Alkaline ingestions

In Vitro Fossilization for High Spatial Resolution Quantification of Elements in Plant-Tissue Using LA-ICP-TOFMS

Laser ablation in combination with an inductively coupled plasma time-of-flight mass spectrometer (LA-ICP-TOFMS) is an upcoming method for rapid quantitative element mapping of various samples. While widespread in geological applications, quantification of elements in biotissues remains challenging. In this study, a proof-of-concept sample preparation method is presented in which plant-tissues are fossilized in order to solidify the complex biotissue matrix into a mineral-like matrix. This process enables quantification of elements by using silicone as an internal standard for normalization while also providing consistent ablation processes similar to minerals to reduce image blurring. Furthermore, it allows us to generate a quantitative image of the element composition at high spatial resolution. The feasibility of the approach is demonstrated on leaves of sunflowers (Helianthus annuus), soy beans (Glycine max), and corn (Zea mays) as representatives for common crops, which were grown on both nonspiked and cadmium-spiked agricultural soil. The quantitative results achieved during imaging were validated with digestion of whole leaves followed by ICP-OES analysis. LA-ICP-TOFMS element mapping of conventionally dried samples can provide misleading trends due to the irregular ablation behavior of biotissue because high signals caused by high ablation rates are falsely interpreted as enrichment of elements. Fossilization provides the opportunity to correct such phenomena by standardization with Si as an internal standard. The method demonstrated here allows for quantitative image acquisition without time-consuming sample preparation steps by using comparatively safe chemicals. The diversity of tested samples suggests that this sample preparation method is well-suited to achieve reproducible and quantitative element maps of various plant samples.

Microgels for long-term storage of vitamins for extended spaceflight

Biocompatible materials that can encapsulate large amounts of nutrients while protecting them from degrading environmental influences are highly desired for extended manned spaceflight. In this study, alkaline-degradable microgels based on poly(N-vinylcaprolactam) (PVCL) were prepared and analysed with their regard to stabilise retinol which acts as a model vitamin (vitamin A₁). It was investigated whether the secondary crosslinking of the particles with a polyphenol can prevent the isomerisation of biologically active all-trans retinol to biologically inactive cis-trans retinol. Both loading with retinol and secondary crosslinking of the particles was performed at room temperature to prevent an early degradation of the vitamin. This study showed that PVCL microgels drastically improve the water solubility of hydrophobic retinol. Additionally, it is demonstrated that the highly crosslinked microgel particles in aqueous solution can be utilised to greatly retard the light- and temperature-induced isomerisation process of retinol by a factor of almost 100 compared to pure retinol stored in ethanol. The use of microgels offers various advantages over other drug delivery systems as they exhibit enhanced biocompatibility and superior aqueous solubility.

Macroscopic and histopathological aspects of chemical damage to human tissues depending on the survival time

The ingestion of corrosive substances is a widely treated topic in clinical and forensic practice, as an accidental event or as a consequence of voluntary assumption to commit suicide. However, thorough macroscopic and microscopic surveys focused on the correlation between the ingestion of the substance and different survival times have never been performed. Are the ingestion and the metabolism of the substance within the human tissues still recognizable? How could it be related to death? The study concerns a retrospective analysis on ten cases (two accidental, eight suicides) of lethal ingestion of different types of liquid caustic substances, without instant death and survival times ranging from 12 h to 6 months. For each case, a full autopsy and histological examination of the internal organs were performed. The results showed that the early direct effect of the substances is exerted mainly on the gastrointestinal tract, but as survival time increased, the metabolism of the substance exerted its effects in different target organs. When the cause of death was not directly linkable to the ingestion of the substance (i.e., related to cardiac stress, electrolyte disorders, pneumonia) and macroscopic findings were nonspecific, histological analyses allowed for providing crucial elements towards a link between death and assumption of the substance.

Minimally invasive repair of a late stricture in a reversed gastric tube

Ingestion of caustic agents may result in severe scarring and stricture formation of the esophagus. Reversed gastric tube esophagoplasty is an option for definitive surgical management of severe esophageal stricture refractory to medical treatment. Delayed complications from this procedure have rarely been reported. We present a case involving a patient who developed a delayed gastric stricture three decades after receiving a reversed gastric tube esophagoplasty. A historical review of the reversed gastroplasty is presented as well.

A complicated hospitalization following dilute ammonium chloride ingestion

INTRODUCTION

Unintentional ingestions of dilute (<7.5%) cleaning solutions containing ammonium chloride typically do not cause serious harm. We present a case of an intentional ingestion of a dilute ammonium chloride solution resulting in significant morbidity.

CASE REPORT

A 60-year-old woman with bipolar disorder presented one hour after an intentional ingestion of approximately 15 fluid ounces (500 mL) of an algae and odor humidifier treatment containing a total of 2.25% ethyl ammonium chloride. Initial complaints included nausea with a single episode of nonbilious, nonbloody emesis, mild shortness of breath, and chest and epigastric pain. Physical exam was remarkable for bilateral wheezing and epigastric tenderness. An emergent endoscopy demonstrated a Grade 2b caustic injury in the esophagus and a Grade 3b injury in the stomach. Due to persistent cough, copious oral secretions, and worsening hoarseness, the patient was intubated and admitted to the ICU. Her course was complicated by mild hypotension, nonanion gap metabolic acidosis, and oliguria treated successfully with intravenous (IV) fluids. She also developed bilateral pneumonias later in the hospital course. Bedside bronchoscopy showed laryngeal edema and mucosal injury to the segmental level. The patient underwent tracheostomy on hospital day 6. An upper GI swallow study revealed poor esophageal motility in the mid- to lower third of the esophagus. The patient gradually tolerated oral fluids and on hospital day 20 had her tracheostomy tube removed. The patient was subsequently transferred to the psychiatric ward on hospital day 22.

CONCLUSION

Intentional ingestions of dilute ammonium chloride solutions can cause serious injury to the gastrointestinal tract and pulmonary systems, which can result in a complicated and prolonged hospitalization.

Is esophagoscopy necessary for corrosive ingestion in adults?

The aim of the study was to determine whether early esophagoscopy is really necessary for the patients who have ingested a corrosive agent. Patients who were followed up with the diagnosis of corrosive ingestion in our clinic between the years 1998 and 2008 were studied retrospectively. The data were collected through the medical records of the patients and from interviews with them. The analyzed parameters included age, gender, the nature and the amount of the ingested agent, whether the event was accidental or suicidal, diagnostic tools, treatment and the results of the treatment, and long-term follow up. Over a 10-year period, a total of 124 cases of corrosive ingestion cases were determined. Of these, 64 (51.6%) were male and 60 (48.4%) were female. The mean age was 38 +/- 17.5 years. The most commonly ingested corrosive agents were sodium hypochlorite in 50 (40.3%) patients and hydrochloric acid in 33 (26.6%) patients. The mean admission time for the emergency department after ingestion of the corrosive agent was 2.5 +/- 3.7 hours. Ingestion was accidental in 82% of the patients and as a result of a suicide attempt in 18%. The amount of ingested corrosive agent in the suicidal group (190 +/- 208.3 mL) was higher than that of accidental group (66 +/- 58.3 mL) (P= 0.012). Nine patients underwent esophagoscopy, six of which were performed in other clinical centers. Only three (2.4%) patients experienced esophageal stricture, which were treated with repeated dilatations. In the long-term follow up, we could get in touch with only 63 patients and none of them had complications due to corrosive ingestion. The follow-up period ranged from 1 to 120 months (median 45 +/- 29.2 months). Based on our study, early esophagoscopy appears to be unnecessary in adult patients who ingested the corrosive agent accidentally. A larger prospective study is needed to answer the question.

Critical pH level of lye (NaOH) for esophageal injury

AIM/BACKGROUND

Lye (NaOH) ingestion in humans often results in alkaline damage to the esophagus, but knowledge about this process is limited. Here, we explore the effects of lye on esophageal epithelial structure and function using rabbit esophageal epithelium as a model of lye ingestion.

METHODS

Rabbit esophageal epithelium was mounted in Ussing chambers so that the electrical potential difference (PD), short-circuit current (I (sc)), and transepithelial resistance (R (T)) could be monitored before, during, and after mucosal exposure to lye (NaOH) at pHs ranging from 7.4 to 12.1. Histopathology and dextran fluxes were also performed and correlated with the electrical data.

RESULTS

Mucosal exposure to lye at pHs <11.5 had no damaging effects on the esophagus. However, at pHs >or=11.5, damage was both time- and pH-dependent, as noted by increases in PD and I (sc), and declines in R (T). Further, the electrical changes were paralleled morphologically by epithelial liquefaction necrosis and increases in dextran flux. Also, by pretreating tissues with ouabain, the early lye-induced rise in PD and I (sc) was shown to result from a combination of increased active (sodium) transport and passive (sodium) diffusion which indicates that, even early on, the damaging effects of lye include changes in both apical cell membranes and tight junctions of this epithelium.

CONCLUSION

Lye (NaOH) injury to the esophageal epithelium is both pH- and time-dependent, but requires a minimum pH of 11.5. At pHs >or=11.5, lye produces liquefaction necrosis, an injury that involves both cellular and junctional barriers, and which markedly increases epithelial permeability to ions and uncharged molecules. Based on these results, non-industrial cleaning products in the home are likely to be safer if they have a concentration of lye below pH 11.5.

Ingested button battery retrieved by a modified magnet endoscope

Ingestion of button battery (BB) by toddlers has been seen with increasing frequency over the past decade. Significant morbidity may develop if the ingested BB cannot be removed in time. Herein, we describe 2 infants whose ingested BBs were smoothly and successfully retrieved, from a stenotic esophagus and stomach, by the use of a self-made modified magnet endoscope.

A novel approach for preventing esophageal stricture formation: sphingosylphosphorylcholine-enhanced tissue remodeling

Using a new class of intracellular 2nd messengers to prevent stricture formation after caustic ingestion, sphingosylphosphorylcholine (SPC) has a wide spectrum of activity in cell growth regulation and signal transduction. Caustic esophageal burns were created with 15% NaOH in an experimental rat model. Control group animals (n = 10) had esophageal burns with no treatment, whereas the SPC group (n = 10) had esophageal burns gavaged with SPC for 7 days. Efficacy of treatment was assessed in 28 days by contrast esophagograms, histopathologic evaluation, and biochemically by tissue hydroxyproline (OHP) content. Contrast esophagograms demonstrated that SPC significantly prevented stricture formation. Obvious collagen deposition was present in submucosa, muscularis mucosa, and muscular layers in the control group compared with the SPC group. The damage to the esophageal wall on histopathologic examination was significantly lower in the SPC group (p < 0.05). Tissue OHP contents were significantly lower in the SPC-treated group (3.0 +/- 0.1 microg/mg) compared with the control group (4.3 +/- 0.2 microg/mg) (p < 0.05). We conclude that SPC improves healing following caustic esophageal burns. Furthermore, SPC is effective in preventing caustic esophageal strictures. These effects of SPC occur through its proliferative and specifically its remodeling effects on wound healing.

The effect of halofuginone, a specific inhibitor of collagen type 1 synthesis, in the prevention of esophageal strictures related to caustic injury

BACKGROUND

To assess the effects of halofuginone, a specific inhibitor of synthesis of collagen type 1, which is the major constituent of fibrosis, on esophageal stricture formation due to caustic ingestion.

METHODS

Sixty rats were divided into four equal groups: control group; sham laparotomy group; caustic injury without treatment group; caustic injury with halofuginone treatment group. Caustic injuries were done by 50% sodium hydroxide. Halofuginone was administered by the first postoperative day. All animals were sacrificed on day 21; and the results were evaluated by hydroxyproline levels, stenosis index, lumen diameter, histopathological evaluation, wall thickness, and animal weights.

RESULTS

Mortality differences were significant comparing group 3 with group 1 and 2 (P = 0.006) and group 4 (P = 0.03). According to hydroxyproline levels, the differences are significantly higher (P <0.001) comparing group 3 with group 1, 2, and 4. The P value was considered significant in all other parameters (P <0.001) for all the groups but group 1 versus group 2 (P >0.05).

CONCLUSIONS

Halofuginone, a specific inhibitor of collagen type 1 synthesis, significantly reduced esophageal stricture occurrence.

Black Esophagus

Black esophagus is a rare, relatively newly described, and usually incidental finding. The differential diagnosis includes several disease states, including ischemia, which has been implicated in acute necrotizing esophagitis. Several theories have been proposed to explain its etiology.

Hair relaxers: a benign caustic ingestion?

BACKGROUND

Despite federally legislated safety regulations, caustic ingestions remain a significant problem in the pediatric population. The current standard of care for caustic ingestion includes upper gastrointestinal endoscopy in most cases. Hair relaxers are a common caustic ingestion at our institution, yet few data have been published describing the clinical or endoscopic outcome. We explored the relative frequency of hair relaxer ingestion, the incidence of associated upper gastrointestinal injury, and the adverse clinical sequelae resulting from these ingestions.

METHODS

Consecutive caustic ingestions admitted to our institution between January 1990 and January 2001 were identified. The data were collected through retrospective physician chart review, were analyzed, and were pooled with the existing literature to evaluate for the presence of esophageal injury.

RESULTS

96 charts were reviewed, 29 (30%) of which were hair relaxer ingestions that underwent esophagogastroduodenoscopy; these ingestions served as our study cohort. The median age of the cohort was 14.0 months and patients were evenly divided in gender. The most common symptoms at presentation were drooling and emesis. At endoscopy, lip and oropharyngeal mucosa were most commonly affected. While six patients (20.7%) had Grade I esophageal mucosal injury and five patients (17.2%) had Grade I gastric mucosal injury, none had greater than Grade I mucosal damage. No adverse clinical events were identified. When our data were combined with all previously published cohort data, the findings were similar and no adverse clinical outcomes were reported.

CONCLUSIONS

Hair relaxer is the most common childhood caustic ingestion presenting to our large metropolitan tertiary care center. Symptoms are common at presentation. However, despite the high pH of these products, no clinically significant esophageal or gastric mucosal injuries and no long-term sequelae were identified.

Systemic and local effects of long-term exposure to alkaline drinking water in rats

Alkaline conditions in the oral cavity may be caused by a variety of stimuli, including tobacco products, antacids, alkaline drinking water or bicarbonate toothpaste. The effects of alkaline pH on oral mucosa have not been systematically studied. To assess the systemic (organ) and local (oral mucosal) effects of alkalinity, drinking water supplemented with Ca(OH)2 or NaOH, with pH 11.2 or 12 was administered to rats (n = 36) for 52 weeks. Tissues were subjected to histopathological examination; oral mucosal biopsy samples were also subjected to immunohistochemical (IHC) analyses for pankeratin, CK19, CK5, CK4, PCNA, ICAM-1, CD44, CD68, S-100, HSP 60, HSP70, and HSP90. At completion of the study, animals in the study groups had lower body weights (up to 29% less) than controls despite equal food and water intake, suggesting a systemic response to the alkaline treatment. The lowest body weight was found in rats exposed to water with the highest pH value and starting the experiment when young (6 weeks). No histological changes attributable to alkaline exposure occurred in the oral mucosa or other tissues studied. Alkaline exposure did not affect cell proliferation in the oral epithelium, as shown by the equal expression of PCNA in groups. The up-regulation of HSP70 protein expression in the oral mucosa of rats exposed to alkaline water, especially Ca(OH)2 treated rats, may indicate a protective response. Intercellular adhesion molecule-1 (ICAM-1) positivity was lost in 6/12 rats treated with Ca(OH)2 with pH 11.2, and loss of CD44 expression was seen in 3/6 rats in both study groups exposed to alkaline water with pH 12. The results suggest that the oral mucosa in rats is resistant to the effects of highly alkaline drinking water. However, high alkalinity may have some unknown systemic effects leading to growth retardation, the cause of which remains to be determined.

Chemical Hazards and Poison Control for the Health Professional—Review of Select Principles and Exposures

Exposure to a wide variety of chemicals can pose significant hazards to patients, and present health care professionals with scenarios that require proper assessment and treatment. Knowing when a chemical exposure requires emergency medical attention is equally as important as knowing when such assistance is not necessary and that simple treatment measures performed at home will suffice. This current discussion is intended to highlight selected principles and clinical information pertaining to common chemical exposures, but not to replace the full spectrum of information that would be available to health care professionals (and the lay public) by contacting their nearest poison control center. There are several factors that should be considered when assessing the nature of and possible clinical outcomes (and medical needs) from patient exposure to chemicals. Identification of the chemical(s) involved, events leading up to the exposure, route of exposure (e.g., ingestion, dermal, inhalation, ocular), patient medical history and current symptoms, are just a few of the variables that must be ascertained before various treatment approaches can be undertaken.

The preventive effect of heparin on stricture formation after caustic esophageal burns

BACKGROUND/PURPOSE

Preventing thrombus formation after caustic esophageal ingestion has been proposed to have beneficial effects. Therefore, an experimental study was carried out to investigate the effects of heparin on the esophagus after caustic burns.

METHODS

Caustic esophageal burns were produced in rats by irrigation with 50% NaOH as described by Liu. Rats were divided into four groups as follows: group A, animals with esophageal burns, received placebo and underwent autopsy 48 hours after caustic injury; group B, animals with esophageal burns, received subcutaneous heparin treatment and underwent autopsy 48 hours after caustic injury; group C, animals with esophageal burns, received placebo and underwent autopsy 28 days after caustic injury; group D, animals with esophageal burns, received subcutaneous heparin treatment for 7 days and underwent autopsy 28 days after caustic injury. Histopathologic evaluation was performed in all groups, and collagen content of esophageal sections was analyzed by determination of hydroxyproline levels.

RESULTS

Submucosal vascular thrombosis was encountered in all group A animals but the submucosal venules and arterioles were patent in most of group B animals. Esophageal strictures did not develop in any of group D animals, although varying degree of esophageal stenoses were encountered in all animals of group C. The circumferences of the burned segment have been narrowed to 3+/-1 mm in group C rats. There was obvious collagen deposition in submucosa, and epithelial regeneration was not complete in group C rats. Submucosa and epithelial integrity seemed normal in group D animals. Hydroxyproline contents in group D were significantly lower compared with group C (P < .05).

CONCLUSIONS

Heparin has ameliorating effects on stricture formation after caustic esophageal burn. Those effects may occur through possible anticoagulant, antithrombotic, and endothelial protective effects, and modifying effects of heparin on wound healing.

Thermal characteristics of neutralization therapy and water dilution for strong acid ingestion: an in-vivo canine model

OBJECTIVE

To determine whether in-vivo neutralization therapy for acid ingestions will superimpose a thermal injury upon tissue already damaged by acid.

METHODS

An in-vivo canine model was used with repeated measures of tissue and luminal temperatures. All dogs were placed under halothane general anesthesia. The stomach was exteriorized and temperature probes were placed in the lumen and mucosa. 25 mL of 0.5 N HCl (25 degrees C) was placed in the gastric lumen followed 5 minutes later by 75 mL of either 8% NaHCO3 neutralization (25 degrees C, n = 10) or water dilution (25 degrees C, n = 10). Temperature measurements were recorded at specified intervals for 5 minutes post HCl acid exposure and for 30 minutes post treatment. Temperature profiles were analyzed by repeated-measures ANOVA. Post-treatment changes were evaluated using signed-rank tests.

RESULTS

In both treatment groups, treatment resulted in significant decreases in initial mucosa and intraluminal temperatures. Both the mucosa and intraluminal temperatures decreased immediately after treatment with HCO3 by an average of 1.6 degrees C (p = 0.05). In the water dilution treatment group, both temperatures decreased by 1.1 degrees C (p = 0.05). Ensuing post-treatment temperatures increased but did not reach baseline temperatures at any time up to 30 minutes post treatment.

CONCLUSIONS

In the in-vivo setting, there is no evidence of hazardous temperature elevation when a weak alkali or dilution therapy is used to neutralize strong acid-induced injury. Contraindication of this form of emergency treatment should not be based on the preconceived idea that a resultant exothermic reaction will cause a superimposed thermal injury. Further clinical study is needed to determine the clinical utility of this emergency therapeutic modality.

Ingestion of caustic hair relaxer: is endoscopy necessary?

Hair relaxer, a commercially available alkaline product, is commonly the offending agent in caustic ingestion. These patients often experience oral cavity and facial burns; however, no clinically significant esophageal injuries have been reported. Therefore, we questioned the therapeutic and economic efficacy of the "standard treatment protocol" that includes hospitalization and endoscopic evaluation. Twenty-six patients over a 7-year period presented to our institution having ingested hair relaxer. Presenting signs and symptoms, esophageal findings, and cost of the standard treatment protocol were reviewed. Also, we analyzed the caustic potential and current packaging of hair relaxer. Our findings support modifications in the standard treatment protocol for hair relaxer ingestion including elimination of hospitalization and endoscopy in most patients. We also question compliance with childproof packaging laws and suggest avenues for prevention of hair relaxer ingestion.

Thermal effects of neutralization therapy and water dilution for acute alkali exposure in canines

OBJECTIVE

To evaluate the change in temperature of the gastric mucosa and lumen contents when a weak acid or water is used to manage acute alkali exposure.

METHODS

A prospective in-vivo canine model was used in a university-based animal laboratory setting. Eighteen adult canines weighing 20-25 kg were placed under a surgical plane of anesthesia and a laparotomy was performed. A gastrotomy was then made later ligation of the distal esophagus and proximal duodenum. Separate mucosa and lumen temperature probes were placed. Then 25 mL of room-temperature (24-26 degrees C) 50% sodium hydroxide (NaOH) was instilled in the gastric lumen. After 5 minutes, each canine was given treatment. Group 1 (n = 10) was treated with 75 mL of room-temperature orange juice. Group 2 (n = 8) was treated with 75 mL of room-temperature water. Continuous mucosa and lumen temperatures were observed and recorded at baseline and at specified intervals for 35 minutes after the alkali insult. Repeated-measures analysis of variance was used to evaluate the overall temperature profile. Signed-rank tests were used to compare the changes in temperature immediately following neutralization treatment.

RESULTS

Significant temperature decreases of 1.1 degrees C and 2.1 degrees C were observed for both mucosa (p = 0.002) and lumen (p < 0.001) temperature, respectively, following neutralization therapy with room-temperature orange juice. In the group treated with room-temperature water, significant temperature decreases of 2.1 degrees C for mucosa (p = 0.01) and 2.4 degrees C for lumen (p = 0.01) were observed. Posttreatment temperatures did not exceed baseline for the entire observation period.

CONCLUSION

Neutralization therapy with room-temperature orange juice or water dilution for acute gastric injuries by liquid alkali does not cause a rise in mucosal or intraluminal temperatures in an in-vivo canine model.

Effective treatment for acute alkali injury to the esophagus using weak-acid neutralization therapy: an ex-vivo study

OBJECTIVE

1) To evaluate whether neutralization therapy with weak acid is effective in reducing observed histopathologic esophageal tissue injury secondary to liquid alkali, 2) to quantify the temperature change of the neutralizing agent, and 3) to determine the effect of interval to therapy on injury severity.

METHODS

Harvested Sprague-Dawley rat esophagi were catheterized and placed in an oxygenated saline bath (37 degrees C) for 60 minutes and then fixed in 10% formalin. Nine groups (n = 10) were perfused with 50% sodium hydroxide (NaOH). Six of the groups were treated by neutralization with cooled orange juice (OJ) or cola that was maintained between 2 degrees C and 4 degrees C. This was performed at 0, 5, or 30 minutes after injury. In addition, two positive control groups were exposed to OJ or cola at time 0 and were not exposed to strong alkali. A third control group was exposed to strong alkali but was not administered any subsequent treatment. The temperature of the neutralizing agent was recorded prior to instillation and after exiting the esophagus. Blinded pathologic scoring of 0 (no injury) to 3 (severe) was recorded performed for six histopathologic categories: epithelial cell viability, cornified epithelial cell differentiation, granular cell differentiation, epithelial cell nuclei, muscle cells, and muscle cell nuclei. Comparisons were made among treatment times using the Kruskal-Wallis test and linear trend analysis.

RESULTS

For each histopathologic category and each treatment mode, the Kruskal-Wallis test showed significant differences between the groups (p < 0.002) over time. Trend analyses showed more severe injury with delayed neutralization therapy (p < 0.05) for each treatment mode and histopathologic category.

CONCLUSION

Early neutralization therapy with OJ or cola reduces acute esophageal alkali injury. Additional in-vivo study is needed before neutralization therapy is adopted for clinical use.

Consequences of caustic ingestions in children

A retrospective analysis of 98 patients, less than 15 years of age, treated for caustic ingestion during 1976-1990 was performed to evaluate the modern consequences of caustic ingestion in children and to set indications for esophagoscopies and radiographic and laboratory examinations. Dishwasher detergents were ingested by 56 children. There were no lye ingestions, since lye has not been freely available in Finland since 1969. Household acetic acid (vinegar) was the most commonly (12/23) ingested acid. Primary esophagoscopy was performed in 79 of the 98 cases (80.6%). Esophageal burns were found in 20 patients. Acids caused burns more often than alkalies (9/23 (39.1%) versus 11/75 (14.7%); p = 0.011; 95% confidence intervals (CI) for the difference 5.6-43.3%) and acid burns more often developed into scars (7.4% versus 4%; p = 0.029; 95% CI for the difference 1.4-25.4%). The only esophageal stricture developed after ingestion of a Clinitest tablet. The mean time for hospitalization as a result of acid ingestion was significantly longer than after alkaline ingestion (3.2 (SD 3.5) days, n = 23 versus 1.5 (1.6) days, n = 75; p < 0.05; 95% CI for the difference 0.7-2.8 days). Prolonged drooling and dysphagia (12-24 h) predicted esophageal scar formation with 100% sensitivity and 90.1% specificity, but signs and symptoms did not predict esophageal burns after primary esophagoscopy. Radiographic examinations and leukocyte counts were of no value in predicting esophageal burns and scars. The panorama of caustic ingestion appears to have changed, probably due in part to the law banning sale of lye products since 1969. This type of law should be encouraged elsewhere. Acids cause even more caustic burns than alkalies. Vinegar should be regarded as a potent caustic substance and distributed in baby-safe bottles with appropriate information on its caustic nature. As severe esophageal lesions after accidental ingestion of caustic substances are now rare in children, primary esophagoscopies and hospitalization of patients are not indicated routinely. The decision on esophagoscopy can be made on the basis of drooling and dysphagia during follow-up.

Ingestion of caustic cosmetic products

Twelve children over a 6-year period (1985 to 1991) underwent aerodigestive tract endoscopy after ingestion of lye-containing cosmetic products. All children were less than 2 years of age and had facial and/or oral cavity burns. Eleven of these patients ingested alkaline hair products such as "activators" or "relaxers." Endoscopy revealed pharyngeal burns in five patients but no laryngeal or esophageal burns in any patient. Erythema of the esophageal mucosa was seen in one patient. One patient ingested a solution used in fingernail decorating. This patient sustained extensive superficial burns of the pharynx, larynx, and esophagus and required intubation and admission to the intensive care unit. No long-term sequelae developed. Cosmetic products containing caustic chemicals represent a significant health risk to small children, especially because child-proof packaging is not standard for these products.

Hair relaxer ingestion: a new trend

Although the health care system has done much to reduce the incidence of ingestion of such alkalis as drain and oven cleaners, in recent years we have seen an overwhelming increase in the incidence of hair relaxer ingestion. In a 5-year review (1987 to 1992) of 48 cases of caustic ingestion, 15 cases involved alkaline hair-relaxing agents. This retrospective study was undertaken to evaluate the agents ingested, the presenting signs and symptoms, the diagnostic procedures, and the outcomes in those 15 cases. Oral cavity and lip burns were common in these children, but none of the 15 had significant esophageal burns. Education of the medical and lay community about the risk of hair relaxer ingestion should be undertaken to reverse this worrisome trend.

Effective treatment of acute alkali injury of the rat esophagus with early saline dilution therapy

BACKGROUND

Controversy persists regarding the appropriate treatment of acute alkali injury to the esophagus. The current study establishes a controlled model of alkali esophageal injury and examines the efficacy of saline dilution therapy.

STUDY HYPOTHESIS

Early saline dilution therapy effectively reduces esophageal injury resulting from acute alkali exposure.

METHODS

The esophagi were harvested from 60 Sprague-Dawley rats. Each end was cannulated with a 20-gauge catheter. Specimens were maintained in an oxygen-perfused saline bath (37 C) during a 60-minute experimental period and then fixed immediately in 10% formalin solution for histologic examination. Three experimental groups (A, B, and C) were perfused with 50% NaOH solution at time zero. Treatment with saline perfusion was performed immediately in group A, five minutes after injury in group B, and 30 minutes after injury in group C. The positive control group D was perfused with saline at time zero. A negative control, group E, was perfused with 50% NaOH at time zero. This group did not receive subsequent treatment with saline. Pathologic examination was performed in a blinded fashion using a score of 0 to 3 (0, no injury; 1, minimal; 2, moderate; 3, severe) for seven histologic criteria: epithelial viability, extent of injury, cornified epithelial cell differentiation, granular cell differentiation, epithelial cell nuclei, muscle cells, and muscle cell nuclei.

RESULTS

The positive control group demonstrated scores of zero. Nonparametric analysis showed a significant difference among treatment groups for each injury category. Trend analysis revealed a significant progression of injury for each category associated with time to treatment. Discriminant analysis indicated that the muscle cells category was the most useful category with which to distinguish injury among groups.

CONCLUSION

In our model, saline lavage decreased objective evidence of esophageal injury after a severe alkaline exposure, and early therapy enhanced this beneficial effect.

Cutaneous button battery injury: a new paediatric hazard

Button or disc batteries have become increasingly popular as the energy source for electronic devices such as cameras, calculators, computers, watches, hearing aids and children's toys. Button battery burns to the gastrointestinal tract, ear and nose have been reported in children from many centres. Cutaneous injury from these sources has not been similarly reported. We believe our case represents the first, reported to date, to have suffered this injury and highlights this further potential hazard of the small, benign-looking button batteries.

Perioperative management of paediatric microstomia

Paediatric microstomia may occur congenitally in the whistling face syndrome but is more often acquired after accidental thermal injuries such as biting an electrical extension cord or ingesting household lye. The surgical correction of microstomia includes separation and cosmetic reconstruction of the fused lips and postoperative oral splinting. Microstomia from lye ingestion may be associated not only with limited mouth opening but also with such severe intraoral scarring that common landmarks guiding either rigid or flexible fibreoptic laryngoscopy are obscured, rendering oral and nasotracheal intubation difficult or impossible. We report a case of paediatric microstomia after lye ingestion in which conventional direct laryngoscopy, flexible fibreoptic laryngoscopy, and multiple blind nasal approaches to tracheal intubation were unsuccessful. However, tracheostomy was avoided and successful tracheal intubation was accomplished using a new rigid tubular pharyngolaryngoscope.

Toxicology of household cleaning products and disinfectants

Hundreds of different household cleaning products are available in homes, presenting potential hazards to pets. These products are complex mixtures of chemicals that vary widely in their toxic potential. Prevention of toxicoses in companion animals follows the same guidelines as those recommended for children: Keep cleaning products out of the reach of pets, do not leave open containers or solutions of cleaning products unattended where animals may get into them, make sure containers of cleaning products are tightly sealed and properly labeled, and dispose of any cleaning solutions promptly after use. If a companion animal has ingested or spilled a cleaning product or disinfectant on itself, it is very important to assess the potential hazard to the animal promptly. Many products contain warnings regarding the corrosive or irritation potential of the product and instructions on the label for preliminary action in the case of accidental oral, dermal, or ocular exposures in humans. These instructions can generally be followed initially until further information on the product can be obtained, although the recommendations on some product labels may be outdated. In general, the clinical management for toxicoses caused by cleaning products and disinfectants involves the prevention of further contact with the concentrated product through either dilution or bathing; emergency stabilization of the patient if clinical signs are present; instituting specific therapies, if available; and use of general supportive care.

Button battery ingestions

Although ingestions of button batteries can have serious complications, the majority of these ingestions will be benign. Button batteries that lodge in the esophagus should be removed immediately by endoscopy. Other ingestions can be managed with observation at home unless symptoms develop. Weekly radiographic examinations should be done to follow the progression of the button battery in these patients. The expected threat of mercury toxicity has not materialized. Patients who ingest mercury-containing button batteries should undergo chelation therapy and monitoring of levels only if symptoms characteristic of mercury toxicity develop. Cathartics and water-soluble enemas, although not indicated for intact button batteries, may be useful in speeding transit of mercury if it is released into the bowel. Other metals present in button batteries appear to pose no health threat.

Comparison of titratable acid/alkaline reserve and pH in potentially caustic household products

Exposure to caustic agents is a common problem, affecting thousands of individuals annually. Despite this incidence, the factors responsible for the production of injury remain poorly defined. Although extremes of pH seem to correlate well with the production of esophageal lesions, pH alone fails to explain the damage resulting from exposure to agents with near neutral pH, such as soldering flux containing zinc chloride. We determined titratable acid/alkaline reserve (TAR) in 38 potentially caustic household agents. A subset of these products was evaluated in an in-vitro canine esophageal model to determine whether TAR correlated with esophageal injury. The results indicate that for the products evaluated TAR correlated better than pH with the production of caustic esophageal injury.