This 65 year old man with a prior history of COPD, and HBP was admitted to the medical ICU 30 hours after consuming an unknown amount of a liquid sodium hydroxide based cleaner in an apparent suicide attempt. At transfer, he was acidotic with a serum pH of 7.1 and he was hypoxic requiring ventilatory support. A CT scan demonstrated a small amount of air in the perigastric region suggestive of perforation. Because he was too ill for surgery, we were asked to perform this upper endoscopy in hopes of defining the extent of injury and to leave a small drainage catheter. This upper endoscopy was performed with minimal air insufflation.
The tongue already shows signs of desquamation from the caustic lye injury. A brief view into the upper trachea shows the mucosa to be intact there. Very carefully the small caliber endoscope is passed into the upper esophagus. Here the full effect of the alkali injury is clearly demonstrated. The major difference between acid and alkali injury relates to the rapid tissue absorption of alkali through the mucosa into the deeper tissues producing liquefaction necrosis and a tendency for full thickness injury. Acid injury results in coagulative necrosis which may be more superficial. Through the esophagus and into the stomach, thrombosis and tissue sloughing is already evident. The injury seen here in the esophagus and the stomach is severe and can only be managed surgically. A drainage catheter was left with little expectation of benefit.
The patient died 24 hours later. Post mortem exam demonstrated extensive liquefaction necrosis of the esophagus and stomach with areas of full thicken injury.
Early management of caustic ingestions may include endoscopy to define the extent of injury and surgery to manage complications such as perforation. In general, endoscopy is contraindicated with CT evidence of perforation. The maximum extent of injury probably occurs within the first several hours of exposure and thus administration of neutralizing agents or emetics may be of no benefit or even harmful. There is no proven benefit for the use of steroids to reduce stricture formation or antibiotics to reduce infectious complications though both are used.
Alexandra Gutierrez, M.D., Massachusetts General Hospital