Like Vampires Drinking Holy Water – Part 1

When I read about the evils of drinking, I gave up reading.

Henry Youngman

Hello everyone!!! It’s nice to have you back with us…

Today we will talk about an event that may be a real emergency… For now, let’s start with the usual clinical scenario…

You are in your office reading a book. Obviously, you are on call… When are you not after all?!…

The beeper has been silent for the whole day, when, suddenly, it starts ringing.

It’s the ER doctor… He has a problem: a woman came in after having drunk bleach by mistake (at least this is what she said), and he does not know what to do.

You go to the ER. The woman seems quite fine, she complains of a retrosternal burn sensation on swallowing.

What to do now?

Introduction

Greetings… You guessed it right… Today we are going to talk about caustic ingestion… But, what is a caustic substance?

A caustic is a substance with the property of being able to burn, corrode and/or destroy organic tissue by chemical action. As reported in the image below, a caustic substance may be either acid or alkaline, and these elements may be either strong or weak.

Caustic ingestion may be accidental or the consequence of attempted self-harm. The first case usually involves children (80% of the overall caustic ingestion population), whereas the second one is adults. Because of the reason behind the ingestion, in adults the quantity of substance swallowed is greater than in children, meaning more life-threatening injuries.

In the last few years, an increase in caustic lesions in children has been reported, and this is to be reconducted to the diffusion of the so-called pods, the laundry-detergent capsules, that have bright colors and are so attractive to small children.

Epidemiologically, caustic ingestion is more common in eastern countries compared to western countries.

Alkaline substances broadly account for more events in Western countries, whereas acid ingestion is more common in developing countries.

Strong acids or alkalis have higher destructive power than weak ones. However, the characteristics of acid and alkali are completely different, causing distinct effects. Usually, the destructive power of caustic substances appears in case of pH <3 or >11, when the tissue resistance falls, and the most extensive injuries are found if pH is <2 or >12.

The main differences between the two categories of caustics are reported in the following table…

Clinical Presentation

Caustic substances usually cause local injuries, without giving systemic consequences. However, some materials may be absorbed producing generalized problems. For example, hydrofluoric acid is able to ligate the ionized plasmatic calcium and magnesium causing severe hypocalcemia and hypomagnesemia. Moreover, alkali, if absorbed, may lead to thromboembolic events. However, strong acids can easily cause acute kidney injury, hepatic failure, thrombosis, and hemolysis. A small group of caustics, the peroxides (e.g. hydrogen peroxide at a concentration higher than 3%), in addition to the local damage to the membrane lipids due to the peroxidation, can generate large volumes of gaseous oxygen. This causes significant gastric distension and, in some cases, portal embolism which may require hyperbaric oxygen treatment.

For what concerns local injuries, the clinical presentation depends on the quantity, the quality, the physical form, and how much time has passed since the caustic substance ingestion.

• General – asymptomatic or oral, epigastric and/or retrosternal pain
• Laryngeal injury – shortness of breath, stridor, hoarseness
• Esophageal injury – dysphagia, odynophagia, sialorrhea
• Gastric injury – abdominal pain, vomiting, hematemesis
• Bowel perforation – abdominal pain, peritonism, tachycardia, leukocytosis, acidosis

Remember that asymptomatic patients are not excluded from severe injuries… They may not have manifested yet…

Interestingly, children with facial or oral signs of ingestion do not necessarily have gastrointestinal injuries, and vice versa. On the contrary, adults with oropharyngeal signs usually have upper gastrointestinal lesions. The reason behind this lies in the motive of ingestion (exploratory in children vs. intentional in adults).

Initial Management

A complete and accurate history of the event is the most important step to take. More information you have and the more you can calibrate your management. Do not forget to ask about the kind of substance ingested, the amount (<15 mL usually causes <grade 2 injuries, >30 mL causes >grade 2B), the physical form (e.g. liquid, solid, powder), why the patient drank it, and how much time has passed since the incident.

Generally, the clinical examination is negative, without any particular signs or symptoms. The patient may complain of mild pain at swallowing. Worrisome clinical features that must raise the suspicion of severe injuries are dyspnea, dysphagia, sialorrhea, and hematemesis.

Remember that the management of all these potentially critical patients must follow the ATLS protocol, similar to what happens in the management of upper gastrointestinal bleeding. Securing the airways may be mandatory in these patients. About 40% of patients who ingested caustic substances have respiratory tract injuries, and 5-15% of those presenting with dyspnea, stridor, and/or glottic edema need orotracheal intubation. Statistically, 12% of children require intubation, whereas about 50% of adults need it, and 21% of them are classified as having difficult intubation… Be prepared and keep a “plan B” by your side… A definitive airway should be placed at the first sign of a change in voice, stridor, inability to control oral secretions, or when there is any sign of possible impending airway loss.

Another important step to take is to maintain fluid and electrolyte balance, like what happens in burn patients. Hemodynamic monitoring may be useful in potentially critical patients.

Painkillers administered intravenously are needed in suffering patients.

Local measures such as gastric lavage or inducing vomiting are counterproductive, increasing the upper gastrointestinal and airway tract exposure to the caustic substance, thus worsening the local injury. Similarly, administering water or milk as measures to dilute the ingested are not effective. Neutralizing the pH is not a good idea because it may unleash exothermic reactions, creating more damage than benefits. The only exception is sodium hypochlorite: if there is a clear history of ingestion and if the amount drunk is known, you can try to use sodium thiosulphate, but you have to administer it within 30 minutes of ingestion.

Activated charcoal not only does not work with caustics, but it also makes it difficult for the endoscopist to evaluate any injuries.

The nasogastric tube (NGT) should be positioned under endoscopy guidance. Afterward, there is no consensus on how long it should be kept in place. Some authors advocate its use for 1-2 weeks to reduce the risk of stenosis needing endoscopic dilatations. For the same reason, some authors suggest the use of steroids to decrease collagen production and the development of stenosis. There is no evidence their use is really beneficial, though. The only confirmed indication to administer steroids is in the case of respiratory tract edema.

Antibiotics should be used in the case of steroid administration and/or suspicion of infection.

The use of Proton Pump Inhibitors and H2 inhibitors is controversial in the case of esophageal lesions, but some studies have demonstrated their effectiveness and they are still widely used.

Routine lab tests along with blood gas should be asked for. You should suspect severe injury if WCC >20’000/mm³, elevated CRP, pH <7.2, and BE <-12.

A chest x-ray should be done to exclude any kind of perforation: if pneumoperitoneum, suspect gastric perforation; if pneumomediastinum with/without pleural effusion, suspect esophageal perforation. In the case of suspected perforation, this may be confirmed by a Gastrografin swallow test followed by a chest and abdominal x-ray or by a contrast-enhanced thoracoabdominal CT scan.

Remember that all patients who ingested caustics in a suicidal attempt need a psychiatric evaluation.

Ok guys… That’s it for the moment… We don’t want to fill your heads with too much information…

Stay tuned for the conclusion of this epic journey…

Namastè…

References

1. Contini S, et al. Caustic injury of the upper gastrointestinal tract: a comprehensive review. World J Gastroenterol 2013;19:3918-30.
2. Bonavina L, et al. Foregut caustic injuries: results of the world society of emergency surgery consensus conference. World J Emerg Surg 2015;10:44.
3. Kluger Y, et al. Caustic ingestion management: world society of emergency surgery preliminary survey of expert opinion. World J Emerg Surg 2015;10:48.
4. Katz A, et al. Caustic material ingestion injuries – Paradigm shift in diagnosis and treatment. Health Care Current Reviews 2015;3:2.
5. Hoffman RS, et al. Ingestion of caustic substances. NEJM 2020;382:1739-48.
6. Zargar SA, et al. The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns. Gastrointest Endosc 1991;37:165-9.
7. Ryu HH, et al. Caustic injury: can CT grading system enable prediction of esophageal stricture? Clin Toxicol (Phila) 2010;48:137-42.

How to Cite This Post

Bellio G, Bacchion M, Ricci G, Marrano E. Like Vampires Drinking Holy Water – Part 1. Surgical Pizza. Published on November 26, 2022. Accessed on May 28, 2023. Available at [https://surgicalpizza.org/emergency-surgery/like-vampires- drinking-holy-water-part-1/].