A Rare Case Report of Severe Isolated Pre Pyloric Stenosis Developed Forty Days after Accidental Lye Ingestion

Abstract

Introduction: Lye is an alkali tends to cause a more uniformly severe mucosal injury to the esophagus and limited gastric injury as its action is buffered by acid of gastric mucosa. We report a rare case of isolated severe pre pyloric stenosis without formation of esophageal stenosis developed forty days after accidental lye ingestion. Case report: 76 year old female with past medical history of dementia, hypertension, diabetes mellitus, hypothyroidism and accidental lye ingestion forty days ago subsequently developed grade 2B esophagitis, gastritis, erythematous duodenopathy and multiple non-obstructing duodenal ulcers on initial endoscopy (Picture 1) on day 2 of lye ingestion found to be improved on follow up endoscopy on day 14 (Picture 2) then eventually resumed on oral feeding; discharged to subacute nursing home facility. She presented on day 40 with complaint of intermittent nausea and non-bloody post-prandial vomiting for approximately 1 week. Patient denied any fever, dysphagia, abdominal pain and diarrhea. Vital signs on presentation were within normal limits. Physical examination was unremarkable for any swelling in neck and benign abdomen with active bowel sounds. Laboratory results were unremarkable. Patient was kept NPO, started on intravenous fluids and proton pump inhibitors. Barium swallow was done which showed poor transit across the antrum and pylorus. Endoscopy was done which showed moderately severe reflux esophagitis, a large amount of food in the stomach, scar in the gastric antrum and severe intrinsic pre pyloric stenosis. We were unable to advance endoscope or place a PEG tube safely (Picture 3). Eventually patient was started on total parental nutrition and prepared for gastrojejunostomy. Discussion: Acid is said to “lick the esophagus and bite the pyloric antrum”, alkali tends to cause a more uniformly severe mucosal injury to the esophagus and limited gastric injury. Isolated pre pyloric stenosis without esophageal stricture formation is the rarest complication of lye (alkali) ingestion most commonly occurs 6 to 12 weeks after initial ingestion but it may appear even after several years. Gastric stenosis most frequently found after acid ingestion although some cases of gastric stenosis have been reported after alkaline ingestion. Diligent follow-up after lye ingestion is advised to ensure patient has satisfactory gastrointestinal function restored and to correct late onset complications.Figure 1Figure 2Figure 3