Miralax Mix Up: A Case Report on Caustic Injury to the Esophagus

Abstract

Introduction: Ingestion of caustic agents causes a variety of injuries to the esophagus making management difficult. We describe an interesting case of ingestion of an unknown caustic agent and briefly discuss the current recommendations on diagnosis and treatment. Case Report: A 68-year-old Caucasian male presented with a 2 day history of painful swallowing after drinking what he believed was Miralax with water. The patient denied any recent antibiotic or steroid use. The patient’s past medical and surgical history is significant for congestive heart failure status post defibrillator, type 2 diabetes mellitus, coronary artery disease status CABG, bipolar disorder, tobacco abuse and polysubstance abuse. On evaluation, the patient’s vital signs were within normal limits. Physical exam was remarkable for scattered white patches on the surface of the oropharynx, which revealed a denuded area when removed by scraping with a tongue blade. Labs were significant for an elevated white blood cell count of 17,500. Basic metabolic panel was within normal limits. Examination by a fiberoptic nasolaryngoscope revealed burns of the oropharynx and hypopharynx. Esophagogastroduodenoscopy (EGD) showed severe diffuse esophageal injury (Grade 2A/2B) likely related to an inadvertent caustic ingestion. Patient was treated with a proton pump inhibitor drip and broad spectrum antibiotics. After several days, the patient was able to tolerate a clear liquid diet. He continued to improve clinically and was discharged on a soft diet with crushed medications. A follow-up EGD was scheduled for 8 weeks. Discussion: Ingestion of caustic agents occurs most commonly by accident in the pediatric population and as a suicide attempt in adults. These agents include both acidic and alkali chemicals commonly found in household cleaning products, which cause tissue injury resulting in both systemic and focal injuries. Most serious and long-term complications occur in the esophagus and include esophageal ulcerations, edema, perforation, strictures, and an increased lifetime risk for carcinoma. Presenting symptoms can vary from no symptoms to life threatening symptoms depending on the extent of tissue damage. Endoscopy should ideally be performed within 24 hours of ingestion. A 6-point grading system based on endoscopy findings is often used to predict clinical outcomes and treatment plans. Treatment is mainly focused on supportive care depending on the extent of injury and often includes gastric acid suppression and broad spectrum antibiotics until the patient recovers and complications such as strictures and perforations are treated.