Alkali Ingestion Research Articles

Intoxicación por cáusticos

There are discordant guides and protocols when it comes to treating a patient who has ingested a caustic substance. Different ideas or tendencies speak in favour of dilution, neutralization, provoking vomiting, carrying out stomach washes, etc., depending on the milieu where the problem arises: at home, at the health centre, emergency service or hospital. The same occurs with the type of diluent or neutralizing agent to be used, how and when to start the treatment pattern with corticoids and/or antibiotics and antisecretory, if indeed this is necessary. We have carried out an exhaustive bibliographical study, an experimental work and a study of the different diagnosis and treatment guides and protocols used in different Spanish hospitals. At the experimental level it was found that there are histopathological markers that advise against the use of diluent substances following the ingestion of caustic alkali. Except in the cases of ingestion of solid caustic substances -crystalline or granulated- categorical contraindications are given against dilution. Corticoids are not efficient when a caustic acid is ingested; their use is more than questionable following the ingestion of caustic alkali. Diagnosis and quality of treatment are based on endoscopy. There is no single criterion that defines which moment (the time following ingestion) is the most convenient for carrying this out, although the period between the first 6-12 hours is the most suitable. We present an independent protocol of diagnosis and treatment -in the form of algorithms- that must be followed after the ingestion of caustic acids or caustic alkali.

Tratamiento mediante dilatación endoscópica de las estenosis esofágicas cáusticas

To evaluate the results of endoscopic dilatation in caustic esophageal strictures and to analyze the factors associated with a favorable response. We performed a retrospective study of 33 patients who underwent dilatation with Savary bougie between 1989 and 2001. Response to initial dilatation and outcome during follow-up were analyzed. The mean age was 50 years (8-83) and 58% were women. Intake was accidental in 29 (88%). In all patients, the caustic substance ingested was alkali. Dilatation was started in the acute phase in 12 patients (36%) and 13 presented inflammatory phenomena adjacent to the stenosis. During initial dilatation, 2 1.6 sessions (2-18) were performed and a favorable response was obtained in 18 patients (54%). At the end of follow-up, 68% of the patients presented satisfactory health status. The comparative study revealed that statistically significant variables for a favorable response to treatment were: accidental alkali intake, instauration of treatment in the chronic phase, absence of inflammatory phenomena, and a small number of initial dilatation sessions. In our series, more than half the patients with esophageal stenosis due to intake of corrosive alkalis showed a favorable initial response. In these patients with acute-phase stenosis who required a greater number of initial dilatation sessions, endoscopic therapy was less effective.

The changing indications for paediatric tracheostomy

Objective: To investigate whether the incidence and indications for paediatric tracheostomy in this unit have changed over recent years. Methods: All paediatric tracheostomies performed between 1993 and 2001 were identified from our departmental database. The indications for these were ascertained by retrospective case note review. Results: Over the 9-year period studied 362 tracheostomies were performed, the number increased slightly between the first and second half of the period, with peaks in 1997 and 1999. The commonest indication was prolonged ventilation due to neuromuscular or respiratory problems. Conclusions: This large series shows that the increase in frequency of paediatric tracheostomy performed in this unit over the past decade has been due to conditions such as subglottic and tracheal stenosis, respiratory papillomatosis, caustic alkali ingestion and craniofacial syndromes. Conditions in which tracheostomy are now less common are subglottic haemangioma and laryngeal clefts. Prolonged ventilation remains the commonest indication overall.

Metabolic Alkalosis in a Hemodialysis Patient After Ingestion of a Large Amount of an Antacid Medication

A maintenance hemodialysis patient developed metabolic alkalosis in the absence of vomiting or nasogastric suction. The cause of the metabolic alkalosis was ingestion of an exogenous alkali in the form of Bromoseltzer. The metabolic alkalosis improved with hemodialysis using a low-bicarbonate bath.

The Role of Calcium in the Prevention of Kidney Stones

Nephrolithiasis is a common and important condition. Several lines of evidence suggest that increased urinary calcium increases the risk of kidney stones. Since dietary calcium raises urinary calcium, it has been common practice to reduce calcium intake in stone-formers who hyperabsorb calcium from the intestine, although no trial has yet been designed to directly demonstrate the effectiveness of calcium restriction.In contrast, some have suggested that calcium restriction may be harmful due to resultant hyperoxaluria and risk of bone loss. In fact, two powerful prospective observational studies have suggested that increased dietary calcium reduces the risk of the first kidney stone. However, calcium was not the only variable, since those with the highest quintile of calcium intake also ingested more fluid, potassium, magnesium and phosphate. Moreover, the otherwise thorough analysis was not adjusted for alkali intake, which may prevent stones, or oxalate intake, which may increase stone risk.Due to limitations in available data, future prospective studies should be designed to probe the effect of specific interventions with calcium, both dietary and supplemental, on urinary parameters and stone formation, particularly in hypercalciuric stone-formers, who may respond conversely. For now, dietary calcium should be gradually increased in stone-formers as guided by the urinary calcium, and hypocalciuric agents should be added as necessary.

Gastric outlet obstruction as a late complication of formaldehyde ingestion: a case report

A patient who ingested formaldehyde in a suicide attempt is described. Although early clinical and endoscopic manifestations appeared relatively mild, after several weeks the patient developed signs and symptoms suggestive of gastric outlet obstruction that eventually required surgical intervention. Formaldehyde ingestion has only rarely been described in the literature. Formaldehyde is a corrosive that can produce late sequelae, similar to the more common ingestion of acids and alkali.

Gastric outlet obstruction due to corrosive ingestion: incidence and outcome.

A retrospective clinical study was performed to determine the incidence, management, and outcome of gastric outlet obstruction (GOO) caused by caustic ingestion in children. Of 220 patients who sustained caustic substance ingestion and were treated at our unit between 1976 and 1996, 168 ingested alkaline substances; of these, 9 children (5.3%) developed GOO in addition to esophageal strictures. The remaining 52 patients ingested acid agents, and 2 of them (3.8%) presented with GOO without esophageal strictures. The overall incidence of corrosive GOO was 5% (n = 11). The mean age of the patients with GOO was 5.7 +/- 2.8 years (range 2-14) with a female:male ratio of 6:5. Sodium hydroxide (n = 6), potassium hydroxide (n = 3), and hydrochloric acid (n = 2) were the ingested caustic agents. The patients were subdivided into two groups according to serial endoscopic and radiologic findings: group I: moderate (dense superficial and spotty ulcerations with intact mucosa) mucosal injury with partial pyloric obstruction; and group II: severe (deep ulcerations, extreme hemorrhagic erosions, eschar formation with white plaques) mucosal injury with complete pyloric obstruction. Group I consisted of 5 patients who ingested alkali agents while group II included 6 who presented with ingestion of alkaline (n = 4) and acid (n = 2) agents. Surgical treatment included Billroth I (n = 6) operations performed in group II and Finney (n = 3) and Heineke-Mikulicz (n = 2) pyloroplasty procedures done in group I. All patients are alive without any complaints. Fiberoptic endoscopy should be the preferred method of evaluating a patient with ingestion of a corrosive agent. It determines the presence of injury and assesses the extent of damage, establishing the diagnosis and allowing therapy to be instituted immediately. Our experience revealed that substantial damage has occurred early after ingestion, and early surgical intervention has decreased the morbidity and mortality. The extent of the mucosal injury and status of the pylorus and antrum determined the type of surgical treatment. A Billroth I procedure recommended for severely injured mucosa with complete pyloric obstruction, and pyloroplasty for moderate mucosal injury associated with partially obstructed but still viable pylorus. In contrast to the current belief, alkali ingestion also has a high risk of corrosive gastric injury causing GOO, which should be considered during assessment of the injury. We emphasize that a detailed evaluation of radiologic and especially endoscopic findings is very important for determining the timing, necessity, and type of appropriate surgical treatment.

Physiological disposal of the potential alkali load in diet of the rat: steps to achieve acid-base balance.

The purpose of this study was to provide a better understanding of the physiological role of endogenous net organic acid production in rats consuming their usual diet. Balance studies were performed over 24 h, and urine was collected in the day and night portions of the diurnal cycle. A supplemented low-electrolyte diet(LED) was fed to determine whether urinary organic anions were identical to those in the diet. A titration procedure was developed to determine the pK of titratable groups in the urine of rats studied with and without an acid load. Although normal rats excreted net acid (NAE), the latter was inversely related to the amount of food consumed. The rates of excretion of bicarbonate (HCO3), citrate, unmeasured organic anions, and NH+4 were higher in the night portion of the diurnal cycle. NAE rose dramatically when alkali intake was decreased by consuming the LED. Dietary and urinary organic anions were not identical because rats fed the LED supplemented with potassium citrate excreted <10% of this alkali load as citrate and <25% as HCO3. In the 24 h after 3,000 ¿mol NH4Cl was given intraperitoneally, H+ did not appear to be retained, yet NAE rose by only close to 2,000 ¿eq. The rate of excretion of titratable groups with a pK in the 3 to 5 pH range fell by close to 1,000 ¿eq; most of these changes occurred in the first 7 h after NH4Cl was given. We conclude that rat chow provides a large net alkali load. There appear to be two types of endogenous acid production, a form associated with a rise in NAE (e.g., sulfuric acid) and dietary alkali-driven endogenous net acid production, which titrates this alkali. Renal excretion of organic anions makes these acids end products of metabolism.

Prediction of complications following unintentional caustic ingestion in children. Is endoscopy always necessary?

The records of 115 children hospitalized following caustic ingestion over an 18.5-year period from 1976 to 1994 were reviewed. The relationship between types of product ingested, signs and symptoms, degree of esophageal injury and complications was analyzed. All complications were the result of strong alkali ingestion (sensitivity = 1.0). Among the 102 incident patients, 36.8% of lye ingestions resulted in complications, whereas only 2.7% (one) of automatic dishwasher detergent (ADD) ingestions caused any complications (p < 0.01). Endoscopy 6 h to 4 days after injury was accurate in predicting or identifying complications in all types of strong alkali ingestions. In lye ingestions, endoscopy was not superior to the test, "one or more signs or symptoms" in predicting complications (predictivity = 1.0). Endoscopy is recommended to establish or confirm a prognosis, or to identify acute respiratory complications, in symptomatic ingestions of lye or ammonia water, in children with respiratory symptoms, and in rare cases of severe symptoms following ADD or strong acid ingestion. It is suggested that children who are non-symptomatic following unintentional ingestions are not at risk of complications and do not need endoscopic examination.

Prediction of complications following caustic ingestion in adults.

The records of 86 adults admitted to hospital following caustic ingestion were reviewed. Eighteen patients (21%) developed complications; of these, six were fatal. Patients without symptoms or signs did not develop complications. Complications occurred only following lye ingestion, or intentional ingestion of hydrochloric acid or ammonia water. Of patients with such ingestion, and two signs or symptoms or more, 70% developed complications. Oesophagoscopy did not significantly improve the prediction of complications. There was a strong trend, however, for more severe complications with more severe submucosal, circumferential oesophageal injuries (P = 0.003). The study suggests that only adults with symptoms or signs following strong alkali or strong acid ingestion are at risk of complications. In adults who are symptomatic following ingestion of strong acid or alkali, oesophagoscopy is important to identify the potentially fatal transmural injuries.

Hair Relaxer Ingestion: A New Trend

Although the health care system has done much to reduce the incidence of ingestion of such alkalis as drain and oven cleaners, in recent years we have seen an overwhelming increase in the incidence of hair relaxer ingestion. In a 5-year review (1987 to 1992) of 48 cases of caustic ingestion, 15 cases involved alkaline hair-relaxing agents. This retrospective study was undertaken to evaluate the agents ingested, the presenting signs and symptoms, the diagnostic procedures, and the outcomes in those 15 cases. Oral cavity and lip burns were common in these children, but none of the 15 had significant esophageal burns. Education of the medical and lay community about the risk of hair relaxer ingestion should be undertaken to reverse this worrisome trend.

Munchausen Syndrome by Proxy in a Saudi Child

Munchausen Syndrome by Proxy in a Saudi Child

The Milk-Alkali Syndrome

The milk-alkali syndrome became rare with the advent of modern ulcer therapy with nonabsorbable antacids, histamine2 blockers, and sucralfate. An increased frequency of this syndrome seems likely with the growing popularity of the use of calcium carbonate as an antacid or as calcium supplementation to prevent osteoporosis. We treated five patients who had six episodes of the milk-alkali syndrome; four of these cases were diagnosed between 1990 and 1992. All patients were ingesting massive quantities of calcium and absorbable alkali and were unaware of the toxic effects of these compounds. All patients presented with the triad of hypercalcemia, metabolic alkalosis, and renal failure. All metabolic abnormalities were corrected, and renal function improved with appropriate supportive measures and cessation of calcium and alkali ingestion. In two patients, the renal failure was so severe that dialysis was necessary. In four patients, either the serum amino-terminal parathyroid hormone or 1,25-dihydroxycholecalciferol levels were appropriately decreased in response to hypercalcemia. The serum carboxy-terminal parathyroid hormone levels were increased because of renal failure. Since both physicians and patients are often unaware of the calcium and alkali content of many nonprescription medicines, the diagnosis of the milk-alkali syndrome, a reversible cause of renal failure, can be missed if a detailed history of such intake is not elicited. Measurement of the serum amino-terminal parathyroid hormone and 1,25-dihydroxycholecalciferol levels may help differentiate milk-alkali syndrome from primary hyperparathyroidism.

Patterns of hepatitis B virus DNA integration in liver tissue of children with chronic infections.

Although an integration of hepatitis B virus (HBV) DNA in children with chronic HBV infection has been documented at early phases of the disease, the incidence of this process is not known. Therefore we examined nine liver DNA specimens from chronic HBV carriers ages 5-14 years and one sample from a neonate delivered of a carrier mother, in order to determine the HBV DNA patterns of these patients at different ages and phases of chronic infection. The integrated HBV DNA was detected by Southern blot hybridization and analyzed by molecular cloning. Southern blot showed a smear pattern of HBV DNA integration in four of six chronic hepatitis patients (ages 5-14), as well as in one asymptomatic carrier (age 12). Multiple and random integrations occurred during chronic infections in childhood. The neonate did not, however, show signs of any integrations, suggesting that integration starts after HBV multiplication. A band pattern that suggested clonal growth of integrated liver cells was found in a chronic active hepatitis patient (age 9) and in one of two hepatocellular carcinoma patients (age 11). Molecular cloning in two cases with chronic active hepatitis showed that the HBV genome structure was preserved in five of six HBV DNA inserts. Our findings confirm that HBV DNA integration can occur at early stages of chronic HBV infection. In Japanese children, the process of integration seems to be common regardless of HBeAg/anti-HBe status.(ABSTRACT TRUNCATED AT 250 WORDS)

Ingestion of Caustic Alkali Farm Products

SummarySince the Poison Prevention Packaging Act took effect, the number of ingestions of caustic alkali from household products has been significantly reduced. Commercial caustic alkalis used on farms, however, were not included in this legislation. Fourteen children over a 5 year period were seen after ingestion of commercial caustic alkalis used on farms. Seven of the children had ingested liquid pipeline cleaners and seven had ingested solid agents used for a variety of reasons. Six of seven children ingesting liquid agents did so from nonoriginal containers into which the caustic had been transferred for convenience. All seven children ingesting solid agents did so from the original container. Eight of the 14 children were found to have second‐degree or worse esophageal involvement. Both solid and liquid caustic agents used commercially on farms can cause significant morbidity. Development of a child‐resistant container for daily transfer of liquid pipeline agents could be helpful in preventing injuries from liquid pipeline cleaners. Pediatric gastroen‐terologists as well as primary care physicians in rural areas should be familiar with this type of injury and should take an active role in instructing parents of children living on farms to prevent such injuries. Extension of the Poison Prevention Packaging Act to caustic alkalis used on farms needs to be considered.

Ingestion of strong corrosive alkalis: Spectrum of injury to upper gastrointestinal tract and natural history: Zagar SA, Kochhar R, Nagi B. Am J Gastroenterol. 1992;87:337–341

Ingestion of strong corrosive alkalis: Spectrum of injury to upper gastrointestinal tract and natural history: Zagar SA, Kochhar R, Nagi B. Am J Gastroenterol. 1992;87:337–341

Phosphate-dependent glutaminase activity in rat renal cortical and medullary tubule segments

To determine whether local production of ammonium by medullary renal tubule segments may contribute to medullary ammonium accumulation, we measured activities of phosphate-dependent glutaminase (PDG) in microdissected tubule segments from rat medulla and cortex. PDG activities were very low in medullary loop of Henle segments but surprisingly high in inner medullary collecting duct (IMCD). In cortex, PDG levels were highest in distal convoluted tubule and cortical thick ascending limb, but substantial levels were also found in proximal segments, as reported previously. To determine effects of acid loading and alkali loading on PDG activity, 0.28 M NH4Cl (acid) or 0.28 M NaHCO3 (alkali) was added to rats' drinking water for 7 days. PDG activities in medullary segments were not affected by acid or alkali intake. Acid intake by rats increased PDG activity in S1 and S2 proximal convoluted tubules severalfold but did not affect the other cortical segments. We conclude that medullary loop of Henle segments probably contribute relatively little to medullary ammonium accumulation because of their low activities. The high PDG activity in IMCD suggests that ammonium could be produced and secreted by this segment. However, because total tubule length of IMCD is very low compared with proximal tubules, it appears unlikely that IMCD contributes substantially to overall renal ammonium production. PDG activity is regulated only in S1 and S2 proximal tubules, consistent with the view that the proximal tubule is the major site of regulation of renal ammonium production.

Glutamate dehydrogenase activities in microdissected rat nephron segments: effects of acid-base loading

A method for measurement of glutamate dehydrogenase (GDH) activity in single renal tubules was employed to determine the distribution and regulation of GDH in tubule segments. Fresh microdissected tubules from collagenase-treated kidneys were permeabilized by hyposmotic shock and freezing. The rate of conversion of alpha-ketoglutarate, NH4+, and NADH to glutamate and NAD was measured at 37 degrees C fluorometrically. Very high activities were found in proximal tubule segments (150-210 pmol.min-1.mm tubule length-1), intermediate values (40-90 pmol.min-1.mm-1) in distal convoluted tubules, cortical thick ascending limbs, connecting tubules, medullary thick ascending limbs, and lower values (5-30 pmol.min-1.mm-1) in cortical collecting ducts, inner medullary collecting ducts, outer medullary collecting ducts, outer medullary thin limbs, and inner medullary thin limbs. To determine the effects of acid-base loading on GDH activity, 0.28 M NH4Cl (acid) or 0.28 M NaHCO3 (alkali) was added to the animals' drinking water for 7 days. Acid intake by the rats increased GDH activity in S1 and S2 proximal tubules by threefold, with no effect in other segments, including S3 proximal tubules. Alkali intake decreased GDH activity in the S3 proximal tubule by 40%, with no effect in other segments. We conclude that GDH activities are highest in proximal tubule segments and are regulated only in proximal tubule segments. Thus the results are consistent with the view that the proximal tubule is the chief site of the regulated production of ammonium in the kidney.

Corrosive oesophageal strictures following acid ingestion: Clinical profile and results of endoscopic dilatation

There are several reports on oesophageal strictures caused by alkali ingestion, but information on oesophageal strictures due to acid ingestion is scarce. Endoscopic dilatation, which has been found to be quite safe and effective in the treatment of benign oesophageal strictures of other aetiology, has also not been evaluated adequately in the treatment of these strictures. Over a period of 2 years, of 47 patients treated at this centre of benign oesophageal strictures, 17 (36.2%) patients had strictures following ingestion of corrosive agents. Thirteen patients had ingested acids and only four gave a history of alkali ingestion. The age range of these 13 patients was 14-50 years (mean = 25.5 years, s.d. = 2.6). The amount of acid ingested varied from 10 to 100 ml (median = 50 ml). The interval between acid ingestion and presentation to hospital ranged from 1 to 60 months (median = 2 months). Ten patients had multiple strictures, and the most common site of involvement was the upper third followed by the lower third of the oesophagus. Only five of these 13 patients had evidence of gastric involvement in the form of antral stricture (four) and hour glass deformity (one). Strictures were dilated using Eder-Puestow metal olives passed over a guide wire. The total number of sittings required to achieve adequate dilatation in this group ranged from 1 to 30 (median = 14). Most patients were managed successfully with dilatation (good response 63.6%, satisfactory response 18.2%). On follow-up, recurrence of dysphagia was seen in a high number of patients (66%), but this could be managed easily with repeat dilatation.(ABSTRACT TRUNCATED AT 250 WORDS)

Progressive roentgenographic appearance of caustic esophagitis.

We observed progressive roentgenographic changes in five patients who had caustic esophagitis after accidental ingestion of a liquid alkali. Initial endoscopic examination showed moderate caustic esophagitis in all patients, and esophageal atony and poor distension were early roentgenographic observations. Esophageal strictures developed 13 to 44 days after caustic ingestion in all patients. Intramural pseudodiverticula complicated stricture formation in two patients. Esophageal diverticula developed in two cases, three months to one year after caustic ingestion. In summary, moderate caustic esophagitis is associated with esophageal dilatation, atony, and peristaltic abnormalities initially, and with eventual stricture formation.