Ingestion of caustic substances: a 15-year experience

OBJECTIVE

The objective of this study was to analyze the circumstance, demographic features, clinical findings, and complications of caustic ingestion in relation to the type and amount of caustic substance.

STUDY DESIGN

The authors conducted a retrospective cohort study in a tertiary medical center.

METHODS

The authors reviewed medical records from 1988 to 2003 of patients with a history of caustic ingestion and clinical signs of injury to the aerodigestive tract. Parameters examined included age at presentation, gender, demographic status, nature of the caustic substance ingested, amount of substance, circumstance of the event, diagnostic tools, degree of injury, and anatomic distribution of the injury, early and late complications, and requirement for ventilatory support.

RESULTS

A total of 50 cases of caustic ingestion were identified (age range, 5 months-71 years). A biphasic distribution of the patients was noted; half were children under 5 years old and the remainder was adults. The most common caustic agent ingested was alkaline (42%) followed by acidic (32%) and chlorine bleach (26%). The most frequent cause for ingestion was accidental (67%) as opposed to attempt suicide (33%). All cases of attempted suicide occurred in adults. Most of them reported ingestion of large amounts of caustic substance. In the pediatric group, an association between the caustic agent and ethnicity was observed. Among Jewish children, alkaline cleaning agents were the most common cause (82%). Acetic acid was the most common substance ingested by the Arab children (100%). The findings of rigid esophagoscopy in 36 patients were as follows: first-degree esophageal injury in 16 (44%), second-degree in 6 (17%), third-degree in 7 (19%), fourth-degree in 6 (17%), and one (3%) was normal. Mucosal injury to the esophagus was worse in the acidic ingestion group as compared with the alkaline substance ingestion group with marginally statistically significant difference in the median degree of injury between the three types of ingested substances (P = .054). Mucosal injury to the esophagus was worse among patients who attempted suicide as compared with accidental ingestion with a statistically significant difference in the median degree of injury between the two reasons for ingestion (P = .002).

CONCLUSION

Severity of injury from caustic ingestion damages depend on the type of ingested substance, which varies depending on ethnicity. Ingestion of caustic agents by children involves specific substances according to the season, cultural and religious festivals, and ethnicity. The majority of adult cases are intentional with more serious injuries and a higher rate of complications. In our series, ingestion of acidic substances and ingestion associated with suicide attempt had the most severe consequences.

Management of esophagogastric corrosive injuries in children

There has been an increase in the number of patients admitted to our hospital with caustic esophageal injuries during the last five years. The aim of this study was to analyze the complications and results of the treatment of corrosive esophagogastric injury. Between 1990 and 2000, 120 caustic ingestion accidents were admitted to our unit. The mean age was 4 years, with a 2 : 1 male to female ratio. The average time between the caustic ingestion and admission to hospital was 14.9 days. The ingested substances were alkali in 80.9 % and acid in 19.1 % of the cases. Stenosis of the esophagus developed in 31 (25.8 %) and gastric outlet obstruction (GOO) in 6 (5 %) patients. Management of the esophageal stricture consisted of dilatation in 28 patients. Three children underwent colonic interposition without a dilatation attempt. Six children were lost to follow-up; 4 patients were successfully treated; 13 patients were still in the dilatation program at the time of writing with 6 improving and 2 patients waiting for interposition surgery; 4 patients underwent colonic interposition and 1 patient underwent resection of the stenotic part of the esophagus. Among the patients in the dilation program, we observed 4 esophageal perforations. Three of them were treated medically and further dilatations were carried out, while one was managed by colonic interposition. The treatment modalities for GOO cases consisted of pyloroplasty in 3, Billroth I in 2 and balloon dilation of the pylorus in 1 child. Although balloon dilatation of the esophagus carries the risk of perforation, it should be the first line of treatment in suitable cases. GOO cases may require surgical therapy following a detailed endoscopic evaluation.

Caustic esophageal strictures in children: 30 years' experience

Many children in developing countries continue to sustain caustic esophageal injures. The first line of treatment is dilatation, unless contraindicated, where 60% to 80% success rate is expected. In cases of failure, esophageal replacement is the only hope for achieving normal swallowing. Over the last 30 years, more than 850 cases of esophageal replacement were done in the Pediatric Surgery Department at Ain-Shams University. Three types of replacement were performed, gastric pull-up (75 cases), retrosternal colon replacement (550 cases), and, in the last 12 years, transhiatal esophagectomy with posterior mediastinal colon replacement (225 cases). Complications in the last 475 cases include 10% cervical leakage, 5% proximal strictures, 2% postoperative intestinal obstruction, 1% mortality, and 0.6% late graft stenosis. Colonic replacement of the esophagus is the ideal treatment in cases of caustic esophageal strictures after failure of dilatation. The posterior mediastinal route is shorter, and in long-term follow-up results show improved evacuation and less reflux than with the retrosternal route.

Elective surgery for corrosive-induced gastric injury

Gastric cicatrization is a well recognized late sequela of corrosive gastric injury, but the optimum timing and type of surgery for this complication are still unclear. Over a 7-year period (1988-1994) 34 patients underwent elective surgery for gastric lesions secondary to corrosive ingestion. A total of 18 (53%) patients had an associated esophageal stricture and presented with dysphagia, 15 (44%) patients had features of gastric outlet obstruction, 6 (18%) had diffuse gastric injury, and 28 (82%) had a segmental lesion. A tube jejunostomy was done in 23 (68%) patients to improve nutrition and resulted in a significant increase in weight and in the serum protein level after 8 weeks of tube feeding. Elective surgery was performed 3 to 24 months (average 7 months) after ingestion of the corrosive substance. Gastric resection was done in 20 (59%) patients and gastrojejunostomy (without vagotomy) in 11 (32%); at follow-up the latter group did not exhibit development of a stomal ulcer. In patients with an associated esophageal stricture, endoscopic dilatation was successful in 89% patients and simplified the surgical approach. In conclusion, the success of surgery for corrosive-induced gastric injury depends on selecting the right procedure and intervening at the appropriate time.

Corrosive injuries of the oesophagus and stomach: experience in management at a regional paediatric centre

In a 21-year period between June 1974 and May 1995, eight children required surgery for the treatment of complications after ingestion of corrosive substances. There were six oesophageal injuries due to alkali ingestion and two gastric injuries secondary to acid ingestion. Of those ingesting alkali, diagnosis of stricture was made at a mean of 28 days and all children underwent endoscopic dilatation with a mean of six treatments (range 2-13). Two children subsequently required oesophageal replacement and colonic interposition. One of the children ingesting acid presented as an emergency with peritonitis and required laparotomy at which partial gastrectomy and pyloroplasty were performed. The second child presented 3 weeks after ingestion with a gastric stricture and required gastrostomy. All children are currently alive and well and are asymptomatic. The details of management are discussed, together with a review of the literature.

Battery acid--an agent of attempted suicide in black South Africans

Over a 36-month period 27 black adults, who had taken battery acid in apparent suicide attempts, were admitted to a major South African general hospital for assessment and treatment. There were no deaths. Patient features included limited schooling, unemployment and a male/female ratio of 2.4:1. Triggers were minor to moderate stressors (mainly domestic arguments) in 23 patients. Nine had a diagnosable psychiatric disorder and 5 required further psychiatric hospitalisation following discharge from the general hospital. The reported high mortality rate from acid ingestion was not observed; however, 4 patients required surgical intervention to deal with stricture formation. The average duration of stay was 7.6 days. There were no repeat suicide attempts during the study period.

[Toxic contact dermatitis]

Two types of irritant contact dermatitis are described: the acute and the cumulative toxic contact dermatitis. The acute contact dermatitis causes many different lesions on the skin. The most frequent irritants are acids and alkaline solutions. Chemical burns by hydrofluoric acid are the most dangerous of all injuries caused by acids and need special treatment. Cumulative toxic dermatitis is often observed on the back of the hands and forearms after exposure of several weeks or months. Repeated skin contact by harmless products can also cause cumulative toxic dermatitis. Xerodermatitis is the most frequent type of cumulative toxic dermatitis. Phototoxic reactions of the skin are not caused by immunologic factors, and they are only observed at sun-exposed areas. Drugs can cause frequently phototoxic reactions. The lesions on the UV-A-exposed skin are mainly erythema and blisters.

Organic acids and bases: review of toxicological studies

Organic acids and bases are among the most frequently used chemicals in the manufacturing industries. However, the toxicology of only a number of them has been fully characterized, and for fewer still have occupational exposure limits been established. This paper reviews the acute and chronic toxicity data of the organic acids and bases, and considers the mechanism by which these chemicals produce their effects. A methodology for establishing preliminary occupational exposure limits based on the physicochemical properties of these chemicals is presented. Workplace exposure limits for 20 organic acids and bases which currently have no exposure guidelines are suggested. Advice regarding appropriate medical treatment of exposure to these materials is discussed.

Corrosive acid gastric stricture: a plea for conservative surgery

Acid ingestion is known to cause a corrosive stricture of the stomach. Subsequent metaplasia in the gastric mucosa has been noted and cases of malignant change shown to have occurred. Gastrectomy has, therefore, been advocated. A less radical approach of gastrojejunostomy with regular endoscopic follow-up is here recommended.

Acid ingestion in an experimental model

Following acid ingestion, the mortality of operative intervention is clearly related to late recognition of perforation. Experimentally, fiber-optic endoscopy can be used to accurately predict the depth of gastric injury. Operative intervention can be undertaken before gross perforation. Flexible endoscopy should be performed upon admission and repeated at intervals of 12 to 24 hours until one is satisfied that the injury is stable, reversible and will not progress. The risk of gastric perforation is minimal if the endoscopic procedure is performed by a competent individual. Continued careful medical follow-up examination and nutritional support is indicated when major damage to the stomach occurs to ensure that the patient will tolerate anticipated operative reconstruction.

The emergency management of caustic ingestions

In the emergency department, any patient who is suspected of having sustained a caustic ingestion must be handled in a serious manner. All patients should be initially stabilized with regard to airway and circulatory status. Initial questioning concerning the type and quantity of agent ingested will be most helpful. Signs and symptoms of shock, impending perforation, or airway distress take precedence over any further work-up. Patients who have a known history of ingestion require admission to the hospital. Complete physical examination should be carried out, bearing in mind that the lack of oropharyngeal involvement or other symptoms does not rule out the possibility of esophageal burns. One should avoid emesis and should begin early dilutional therapy. Water may be used initially to dislodge adherent solid particles, as well as to dilute the caustic ingestion. It is important not to be excessively aggressive with dilution, as this may cause nausea, vomiting, and possible aspiration. Early otolaryngologic evaluation will be most helpful. The role of early esophagoscopy has been demonstrated to aid greatly in determining the further management. This diagnostic procedure should be carried out within 48 hours after ingestion. Based on the information obtained with esophagoscopy, patients who have had moderate esophageal burns should receive 20 mg methylprednisone intravenously every eight hours if under the age of two and 40 mg intravenously every eight hours if over the age of two. When oral preparations can be used, 2 mg per kg of prednisone should be continued for three to four weeks. Antibiotic coverage should be reserved until the first sign of infection occurs.

Corrosive acid ingestion in man - a clinical and endoscopic study

Sixteen patients with corrosive acid ingestion were studied. The majority of patients (n = 10) had ingested sulphuric acid, and three other patients had ingested hydrochloric acid. The extent and severity of upper gastrointestinal tract injury was determined by fibreoptic endoscopy and necropsy. All the patients had oesophageal and gastric involvement but the duodenum was spared in the majority. The injury was not considered as mild (grade I) in any of these patients; five patients having moderate (grade II) and 10 patients having severe (grade III) injury. Complications and mortality occurred only in patients with grade III injury. Feeding jejunostomy for nutritional support was used in five patients (all grade III) with good results.

Potential occupational health hazards in the microelectronics industry

The microelectronics industry is a major user of a wide variety of chemicals and other toxic materials. In the recent past semiconductor manufacturers have located in many countries and brought a new set of challenging clinical problems to occupational physicians. California, an area with a significant history in the statistical study of health and safety in the microelectronics industry, presents some evidence of potential health hazards in the semiconductor manufacturing process. The Semiconductor Industry Study done in California in 1981 explains the application of many toxic materials in the semiconductor manufacturing process, including a variety of solvents, acids, and metals such as arsenic. The Study documents the extensive use of dopant gases, primarily arsine, phosphine and diborane. Further study is necessary to assure the health and safety of microelectronics workers, particularly in the application of dopant gases.

Acid ingestion: toxicology and treatment

The effects of strong acid ingestion are distinctly different from those of alkali. Strong acids produce superficial injuries to the esophagus and deep injuries to various portions of the stomach. Prevailing early treatment recommendations of simple dilution or weak-base neutralization are inappropriate because of their extraordinary thermal results. Dilution of concentrated sulfuric acid with an equivalent volume of water results in a temperature elevation of approximately 80 C. Neutralization results in even greater heat production. Vigorous gastric aspiration prior to cold fluid lavage is the management of choice in cases treated immediately following acid ingestion.

Corrosive injury to the stomach: the natural history and role of fiberoptic endoscopy

Most physicians recognize that the ingestion of lye is associated with severe esophageal damage. It is much less widely known that gastric injury is the predominant finding when acid is ingested. We are reporting on five patients who had severe gastric damage after ingestion of diluted sulfuric acid (three cases), capsules of potassium hydroxide, and Clinitest tablets (one case each). Fiberoptic endoscopy was used to localize the extent and severity of injury and to follow the evolution of the damage. The extent and location of injury varied with the amount and type of agent ingested. Acid ingestion resulted in severe gastritis, which eventually led to antral stenosis and gastric outlet obstruction requiring operative intervention in two cases. Potassium hydroxide capsules produced diffuse esophagitis, gastritis, and a non-healing large gastric ulcer. Clinitest tablets produced distal esophagitis and stricture and antral damage leading to gastric outlet obstruction which required operative intervention. These cases demonstrate the natural history of corrosive injury to the stomach and the value of fiberoptic endoscopy in the management of this problem.

Emergency management and sequelae of acid ingestion

Because it causes immediate pain when taken into the mouth, strong mineral acid is less often swallowed than corrosive alkali, but psychotic, inebriated or determined individuals may consume lethal amounts. Burns of the oropharynx and glottis may lead to asphyxial death. Acid has only superficial effects upon the esophagus but, upon reaching the stomach, flows along the lesser curvature, induces pylorospasm, and pools in the distal antrum. Pyloric stricture is the most common late complication among survivors. Due to the rapidity with which acid acts, local and systemic therapy must be expeditious. Neutralization and demulcification are recommended but no time should be lost if weak alkali is not readily available. Lavage has limited applicability and induced emesis is strictly contraindicated. Aggressive intravenous fluid therapy, antibiotics, and opiates for pain are needed in most instances. Immediate gastrectomy and steroids are controversial but operative intervention is eventually required following most significant ingestions.

Pediatric otolaryngologic crises

In the second article on pediatric otolaryngology, speed of diagnosis is stressed as vital to prevent permanent aftereffects such as deafness or facial paralysis. Aggressive education of parents in preventing emergencies is recommended.

Effect of hydrofluoric acid on glucose metabolism of the mouse studied by whole-body autoradiography

Distribution of radioactive carbon from [U-14C]glucose in the mouse poisoned by hydrofluoric acid has been studied by whole-body autoradiography. Under normal conditions, the highest autoradiographic density was found in the Harder's gland, palatine gland, sublingual gland, large intestinal mucosa, and many regions of the central nervous system 30 minutes after intraperitoneal injection of [U-14C]glucose. On the other hand, after hydrofluoric acid poisoning, it was found that (1) the radioactivity of brain was unchanged throughout all the poisoning; (2) the liver, renal cortex, lung, and blood showed an increase in radioactivity at 180 minutes of poisoning; (3) the abdominal cavity showed a tendency to residual radioactivity with the poisoning; (4) by contrast, Harder's gland, the palatine gland, sublingual gland, and large intestinal mucosa showed a decrease in radioactivity at 180 minutes of poisoning.

Acute corrosive oesophagitis

This paper concerns the diagnosis, pathology, and treatment of oesophageal injuries caused by swallowing acids or alkalis. The treatments recommended aim not only at saving life in the early phase but in preventing intractable stricture later on.

Dental erosion in industry

Five hundred and fifty-five acid workers were examined between March 1962 and October 1964. One hundred and seventy-six (31·7%) were affected by industrial dental erosion at the first examinations. In 33 cases (6·0%) the dentine was affected. During the period of the survey, 66 (20·4%) of 324 workers examined more than once showed evidence that erosion was progressing. The prevalence and incidence of erosion were highest among battery formation workers, lower among picklers, and least among other processes covered by the survey. The age of workers did not appear to influence their susceptibility to erosion. The habit of working with the lips slightly parted had little effect. Erosion superimposed upon attrition predisposed to more severe loss of tooth structure than either operating alone. Little inconvenience or functional disability was suffered by acid workers due to erosion. Twenty-seven (23·7%) of 114 erosions were considered to be disfiguring. Regular dental treatment was sought less by acid workers than by controls, and the oral hygiene of the latter was superior. There was no evidence to show any difference between caries experience among acid workers and controls. Calculus and periodontal disease were more prevalent among acid workers than among controls, but it was not possible to attribute this to the working environment. Black staining in iron picklers was considered to be due to the working environment. The use of closed acid containers or lip extraction on open acid vats prevented significant atmospheric contamination and diminished the prevalence of erosion. The use of wall fans and detergent foaming agents was helpful.

Tris buffer (THAM). An appraisal of its physiologic effects and clinical usefulness

It has been the purpose of this discussion to review critically the physiologic considerations and clinical evidence regarding the use of Tris buffer in the treatment of acid-base disorders. It is concluded that there is little current evidence, theoretical, experimental, or clinical, to support the view that Tris has a significant therapeutic role. Some possible exceptions to this general conclusion are considered.