Home-Made Tooth Whitener: An Unusual Cause of Dysphagia

Abstract

A 54 yo female with a history of presumed reflux that did not improve despite being on omeprazole 40mg daily was evaluated for a several month history of worsening dysphagia to solids only. An upper endoscopy showed diffuse proximal esophageal fibrosis with two rings that caused moderate to severe obstruction in the proximal and middle esophagus. Balloon dilation using a 6-7-8 mm dilator was required to traverse the stricture. The rest of the esophagus also showed extensive scarring and trachealization with minimal to completely absent peristalsis. Biopsies showed benign squamous mucosa with focal mild acute inflammation and was negative for features of eosinophilic esophagitis, dysplasia, malignancy and organisms. No obvious risk factor or etiology were identified. She denied any history of radiation. Chest CT was negative for extrinsic pathology. On further questioning the patient admitted to using a diluted form of cleaning bleach to whiten her teeth. She reported using this concoction for the past 6-8 months several times per week. Due to resultant burning in the mouth she would subsequently swallow this solution. The patient is currently undergoing twice monthly dilation of her esophagus with mild improvement in her dysphagia. House hold bleach is a strong alkali with a pH of 12 to 13, depending on the strength, that usually contains approximately 5.25% sodium hypochlorite. Bleach ingestion has been rarely reported to cause severe esophageal injury. Considering absence of other causes in our patient we construed that the repetitive ingestion of small amounts of bleach over time caused esophageal injury which likely lead to fibrosis and eventual stricture formation. In some severe cases of alkali ingestion esophageal stent placement or even esophagectomy may be required. In addition patients who suffer esophageal damage from alkali ingestion have an increased risk of corrosive-induced carcinoma (CIC) that can be as high as 1000 fold. However, no official guidelines for the surveillance of CIC have been established. On review of the literature no cases like this have been reported. This practice may potentially be more prevalent in our region and lack of awareness amongst patients may lead to more cases in the future. This case emphasizes the importance of history taking and highlights an additional risk factor for physicians to rule out amongst patients presenting with dysphagia and esophageal stricture without any obvious etiology.1713_A Figure 1. Esophageal Ring.1713_B Figure 2. Trachealization of the Esophagus.