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.
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.