The patient and her story
The 58-year-old woman had dissolved half a bottle of pipe unblocking pellets in a glass of water and drank it, she said, to draw attention to herself. As reported by the emergency physician and her colleagues, when she arrived at the emergency room of the University Hospital of Cologne, her vomit contained blood, she presented symptoms of shock and severe chest pain.
Clinical presentation and first measurements
- In the trauma room, the patient was awake but hypotensive and in tachycardia (blood pressure: 90/70 mmHg, heart rate: 110/min), she continued to vomit mucus slightly tinged with blood and to feel severe pain.
- Hoarseness, salivation, progressive swelling of the upper and lower lip.
- Lesions of the oral mucosa, swelling of the epiglottis and arytenoids on videolaryngoscopy.
- Gastroscopy: extensive detachment of the mucosa of the esophagus and stomach with the presence of necrotic areas, extending to the duodenum.
- CT scan of the chest and abdomen: edematous changes in the area of the pharynx and larynx as well as the wall of the esophagus and stomach.
- Suspected aspiration pneumonia.
Evolution
- Intensive care, including ventilation and parenteral nutrition, and antibiotic treatment with piperacillin/tazobactam.
- Transfer to normal service after five days.
- Continuation of opiate analgesia due to severe substernal pain.
- Approximately 14 days after the event, resumption of oral hydration, careful diet for weeks.
- Due to increasing dysphagia and progressive retrosternal pain, repeat endoscopy two months after the event: from the junction between the hypopharynx and esophagus, long-term stenosis with fibrin deposits and inflammation still florid.
- According to the authors, it was not possible to pass the stricture with the standard endoscope (diameter of approximately 8 mm).
Discussion
As Victor Suárez and colleagues explain, accidental ingestion of corrosive household substances is mostly seen among children. In adults, it is usually a suicide attempt. The main component of pipe unblocking granules is, in addition to aluminum shavings, sodium or potassium hydroxide. By adding water, these substances formed very corrosive lye of soda or potash. Furthermore, the oxidation of aluminum results in a strong release of heat.
When taken orally, both reactions caused thermal and chemical burns with the formation of so-called liquefaction necroses. Contact with acids causes coagulation necrosis, in which the coagulated layer prevents the progression of the lesion. In case of liquefaction necrosis, the tissues liquefy like jelly, there is saponification of subcutaneous lipids; the injury continues into deeper layers of tissue, a process that can last a long time. It can therefore have a superficial effect initially, but can then penetrate into the deeper layers of the tissues.
The main clinical symptoms of esophageal/gastric lesions caused by unblocking products are vomiting with blood and very severe pain in the throat and chest.
However, symptoms and possible visible burns generally correlate poorly with the degree of esophageal/gastric injury, particularly in children. This is why the emergency physician and his colleagues recommend that in case of suspicion of oral poisoning by a product to unclog the pipes, a gastroscopy should be carried out quickly, even in the absence of external signs.
Emergency advice
According to the authors, the face, mouth and eyes should be immediately rinsed with plenty of water. In conscious patients, an attempt should be made to continue flushing out any granules still present in the esophagus by drinking water. However, the usefulness of a gastric tube is controversial due to the risk of perforation. Under no circumstances should you induce vomiting. A rapid gastroscopy is indicated to try to eliminate toxins and assess the extent of the burns. As glottis edema can also occur with a risk of life-threatening airway obstruction, the indication for intubation should be made early. General use of cortisone is not recommended in adult patients. In children with moderate-severity chemical burns, 3 days of cortisone therapy reduced the occurrence of strictures, but prolonged steroid treatment is also not recommended in pediatric patients.
This case study was originally published on Univadis.de.
