: NEET-PG · Subject: Surgery - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Caustic Oesophageal Strictures: Management", PrepElephant, https://prepelephant.com/topics/neet-pg/surgery/caustic-strictures-management ## Direct answer Caustic ingestion injures by chemistry: alkalis produce liquefactive necrosis that penetrates deeply, while acids coagulate protein into an eschar that limits depth but pools in the stomach, damaging the antrum and causing gastric outlet strictures. Strictures evolve from the healing response of deep (grade 2B and 3) burns, appearing from the third week onwards, most commonly in the oesophagus. Management is protocolised: early endoscopy within 12-24 hours to grade injury (Zargar classification), supportive care and nutrition, barium contrast study around three weeks, then a graded dilatation programme; resection or bypass with colon or jejunum interposition is reserved for strictures that dilatation cannot hold open. ## What you must remember - **Acid versus alkali:** alkali (sodium hydroxide in drain cleaners) causes liquefactive necrosis — saponification of fats and protein dissolution, deep and progressive; acids cause coagulative necrosis with an eschar barrier, but fast emptying into the stomach produces pylorospasm and stasis, so acid ingestion disproportionately causes gastric (antral) strictures. - **Physical state matters:** solids adhere to the oropharynx (more mouth and pharyngeal injury), liquids are gulped down (more oesophageal and gastric injury); suicidal intent with household acids is the common Indian pattern. - **Endoscopy timing:** within 12-24 hours of ingestion — beyond the fifth day and until about the third week endoscopy is avoided, when granulation tissue makes perforation likely. - **Zargar endoscopic grading:** grade 0 normal; 1 oedema and hyperaemia; 2A superficial, non-circumferential ulceration; 2B deep or circumferential ulceration; 3A scattered deep ulcers with microperforation or small islands of necrosis; 3B extensive necrosis — grades 2B and above predict stricture formation. - **Steroids are not routine:** the Zargar randomised study showed no benefit in preventing strictures and concern for masking sepsis; nutrition (nasogastric or feeding jejunostomy) matters more. - **Dilatation programme:** barium swallow around 3 weeks to map the stricture; dilatation starts about 3 weeks after injury using Savary bougies or balloons, repeated at intervals of 1-2 weeks, aiming for increasing diameters; perforation risk is real and a surgical team should stand ready. - **Surgery for refractory disease:** colonic interposition or jejunal interposition, or gastric transposition where the stomach is healthy; resection of a burned-out gastric antrum for acid injuries; malignant change in long-standing strictures needs a generation-long vigil. ## A dilatation calendar worth memorising A 24-year-old woman ingests toilet cleaner in a moment of distress. At 14 hours, endoscopy shows circumferential deep ulceration of the mid-oesophagus — Zargar 2B — and an intact stomach. She receives PPIs, analgesia, and a nasogastric tube past the burn for enteral nutrition; no steroids are given, and the fifth-to-twenty-first-day window passes without endoscopy because this is exactly when the friable granulating oesophagus perforates at a probe's touch. At three weeks a barium swallow outlines a 3 cm smooth mid-oesophageal stricture, and the dilatation programme begins: Savary bougies over a guidewire, weekly sessions, each recording the largest diameter achieved and resistance felt. Most grade 2B strictures yield within a handful of sessions; when the stricture refuses — re-tightening within two weeks of each dilatation through months of effort — the conversation shifts to colonic interposition, using the left or right colon with its vascular pedicle raised to the neck. The calendar is the exam: endoscopy day 1, nothing invasive day 5-21, barium and first dilatation week 3, and surgery only for the refractory minority. ## Where students slip The classic confusion is the acid-alkali geometry: alkali wounds the oesophagus deeply, acid spares depth but punishes the stomach antrum — stems exploit exactly this. Timing slips follow: endoscopy performed at two weeks (perforation phase) or dilatation attempted in week one (same hazard) are both wrong answers built from real harm. Students also over-order steroids; the Zargar trial's null result is the expected justification for restraint. Finally, remember to feed the patient early through a tube rather than starve them, and to keep a lifelong eye on long-standing strictures for squamous malignant change. ## Frequently asked questions ### Why do alkali injuries penetrate deeper than acids? Alkali saponifies membranes and dissolves protein, producing liquefactive necrosis that spreads; acids coagulate surface protein into an eschar that checks depth. ### Why does acid ingestion damage the stomach? Acid empties quickly into the stomach and induces pylorospasm, so the antrum holds the pool of acid — antral strictures and gastric outlet obstruction dominate. ### When is endoscopy performed after caustic ingestion? Within 12-24 hours to grade the burn by the Zargar classification; endoscopy is avoided between roughly day 5 and week 3, when perforation risk peaks. ### What is the role of steroids? Routine steroids are not recommended — the Zargar randomised study found no stricture-prevention benefit and risk of masking early sepsis. ### What is the operation for a refractory stricture? Bowel interposition — colon or jejunum on its vascular pedicle — or gastric transposition, reserving dilatation failure as the indication.