Larger staging of mucosal injury
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Zarger staging
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Here is a complete summary of the Zargar Endoscopic Staging of Caustic Mucosal Injury:
Zargar Endoscopic Classification of Caustic Injury
Zargar's classification is the most widely used endoscopic grading system for assessing the severity of mucosal injury following ingestion of corrosive (acid or alkali) substances. It is performed ideally within 12-24 hours of ingestion. The system is analogous to burn depth classification applied endoscopically.
(Source: Zargar SA et al. Gastrointest Endosc. 1991;37(2):165-169)
| Grade | Endoscopic Findings | Clinical Implication |
|---|---|---|
| 0 | Normal appearance | No injury |
| 1 | Mucosal oedema and hyperaemia (erythema) | Superficial; heals without sequelae |
| 2a | Superficial, non-circumferential ulceration, whitish membranes, shallow ulcers, haemorrhage, friable exudates | Heals well; low stricture risk |
| 2b | Deep or circumferential ulceration with structure formation | Higher stricture risk |
| 3a | Small, scattered areas of focal necrosis | Significant stricture and complication risk |
| 3b | Extensive necrosis | Highest morbidity and mortality |
| 4 | Perforation | Surgical emergency |
(Bailey and Love's Short Practice of Surgery, 28th Ed.; Cummings Otolaryngology, Head and Neck Surgery)
Key Clinical Correlations
- Grade 0 and 1 - conservative management; good prognosis
- Grade 2a - admit, observe; stricture risk is low
- Grade 2b - higher risk of stricture formation; monitor closely
- Grade 3a and 3b - high risk of stricture, perforation, mediastinitis; may need surgery
- Grade 4 - immediate surgical intervention required
Pathophysiology (NaOH/Alkali injury)
- Day 0-2: Intense inflammatory reaction, oedema, haemorrhagic congestion, eosinophilic necrosis
- Day 4: Fibroblast and new blood vessel emergence; necrosis typically complete by day 7
- Week 2+: Granulation tissue predominates → contractile phase → stricture formation
Complications by Grade
- Stricture: Most common with grades 2b and above - often long, resistant to dilation
- Malignancy: Long-term risk in the damaged oesophagus (especially corrosive strictures)
- Perforation/Mediastinitis/Peritonitis: Grades 3b and 4
Endoscopic image - caustic burn to the oesophagus:
Note: Grade 4 (perforation) was added in the modified Zargar classification (1991) - the original 1989 classification only went to Grade 3b. Endoscopy should be performed with caution in suspected Grade 3b injury, as advancing the scope risks iatrogenic perforation.
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