Case study – Ingestion of a drain cleaner: what are the consequences?

The patient and her story

The 58-year-old woman dissolved half a bottle of pipe unblocking tablets in a glass of water and drank them, she said, to attract attention. When she arrived at the emergency department of Cologne University Hospital, her vomit contained blood and she had symptoms of shock and severe chest pain, the emergency physician and her colleagues reported.

Clinical picture and first measurements

• In the trauma department, the patient was awake, but had hypotension and tachycardia (blood pressure 90/70 mm Hg, heart rate 110/min), continued to vomit mucus, slightly stained with blood, and felt severe pain.
• Hoarseness of voice, drooling, progressive swelling of the upper and lower lips.
• Lesions of the oral mucosa, swelling of the epiglottis and arytenoid cartilages during videolaryngoscopy.
• Gastroscopy: extensive detachment of the mucous membrane of the esophagus and stomach with the presence of areas of necrosis extending to the duodenum.
• CT scan of the chest and abdominal cavity: edematous changes in the pharynx and larynx, as well as the walls of the esophagus and stomach.
• Suspicion of aspiration pneumonia.

Evolution

• Intensive care, including ventilation and parenteral nutrition, and antibiotic treatment with piperacillin/tazobactam.
• Transfer to regular service in five days.
• Continued opiate analgesia due to severe chest pain.
• Approximately 14 days after the incident, resumption of oral hydration, careful diet for several weeks.
• Due to increasing dysphagia and progressive chest pain, repeat endoscopy two months after the incident: from the junction of the hypopharynx and esophagus, long-term stenosis with fibrin deposits and still pronounced inflammation.
• According to the authors, it was not possible to penetrate the stricture using a standard endoscope (about 8 mm in diameter).

Discussion

As Victor Suarez and his colleagues explain, accidental ingestion of corrosive household substances is most often observed among children. In adults, this is usually a suicide attempt. The main component of pipe unblocking granules, in addition to aluminum shavings, is sodium or potassium hydroxide. When water was added, these substances formed a very caustic lye of soda or potash. In addition, the oxidation of aluminum leads to a strong release of heat.

When ingested, both reactions caused thermal and chemical burns with the formation of so-called liquefaction necrosis. Contact with acids causes coagulative necrosis, in which the coagulated layer prevents the progression of the lesion. With liquefaction necrosis, tissues liquefy like jelly, saponification of subcutaneous lipids occurs; the injury extends to deeper layers of tissue, and this process can last a long time. Therefore, initially it may have a superficial effect, but then can penetrate into deeper layers of tissue.

The main clinical symptoms of esophageal/stomach lesions caused by unblocking products are vomiting blood and very severe pain in the throat and chest.

However, symptoms and possible visible burns usually do not correlate well with the degree of damage to the esophagus/stomach, especially in children. That is why the emergency doctor and his colleagues recommend that if you suspect oral poisoning with a product, clean the pipes and perform a gastroscopy quickly, even in the absence of external signs.

Emergency consultation

According to the authors, the face, mouth and eyes should be washed immediately with plenty of water. In conscious patients, an attempt should be made to continue to flush out any granules still present in the esophagus with drinking water. However, the usefulness of a gastric tube is controversial due to the risk of perforation. Under no circumstances should you induce vomiting. A quick gastroscopy is indicated to try to remove toxins and assess the extent of the burns. Because glottic swelling can also occur with the risk of life-threatening airway obstruction, indications for intubation should be made as early as possible. General use of cortisone in adult patients is not recommended. In children with moderate chemical burns, 3 days of cortisone therapy reduced the occurrence of strictures, but long-term steroid treatment is also not recommended in pediatric patients.

This case study was originally published on Univadis.de.