Acid ingestion - Forum

[Dottore]

I like to know your opinion about this case. Yesterday was admitted
a 60 years old woman who drunk , 6 hours later, 2 cups of HCL. She
arrived by helicopter from another hospital where was performed
endoscopy and gastric washing via NG tube. he was in shock and plain rx
demonstred free air in abdomen. My partner and i performed a large
transverse laparotomy and we found necrosis extending from cardias to
the 2nd jeunal arcade. We drained abdomen and closed. Any suggestion?
Had you tried to perform an extensive demolition with duodenostomy,
esofageal stapling,cervical esofagostomy and feeding jeunostomy?

[Jorjo]

If the patient recover stability Iwould reoperate promptly and do " multiple
stomies " included an terminal oesophagostomy .
Acid is generally not fatal as alcaline ,but This case seems to be very grave.

[Surgeon]

The case sounds horrible, and the survival of the patient is
unlikely. Did you leave the necrotic stomach, or duodenum or jejunum
behind? With the all of those dead organs still in the peritoneal
cavity, I believe that survival is impossible. I have never seen this,
but I would probably have resected anything that looked dead, and if the
patient made it, reconstructed at another time.

[Schom]

She was dead when you opened her up. You forgot to mention the need for a
Whipple in your list of "needed" procedures.

You took the right decision in not undertaking futile operation and
postoperative care.

[Hans]

When I worked amongst and Indian community in Durban there were a couple of
cases of total oesophageal necrosis from such an event - I was not involved
personally but the surgeon used a vein stripper to remove the oesophagus,
and did a cervical oesophagostomy and gastrostomy. They both survived. In
my own experience I haven't seen anyone survive a perforation - (neither of
these patients had yet perforated). If she stabilises I think you must take
her back ASAP to remove the dead tissue - but delay any reconstruction until
much later.

[Grandpa Phil]

Any advice is irrelevant: she has a fatal injury, and has succeeded
in what she set out to do. We have had one such perforated extensive
case, which died rapidly of multiple organ failure.
For interest, I enclose our recent experience with acid ingestion.
David

INGESTION OF BATTERY ACID:
A SPECTRUM OF DISEASE AND MANAGEMENT.
E Panieri, R Roberts, C Young*, D M Dent
Department of Surgery and Radiology*, University of Cape Town Medical
School and Groote Schuur Hospital, Observatory 7925, Cape Town.

Background. Battery acid ingestion may cause complex upper
gastro-intestinal lesions. Management remains controversial with
regard to initial investigation, immediate / delayed surgery, and type
of surgery performed. We examined causation, and optimal management in
our patients. Patients and methods. We prospectively analysed all data
relating to patients presenting to our unit with acid ingestion over a
14 month period [March 1997 - April 1998]. Results. There were 25
patients (all black, 17 male, 8 female; mean age 25 [15 - 40] years).
The psychological backgound to ingestion varied: two patients reported
accidental ingestion, and in 23 it was a para- or suicidal attempt.
The commonest precipitating event was a stressor such as a break with
a girlfriend, marital discord or financial difficulty. Two patients
subsequently required psychiatric institutionalisation, one was
referred for alcohol rehabilitation, and the remaining 22 received
counselling. Early clinical features correlated poorly with the
severity of injury: all reported dysphagia, most salivary
regurgitation and 4 had epigastric tenderness. One patient developed
emphysematous gastro-duodenitis a week after admission. Endoscopic and
barium meal evidence of damage was evident in 23 on admission: damage
of the oesophagus (12), proximal stomach (22), antrum (21), duodenum
(14). With expectant management (all had liquid supplement, and some
TPN), at a month, 16(66%) had no, or minimal, residual disease and and
did not require intervention. Strictures requiring intervention had
developed in 8(33%) patients: the oesophagus (1), entire stomach (2),
antrum (6), duodenum (4), and jejunum (2). Surgery was performed in 8
patients at a mean of 33 (9 - 62) days. These were (singly or in
combination): oesophageal dilatation (1), laparotomy and feeding
jejunostomy (1), oesophagogastrectomy (1), total gastrectomy (2),
antrectomy (4), gastro-juojenostomy (1) and limited jejunal resection
(2). Morbidity occurred in 2(missed jejunal stricture, pneumothorax
related to central line insertion), and there was no mortality.
Conclusion. Battery acid ingestion was a result of psychological
problems found predominantly in young black patients. Management was
best achieved expectantly, awaiting the site and degree of
cicatrisation, thus sparing surgery in 66% of cases. Stricture
formation complicated a third of cases, frequently but not invariably
the antrum, requiring resection of differing strictured sites. This
suggested that acid ingestion was a spectrum of injuries which
required a spectrum of differing managements.

[Sweden surgeon]

We see a lot of these non- accidental muriatic acid poisonic cases during
the months of Nov. - December (not sure why these months in particular). It
depends on the amount of acid they have injested. If possible, we scope them
to assess the extent of esophageal injury, including the stomach. If patient
presents with an acute abdomen or pneumoperitoneum, then he goes to the OR
after resuscitation. Usually, on openning, the whole esophagus and stomach
is black and necrotic. If this is so, we do an esophagogastrectomy
(transhiatal), cervical esophagostomy, close the duodenum, tube j. Postop,
patient is started on nutritional upbuilding for a colon reconstruction 3
months later. Psychiatric evaluation is also important. The problem is when
the necrosis extends up to the duodenum, jejunum. I have seen 2 of these
where a pancreaticoduodinectomy was needed to remove the burned duodenum and
head of pancreas. A tube was left in the gallbladder, pancreatic duct and
jejunum for feeding. Patient was able to go home but was lost to followup.
The other died in our ICU.

[Loit]

I have had very limited experience with patients with acid ingestion (only one patient in 14 years..). Your abstract (and experience!) really impressed me!