A Patient with

Caustic
Ingestion Injury

Brinna Anindita
Budi Widodo

Department of Internal Medicine

Dr. Soetomo Hospital – Airlangga Faculty of Medicine Surabaya 2018
 Background
 Accidentally or voluntary

 High mortality

 Immediate or late complication

 Different injury depends on the substance

 The incidence of corrosive ingestion is high and

largely unreported in developing countries, where
prevention is lacking.
 Case
Identity  Foto klinis pasien

 Mrs. A

 Female

 36 y.o

 Surabaya

 Housewife
 HISTORY
Chief complain:

 Blackish vomiting about 4 times after drinking

substance to clean the bathroom floor (brand WPC).

 When in the ER patient continued to vomit about 3

times.

 According to her husband, the patient did this to

commit suicide due to their domestic problems
 Physical Examination
anemia (-)
GCS456, somnolent ict (-)/ cyan (-)
/dysp (+)
Vital Sign:
BP 160/80 mmHg Within normal
Pulse 124 bpm limit
Resp rate 28 tpm
Axillary temp 36,70 C
SpO2 97 % Within
normal limit

Within
normal limit
Laboratory Finding
CBC Chemistry Panel ABG
Hb 13,5 BUN 7 pH 7,34
HCT 39,9% Scr 0,64 pCO2 31
MCV 82,9 GDA 164 pO2 203
MVH 28,1 Alb 4,64 HCO3 16,7
MCHC 33,9 SGOT 14 BE -9,1
leuco 12.210 SGPT 11 SO2 100
Gran 72,2 HbsAG NR t 37
PLT 414.000 Na 145
K 3,4
Cl 113
Supportive Examination
 Cor: within normal
limit

 Pulmo: within normal

limit
Supportive Examination
Early Assesment :
• Hematemesis ecIntoxication of caustic substance
and tentamen suicide

Initial Therapy
• Patient was temporarily fasted, infusion of Nacl
0.9% 21 tpm, pump omeprazole 8 mg / hour,
injection of dexamethasone 3 x 1 ampoule
intravenously, orally sucralfat 3 x 1 tablespoon

Consultation with Psychiatry :

• Psychoeducation
• Psychotherapy
Blathford score in this patient was : 2
Rockall score in this patient was : 3
Both score concluded that this patient has high risk of
rebleeding and mortalities.

(Mokhtare, et al, 2016, Shahrami, 2018)

2nd day of treatment :

 Cito endoscopy was performed on patients

 Multiple erythema
appeared in the cavum
oris

 There were erythema

and lacerations in the
oropharynx and
hypopharynx

 Epiglottis looks
edematous
 The proximal to distal
esophagus appeared
hyperemic.

 There were lacerations

 Grade II B ulcers
 Gaster Mucous
appeared to be covered
with blood clots,
including multiple
erythema, lacerations,
and ulcers, with
necrosis in the pre-
pyloric region.
 Discussion
 The degree of injury is determined
 Degree to which it could cause corrosion,
 Amount consumed or its concentration
 State (solid or liquid)
 Time of contact with the gastrointestinal (GI) mucosa

(Park Kyung, 2014)

 Mechanism of Action
Alkali Acid
 Causes liquefaction necrosis.  coagulation necrosis.

 Protein dissolution  Hydrogen (H+) ions

desiccate epithelial cells
 Collagen destruction, producing an eschar
Hemorrhage, thrombosis, and inflammation with oedema
are the dominant processes during the first 24 hours
 Fat saponification,  Edema
following ingestion
 Cell membrane  Erythema, mucosal
emulsification, sloughing,

 Submucosal vascular  Ulceration and necrosis of

thrombosis and

 Cell death

(Naik & Vedivelan, 2012; Park Kyung, 2014)

Time Manifestation
Minutes to hour Bleeding, thrombosis, inflammation,
edema
Ulceration
(risk of perforation when ulcer
reaches muscle layer)

Day 4 Fibroblast initiating wound healing

Week-2 Deposition of Collagen

Ongoing Continuous ulceration due to traumas
provoked by food which disrupt
wound healing

. (Contini & Scarpignato, 2013).

 The role of EGD
 Esophagogastroduodenoscopy is a sophisticated and
sovereign method for diagnostic evaluation of acute
corrosive poisonings and injuries of the upper
gastrointestinal tract

 The most optimal timing for

esophagogastroduodenoscopy is the first 12 – 24 hours
following corrosive ingestion

 Diagnostic evaluation and staging

(Chibishev, et al, 2011)

 The Role of EGD
 The presence of lesions

 The severity of lesions

 The extent of the lesions by considered area

 The topographical distribution in the upper digestive tract

 The presence of objective evidences correlated to the risk of

perforation.

 Endoscopy should be always performed in all patients in whom the

ingestion of caustic in large amount or strong concentration is sure
or at least suspected

 About 20% of them could have visceral lesions without any oral
pathological finding

(Rossi, 2015).
Cito endoscopy was performed on patients and grade II B
esophageal injury, erotion of pangastritis, and gastric ulcer were
obtained

(Naik,&Vedivelan, 2012)
 Management
 Immediate resuscitation

 Damage evaluation

 Neutralizing agents
Therapy: Injection of Methylprednisolon 3 x 62, 5 mg, injection
 Nasogastric tube 2 x 1 gram intravenously, Total Parenteral
of ceftriaxone
Nutrition, orally sucralfat 3 x 1 tablespoon.
 Gastric acid suppression and mucosal protection

 Antibiotics

 Steroids

 Triamcinolon

(De Lu Song MAA, et al, 2017)

 Prognosis
Prognostic factors include

 Degree of tissue injury

 Underlying condition of the patient.

 Most deaths occur because of complications such as

mediastinitis and peritonitis

 Chronic complications include stricture, squamous cell

carcinoma, and a decrease in lower esophageal sphincter
pressure, which leads to reflux esophagitis, esophageal
motility disorder, intractable pain, gastric outlet
obstruction, acidity, and protein losing enteropathy.

(Contini & Scarpignato, 2013)

 Summary
 It has been reported a patient with caustic ingestion
injury.

 Endoscopy done within 12 hours and no later than 24

hours

 Patients with grade 3b burns on endoscopy have high

the risk of perforation and complications.