Death from caustic ingestion:A case report

Rationale:Acute caustic ingestion from suicidal intent is not usual in emergency departments in developed countries.One of the substances commonly ingested by suicidal patients,phosphoric acid,tends to cause multi-system derangements.Patient’s Concern:A 41-year-old male patient presented with complaints of throat discomfort,severe generalized abdominal pain,and multiple episodes of hematemesis after ingesting a restroom cleaning solution.Diagnosis:Poisoning by acute caustic ingestion(containing<30%phosphoric acid and<4%ethylene glycol).Interventions:The patient was administered 50 mL of 8.4%sodium bicarbonate solution followed by an isotonic sodium bicarbonate solution running at 500 mL/h,a hyperkalemia kit,ceftriaxone,metronidazole,omeprazole,and atropine.The patient then underwent urgent hemodialysis.Outcomes:The patient suffered gastrointestinal bleeding as a result of local caustic injury.In addition,his course of illness was complicated by severe acidemia from high anion gap metabolic acidosis and deranged electrolytes(hyperphosphatemia,hyperkalemia,and hypocalcemia).He developed multi-organ failure and eventually demised.Lessons:The clinician needs to be mindful of the multi-system complications arising from such a caustic ingestion.These patients need to be monitored closely for deterioration,and have prompt management of the various arising complications,to reduce the high morbidity and mortality associated with this condition.

Management of esophageal caustic injury

Ingestion of caustic substances and its long-term effect on the gastrointestinal system maintain its place as an important public health issue in spite of the multiple efforts to educate the public and contain its growing number. This is due to the ready availability of caustic agents and the loose regulatory control on its production. Substances with extremes of pH are very corrosive and can create severe injury in the upper gastrointestinal tract. The severity of injury depends on several aspects: Concentration of the substance, amount ingested, length of time of tissue contact, and p H of the agent. Solid materials easily adhere to the mouth and pharynx, causing greatest damage to these regions while liquids pass through the mouth and pharynx more quickly consequently producing its maximum damage in the esophagus and stomach. Esophagogastroduodenoscopy is therefore a highly recommended diagnostic tool in the evaluation of caustic injury. It is considered the cornerstone not only in the diagnosis but also in the prognostication and guide to management of caustic ingestions. The degree of esophageal injury at endoscopy is a predictor of systemic complication and death with a 9-fold increase in morbidity and mortality for every increased injury grade. Because of this high rate of complication, prompt evaluation cannot be overemphasized in order to halt development and prevent progression of complications.

Cardiac arrest due to massive aspiration from a broncho-esophageal fistula: A case report

BACKGROUND Tracheo and broncho esophageal fistulas and their potential complications in adults are seldom encountered in clinical practice but carries a significant morbidity and mortality.CASE SUMMARY We present a case of a 39-year-old otherwise healthy man who presented to our hospital after ingestion of drain cleaner substance during a suicidal attempt.He unexpectedly suffered from cardiac arrest during his stay in the intensive care unit.The patient had developed extensive segmental trachea-broncho-esophageal fistulous tracks that led to a sudden and significant aspiration event of gastric and duodenal contents with subsequent cardiopulmonary arrest.Endoscopic evaluation of extension of fistulous track proved a slow and delayed progression of disease despite initial management with esophageal stenting for his caustic injury.CONCLUSION The aim of this case presentation is to share with the reader the dire natural history of trachea-broncho-esophageal fistulas and its delayed progression.We aim to illustrate pitfalls in the endoscopic examination and provide further aware-ness on critical care monitoring and management strategies to reduce its morbidity and mortality.

Gastric transposition as a valid surgical option for esophageal replacement in pediatric patients:experience from three Italian medical centers

Background:Esophageal replacement in children is an option that is confined to very few situations including long-gap esophageal atresia and esophageal strictures unresponsive to other therapies(peptic or caustic ingestion).The purpose of our work was to describe the experience of gastric transposition in three Italian centers.Methods:This is a retrospective study.The data were extrapolated from a prospective database.We included all patients who had undergone gastric transposition in the last 15 years.Results:In the 15-year period,eight infants and children(3 males and 5 females)underwent gastric transposition for esophageal replacement.Six patients had long-gap esophageal atresia,and two had caustic esophageal stenosis.There were no deaths in the series.Three patients had an early postoperative complication:two had a self-limited salivary fistula at three weeks,and one(a patient with jejunostomy)had a jejunal perforation treated surgically.One late complication,anastomotic stricture,was recorded that required two endoscopic dilatations.The median follow-up was 60 months(range:18–144 months).At final clinical follow-up,six patients had no eating problems,and two patients had some difficulties with eating(jejunostomy in situ),but they underwent logopedic therapy with improved outcomes.All patients had an increase in body weight and height postoperatively.Conclusion:Our small study reports the clinical experience of three Italian centers in which gastric transposition was performed with excellent results,both in terms of surgical technique(simplicity,reproducibility,complication rate)and clinical follow-up(good oral feeding of young patients,normal social life and regular growth curves).