Alkali Ingestion Research Articles

FACTORS ASSOCIATED WITH A HIGHER NUMBER OF ESOPHAGEAL DILATIONS IN CHILDREN WITH A HISTORY OF ALKALINE INGESTION.

Children who experience alkaline injury are at risk for the development of esophageal strictures and the need for esophageal dilations. We aimed to assess predictors for a higher number of esophageal dilatations in children following alkali ingestion. Single-center retrospective cohort study including children who underwent esophagogastroduodenoscopy (EGD) after alkali ingestion. Possible predictive factors for the need for esophageal dilatations were evaluated. A total of 34 patients were included, and 19 were female (55.9%). The median age at the time of the accidents was 20.6 months (IQR 15-30.7). All alkali ingestions were accidental, in all cases involving liquid products, and most (24/34; 70%) occurred at the child's home. Homemade liquid soap was the agent in half of the cases. The most frequently reported symptom at presentation was vomiting (22/34, 64.7%). The median follow-up time was 3.2 years (IQR 1.1-7.4). On follow-up, the median number of esophageal dilatations required for these patients was 12.5 (IQR 0-34). Among demographic factors, male gender (P=0.04), ingestion of homemade products (P<0.01), and accidents happening outside of the household environment (P=0.02) were associated with a greater number of esophageal dilations on follow-up. An endoscopic classification Zargar of 2B or higher (P=0.03), the presence of stricture at the time of the second EGD (P=0.01), and gastroesophageal reflux disease (GERD) as a late complication (P=0.01) were also associated with a greater number of esophageal dilations on long term follow-up. Beyond the endoscopic classification severity - a well-known risk factor for the strictures after alkali ingestions, we found that male gender, accidents with homemade products, and accidents occurring outside the household environment were significantly associated with a greater number of esophageal dilatations in the long-term follow-up of children following alkali ingestion.

Caustic esophageal injury in clinical settings

Background: esophageal stricture is loss of esophageal lumen patency and may involve injuries after ingesting caustic substances. This systematic review aims to review clinical presentations, diagnostic modalities involved, treatments and outcomes, and complications of esophageal strictures following caustic injuries.Methods: this systematic review involves original researches conducted between 2002-2022 indexed in PubMed and EuropePMC searched using following MeSH terms: “((caustic injury) OR (caustic burn)) AND (ingestion) AND (inflammation)” following PRISMA algorithm. Biases were assessed using STROBE checklist and presented as narratives.Results: searches yielded 326 results with 16 studies included in this review. Majority of caustic ingestion and strictures involved pediatric population due to accidental ingestion. Alkali ingestion has more severe presentation. Radiological imaging, including CT and MRI, may help in determining damages involved. Degrees of damages are related with mortalities or morbidities, and dilatation may improve quality-of-life in some cases.Conclusion: pediatric patients are at risk for accidental ingestions and alkali ingestion creates more severe damage. Radiological imaging may assist in determining involvement of underlying tissues.

Catastrophic Upper Gastrointestinal Tract Complications Following Corrosive Ingestion

Ingestion of caustic substances, either acidic or alkali, is a well-known cause of significant mortality and morbidity in the pediatric and adult populations. According to the pH, physical form, amount, and rate of ingestion of these substances, a wide range of immediate as well as possible subsequent chronic complications can result. Some patients may have minimal to mild symptoms. However, others can present with moderate or even serious symptoms, in the form of dysphagia, odynophagia, hoarseness, and epigastric pain. Herein we present a case of a 26-year-old male patient with a history of Nitric acid ingestion. He initially complained of severe chest and abdominal pain, associated with hematemesis, dysphagia, odynophagia, hypersalivation, and inability to tolerate oral intake. Initial Esophagogastroduodenoscopy (EGD) showed diffuse mucosal ulceration reaching the second part of the duodenum. Multiple subsequent EGDs revealed more extensive damage and subsequent esophageal stricture and pyloric stenosis for which multiple dilatation attempts were done. The patient received extensive supportive management during his hospitalization course, but the damage was severe enough that he was referred for surgical management. Such catastrophic sequels of caustic ingestion are still encountered, especially in developing countries. We present this case looking forward to raising awareness about this dangerous phenomenon and highlighting the significance of immediate identification and grading of the injury.

STUDY TO EVALUATE THE ACUTE KIDNEY INJURY IN PATIENTS WITH POISONING

Objective: The goal of the study is to determine the pattern of dangerous material presence in the field, as well as how severely it affects kidney function and can result in death. Methods: An observational study of patients hospitalized to the poison ward of tertiary care hospitals of Gwalior was planned. For data collection a structured questionnaire was used, which includes questions on demographic information, details of poisoned intake, and the time interval between ingestion and hospital admission. Results: There are 79 instances of Celphos poisoning, 157 cases of organophosphorus poisoning, 67 cases of hair dye poisoning, 58 cases of rat killer poisoning, 51 cases of acid or alkali ingestion, 28 cases of alcohol intoxication, and 14 cases of Ethylene dibromide poisoning. Organophosphorus poisoning has the highest number of instances (157), whereas ethylene dibromide poisoning has the lowest number (14). Except in the situations of acid/alkali ingestion and ethylene dibromide ingestion, where the age range of 26–40 years was more involved, the majority of serious cases were in the 10–25 year old age group. Poisonings show male dominance over female dominance. Almost all poisonings result in a deranged renal profile; however, ethylene bromide poisoning has the greatest rate (21.4%), whereas celphos poisoning has the highest rate (28.37%) in terms of term mortality. Conclusion: The findings show that organophosphorus toxicity, celphos poisoning, hair dye, and rat killer are all prevalent in Gwalior and the nearby region. Acute kidney damage was also detected in hair dye, celphos, organophosphorus, rat killer, and ethylene dibromide poisonings, with ethylene dibromide being the most common. Finally, celphos and Ethylene dibromide poisoning had the greatest fatality rates.

657. COMPARISON BETWEEN GASTRIC TUBE AND COLOPLASTY IN ESOPHAGECTOMY AND ESOPHAGEAL BYPASS IN ESOPHAGEAL STENOSIS DUE TO INGESTION CORROSIVE SUBSTANCE

Abstract The treatment of ingestion of caustic agents is controversial in the literature. Surgical therapy has been shown to be the best way to proceed, but the surgical methodology has been varied according to the patient's involvement. This study aims to expose the experience of a single institution in relation to the methodology used for the surgical treatment of esophageal stenosis by ingestion of a caustic substance. A retrospective study was carried out in which data were collected from 27 patients who underwent a surgical procedure for the treatment of esophageal stenosis due to alkali ingestion at the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo between 2010 and 2019 and their subsequent comparison between the conduits used in the surgical intervention. Fisher's test was performed to compare the groups regarding cervical leakage and post-surgical symptoms with a significance level of 5%. Of the 27 surgical procedures for esophageal stenosis due to alkali ingestion, 12 performed gastric conduits and 15 colon conduits. When comparing the groups regarding cervical leaks, no statistically significant difference was noted (p = 0.7060). There were also no statistically significant differences regarding the presence of symptoms in the postoperative period (p &amp;gt; 0.99...) Surgical intervention by both gastric and colon conduits showed no differences in cervical leakage and symptom control. Surgical intervention by both gastric and colon conduits showed no differences in cervical leakage and symptom control.

Esophageal Dilatation in Patients with Esophageal Stricture Formation due to Corrosive Intake - Clinical Experience of Thoracic Surgery Department at A Tertiary Care Center

Objective: Assessment of the outcome of esophageal dilatation in patients with esophageal stricture formation due to corrosive intake experienced at a tertiary healthcare facility in order to devise a better management plan for such patients. Study design: Retrospective Study Study setting: Sheikh Zayed Medical College/Hospital, Rahim Yar Khan. Study duration: January 2018-June 2021 Methodology: A total of 19 subjects who presented with esophageal stricture formation due to corrosive intake were taken as study subjects. The location of involved mucosa, number of dilatation sessions done, level of symptomatic relief and recurrence rates were assessed for these study subjects. Then the data was gathered and analyzed with the help of SPSS Version. 21. Results: This study comprising of 19 patients who had esophageal stricture formed due to corrosive intake and they underwent esophageal dilatation for it. The age range for the subjects came out to be 5-40 years (Mean= 2.89±8.81). Male to female ratio came out to be 7(36.8%) vs 12(63.2%) respectively. Among these study subjects, 15(78.9%) subjects gave history of an acid ingestion while only 4(21.1%) had a history of alkali ingestion. Majority of them showed relief in response to esophageal dilatation and with low recurrence rates. Conclusion: Esophageal dilatation with bougies is one of the safest, less invasive, and efficient method for the effective management of esophageal stenosis/ stricture formation after corrosive intake that needs to be emphasized specially in healthcare centers which lack specialized departments dealing with more invasive surgical procedure and facilities. Keywords: Esophagus, Dilatation, Corrosive, Stricture, Acid, Alkali

Esophageal Diameter as a Function of Weight in Neonates, Children and Adolescents: Reference Values for Dilatation of Esophageal Stenoses.

IntroductionEsophageal stenoses are frequent complications after esophageal atresia surgery as well as after acid, alkali and battery ingestion. Worldwide, repeated balloon dilatations are the most frequently performed procedures for these stenoses. In most cases the stenoses can be dilated sufficiently to allow adequate enteral nutrition. Until recently, age dependent esophageal lumen size has not been established; which was aim of the current study.MethodsAll children in whom an esophageal contrast imaging was performed between 1/2011 and 5/2021 were included. The width was measured by two investigators at two measuring points in two planes, the diameter was calculated and plotted against the respective weight of the child. Bland-Altmann plots have confirmed the validity of the measurements of both investigators.ResultsEsophagus diameter was measured in more than 100 children. The resulting curves show a very good correlation with weight (upper measuring point: r = 0.86743, p < 0.0001; lower measuring point: r = 0.80593, p < 0.0001).ConclusionThese results are the first to define the esophageal diameter in children. The results of this study may guide physicians performing esophageal interventions including dilatations in future.

Current practices in the management of corrosive ingestion in children: A questionnaire-based survey and recommendations.

Corrosive ingestion causes significant morbidity in children with no standard guidelines regarding management. This survey aimed to understand practices adopted by gastroenterologists, identify lacunae in evaluation and management and suggest a practical algorithm. Indian gastroenterologists participated in an online survey (65 questions) on managing corrosive ingestion. When ≥ 50% of respondents agreed on a management option, it was considered as 'agreement'. Ninety-eight gastroenterologists (72 pediatric) who had managed a total of ~ 2600 corrosive ingestions in the last 5 years responded. The commonest age group affected was 2-5 years (61%). Majority of ingestion was accidental (89%) with 80% due to improper corrosive storage. Ingestion ofalkali and acid was equally common (alkali 41%, acid 39%, unknown 20%). History of inducing-vomiting after ingestion by community physicians was present in 57%.There was an agreement on 77% of questions. The respondents agreed on endoscopy (70%) and chest X-ray (67%) in all, irrespective of symptoms. Endoscopy was considered safe on days 1-5 after ingestion (91%) and relatively contraindicated thereafter. The consensus was to use acid suppression, always (59%); steroids, never (68%) and antibiotics, if indicated (59%). Feeding was based on endoscopic findings: oral in mild injuries and nasogastric (NG) in others. Eighty percent placed a NG tube under endoscopic guidance. Stricture dilatation was considered safe after 4 weeks of ingestion. Agreement on duration of acid suppression and stricture management (dilatation protocol and refractory strictures) was lacking. Corrosive ingestion mostly affects 2-5-year olds and is accidental in majority. It can be potentially prevented by proper storage and labelling of corrosives. An algorithm for management is proposed.

Potassium Loss Promotes Impairments in Insulin Sensitivity in Rats

Clinical observations have associated potassium (K+) wasting with metabolic syndrome and insulin resistance. Chronic alkali ingestion can lead to K+ wasting. The alkali sodium bicarbonate (NaHCO3) is now used commonly in chronic kidney disease (CKD) patients to slow renal functional decline, even in patients without metabolic acidosis. Whether chronic ingestion of alkali like NaHCO3 promotes K+ wasting and loss of insulin sensitivity in CKD remains unknown. We hypothesized that chronic NaHCO3 treatment leads to K+ wasting and impairs insulin sensitivity in a rat model of CKD. To test our hypothesis, 12 male, 12 week old Sprague Dawley (SD) rats underwent a 2/3 nephrectomy and were given 4 weeks to recover prior to being placed on either 0.1M NaHCO3 (n=6) or maintained on tap water (n=6) for 4 weeks. After 4 weeks, rats were given hydrochlorothiazide (HCTZ, 10 mg/kg/day) in the drinking water to promote additional K+ wasting in combination with NaHCO3 or tap water for another 4 weeks. Animals underwent insulin tolerance tests (ITT; 0.75 U/kg insulin i.v.) at 4 and 8 week time points. At the conclusion of the protocol, rats were sacrificed, a terminal blood gas measurement taken, and the remaining remnant kidney harvested. Following 4 weeks of NaHCO3 or tap water there was no difference in the blood glucose response to insulin or in the magnitude of the fall in blood glucose (inverse area under the curve (AUC)) in response to insulin. However, following HCTZ treatment, NaHCO3 treated rats were less sensitive to insulin compared to tap water treated rats (Two-way ANOVA, PRxGroup=0.0005, PTime<0.0001, PInteraction=0.17) and had a smaller AUC (NaHCO3 + HCTZ 1688 ± 815 vs tap water + HCTZ 4002 ± 774; unpaired t-test, p=0.06). To determine if K+ depletion could account for the loss of insulin sensitivity, we placed animals on a low K+ diet for 1 week to deplete total body K+ and then determined insulin sensitivity. 6 naïve male, 10 week old SD rats underwent a baseline ITT and an ITT after 1 week of low K+ diet (0K). There was a significant decrease in plasma K+ (baseline 3.55 ± 0.21 vs 0K 2.71 ± 0.29; paired t-test, p=0.01) and a significant effect of diet and time on the blood glucose response to insulin following dietary K+ restriction (RM Two-way ANOVA, PDiet=0.0004, PTime<0.0001, PInteraction=0.70, PSubjects=0.04). At baseline, fasted blood glucose was 144 ± 9.27 mg/dL and fell to its lowest point of 100 ± 7.05 mg/dL at 60 minutes (min), gradually recovering to 132 ± 4.95 mg/dL by end of study (120 min). In contrast, after 1 week of dietary K+ restriction, fasted blood glucose was 151 ± 5.13 mg/dL and fell to its lowest point of 112 ± 6.15 mg/dL by 40 min and recovered to 142 ± 5.30 mg/dL at 80 min, a level that was sustained until the end of the study. In conjunction with a thiazide, chronic NaHCO3 treatment results in reduced insulin sensitivity in rats. K+ depletion with dietary K+ restriction also results in loss of insulin sensitivity in rats. These data strongly implicate K+ wasting as the cause of reduced insulin sensitivity. These findings suggest that K+ wasting may be a cause of insulin resistance and underscore the importance of access to dietary K+, even for patients with CKD. CKD patients treated with NaHCO3 may be at increased risk due to the K+ wasting effects of alkali, particularly those without prior metabolic acidosis.

ACID-BASE BALANCE IN HYPERTENSIVE PATIENTS WITH CHRONIC KIDNEY DISEASE: INFLUENCE OF DIABETES

Objective: Metabolic acidosis is a common complication of advanced CKD and it has been associated with an increased risk of death and faster renal function decline. Diabetes mellitus is one of the most crucial cause of CKD. The dysregulation of glucose homeostasis may lead to many acid–base balance disorders. Our study was aimed to compare the acid-base status in diabetic patients with severe CKD with non diabetic CKD subjects. Design and method: Study population included 143 consecutive CKD hypertensive subjects attending our Nephrology unit with advanced renal failure. To be included on the study, patients were required to have an estimated eGFR of less than 30 mL/min, no intake of alkali within the previous 30 days, and the absence of pulmonary diseases and other clinical conditions at the time of the study that could explain an acute imbalance of the acid-base status, such as heart failure, hemorrhage, or sepsis. Patients were divided into two groups on the basis of the presence (n = 73) or the absence of Type 2 diabetes mellitus (n = 70) Arterial blood samples were drawn in all the subjects. Results: Age, sex distribution, serum creatinine, eGFR and proteinuria were not different in the two groups. Blood pH [7.406 (7.35–7.43) vs 7.384 (7.32–7.41), p = 0.02], bicarbonate levels [22 (19.1–23.7) vs 20.5 (17.4–23.1); p = 0.05] were higher and the prevalence of metabolic alkalosis (16.8 vs 8.4 %) was greater in diabetic patients as compared to non diabetic ones. The positive associations between diabetes and pH values (beta: 0.186; p = 0.02) and between diabetes and metabolic alkalosis (odds ratio 2.68; p &lt; 0.05), were confirmed respectively in linear multiple regression analyses and in logistic multivariate models even after adjustment for potential confounders. Conclusions: Our results, in agreement with those obtained in a previous study (Caracava F et al, Am J Kidney Dis 1999), seem to suggest that metabolic alkalosis is more common than metabolic acidosis in diabetic patients with severe CKD. Further studies are needed in order to provide the pathophysiological explanations of these findings.

Escape the EM Boards: Interactive Virtual Escape Room for GI Board Review.

This interactive and entirely virtual escape room based on high yield gastrointestinal/abdominal board review material is a didactic activity for emergency medicine residents of all postgraduate years and third- or fourth-year medical students. This escape room can be completed in small teams or as individuals in a remote, in-person, or mixed location setting. 2020 is a year that will forever change medical education. The novel coronavirus 2019 pandemic caused many national, state, local, or hospital specific recommendations for transition of meetings to be completely virtual or to only allow for limited in-person meetings. In order to abide by these recommendations, the majority of medical education transitioned to online platforms. Now more than ever, creative and engaging methods for expanding clinical knowledge and teaching teamwork as well as unique integrations of technology for medical education delivery are needed. By the end of this didactic activity, learners will be able to:Identify causes of upper gastrointestinal bleeding.Recall test-taking buzzwords for infectious causes of diarrhea.Acknowledge the correct hepatitis B titers that correspond with various clinical scenarios.Describe the management for alkali caustic ingestions.Determine the components of Maddrey Discriminant Function Score, Charcot's triad, Ranson's Criteria for Pancreatitis, and Glasgow-Blatchford Score.Diagnose specific gastrointestinal diseases from a clinical description.Choose the correct gastrointestinal diagnosis based on clinical image findings.Demonstrate teamwork in solving problems. "Gamification" is the use of game elements in a nongame context.1 Gamification creates active, engaged learning opportunities and so it is a highly favored educational method for millennial learners.1 An Escape Room is a team-based game where a small group is locked in a room and they pick up objects at random in this room to solve a series of clues that will play a role in solving the final clue to "escape" the locked room. This didactic learning activity utilizes technology to deliver a fun and interactive distance learning activity that resembles a live escape room.The interactive virtual escape room provided is a no cost, unique alternative educational activity that can be done either entirely or partly remotely. In order to replicate this team-based didactic exercise, the instructor needs to simply divide residents and students into small groups and then share with each group the link provided. A five-point Likert scale survey was distributed to participating learners after completing this activity to assess relevance and satisfaction of the high yield gastrointestinal/abdominal board review escape room. Thirty-two of forty-two participating residents/medical students completed this seven-question survey. All participating resident/medical students who completed the survey enjoyed this activity and that this was a unique learning experience, and the majority of participating residents/medical students thought this interactive virtual escape room was easy to use, learned something, thought this was a helpful way to review for emergency medicine boards or in-training exams, and preferred a game like this to a standard lecture. Additionally, over half of survey respondents said they are going to try to come up with a game for their assigned board review presentations. Escape room gamification of high yield gastrointestinal/abdominal board review material was an engaging, fun, and effective distance learning activity for residents and medical students. This didactic activity not only promoted interactive learning but also encouraged virtual teamwork among small groups. Gastroenterology, GI, abdominal, board review, in-training exam review, escape room, virtual didactics, distance learning, high yield, upper GI bleeding, esophageal varices, diarrhea, alkali ingestion, volvulus, foreign body, intussusception.

THE DIGESTIBILITY AND INTAKE OF SODIUM HYDROXIDE OR LOCAL ALKALI-TREATED STRAW BY GOATS

An experiment to compare the effects on digestibility of alkali treated Gamba grass (Andropogon gayanus) straw was conducted with four Borno white male goats (22.25 ± 1.0kg body weight) in a 4 x 4 Latin square design. Treatments were (A) untreated straw (control), (B) Sodium hydroxide (NaOH) treated straw, (C) Kanwa-treated and (D) Kantu-treated straws. Straw was treated separately with solutions (8%) of NaOH, Kanwa and Kantu for 10 minutes prior to ensiling for 20 days. In treatment A, straw was soaked in water before ensiling. Alkali treatment increased the ash and crude protein, but decreased the crude fibre, nitrogen free extract and energy contents of the silage diets. The ether extract content of the diets was not affected by treatment. Dry matter intake (g/day/Wkg ) of alkali treated diets was significantly higher (P&lt;0.05) than the control The NaOH-treated diet was consumed less (P&lt;0.05) than the Kantu-treated diet, but to the same extent as the Kanwa diet. Nitrogen balance was positive in animals consuming the alkali-treated diets and negative for those in the control group. Apparent N-digestibility were similar in the alkali treated diets and better (P&lt;0.05) titan in the control. Digestibility coefficients of dry matter, crude protein and crude fibre were not significantly different among the alkali treated diets. However, they were markedly improved (P&lt;0.05) than in the control diet (A). The results indicated that the natural alkali sources (Kanwa and Kantu) compared favourably with NaOH in improving the nutritive value of Gamba grass hay. Further work however should be undertaken to ascertain the optimal level of their application under the semi-arid environment of Borno State.

S0395 Outcomes of Benign Corrosive Esophageal Stricture Dilation—Single Center Experience

INTRODUCTION: The strictures secondary to caustic ingestion is a debilitating condition causing long-term nutritional challenges. This retrospective study investigates the outcomes of endoscopic dilation in patients with benign esophageal strictures secondary to corrosive ingestion. METHODS: A retrospective study that included patients with esophageal strictures due to caustic injury under follow-up was performed at a tertiary care center. These patients at the centre underwent endoscopic dilation by both Endoscopic Balloon Dilation (EBD) and Gilliard Savary (GS) dilators based on endoscopist comfort (P.K.). Symptomatic relief within 2 months of intervention was considered a successful response. RESULTS: The study included 39 patients including 31 patients with acid ingestion and 8 with alkali ingestion (Figure 1). Of patients with acid ingestion, 32.3% (10/31) underwent EBD and 67.7% (21/39) underwent GSD with only 50% (5/10) and 38.1% (8/21) respectively having symptom relief. Of patients with alkali ingestion, 50% (4/8) underwent EBD and 50% (4/8) underwent GSD with 75% (3/4) and 50% (2/4) respectively having symptom relief. Irrespective of caustic etiology, the composite success for EBD and GSD sub-groups were 61.5% and 38.5% respectively. Short stricture length was associated with successful outcomes among patients with acid ingestion (P = .003) but not among patients with alkali ingestion. Patients with failed outcomes had higher percentages of grade 2B and 3 mucosal injury at time of initial caustic exposure and warranted repeated endoscopic dilations for symptom management. This however did not reach significance in patients with either alkali (P = 0.19) or acid ingestion (likelihood ratio; P = 0.14). In the study population, seven patients had concomitant stomach involvement with three (7.7%) developing gastric outlet obstruction (GOO), all of whom underwent surgical intervention. Other than GOO, no other sequelae like achlorhydria, mucosal metaplasia, carcinoma or protein losing enteropathy were diagnosed during follow up. CONCLUSION: Overall success of endoscopic dilation for caustic esophageal stricture is limited and newer modalities like stent placement or endoscopic incision therapy may play a role in management of refractory strictures. Primary prevention of such injuries should be the preferred approach in managing this public health issue.Figure 1.: Flow diagram describing the endoscopic dilations among the patients with benign strictures.

Corrosive Esophagitis and Gastritis Secondary to Alkali Ingestion Treated with Video-Assisted Thoracoscopic Esophagectomy and Laparoscopic Total Gastrectomy Followed by Second-Stage Reconstruction

Corrosive Esophagitis and Gastritis Secondary to Alkali Ingestion Treated with Video-Assisted Thoracoscopic Esophagectomy and Laparoscopic Total Gastrectomy Followed by Second-Stage Reconstruction

Chronic sodium bicarbonate may promote metabolic dysregulation in a rodent model of CKD

Chronic kidney disease (CKD) has no cure, and few treatment options targeted at slowing the decline in glomerular filtration rate (GFR). Several small clinical trials have indicated that oral sodium bicarbonate (NaHCO3) targets and slows the decline in GFR in CKD. The reported beneficial effects of NaHCO3 in this setting have led to its now common use clinically. It’s known however, that chronic alkali ingestion can promote potassium (K+) wasting, and that K+ depletion has been linked with metabolic dysregulation. Further, CKD patients who are supplemented chronically with oral NaHCO3 display significantly decreased plasma K+ levels relative to control treated counterparts, although these decreases in plasma K+ remain within normal range. No study has investigated the metabolic impacts of chronic NaHCO3 treatment and K+ wasting in CKD. To this end, we tested the hypothesis that in the setting of high tubular flow, chronic NaHCO3 ingestion would promote K+ wasting and metabolic dysfunction. In order to test our hypothesis, 9 male, 8 wk old Sprague Dawley (SD) rats underwent a 2/3 nephrectomy (Nx) and telemetry implantation. The 2/3 Nx is a model of reduced renal mass that has increased single nephron GFR in the absence of metabolic acidosis, similar to most human patients with CKD. Following 4 weeks of recovery, animals were given either 0.1M NaHCO3 (Bicarb, n=3), 0.1M NaCl (Vehicle, n=3) or 0.2M NH4Cl‐NaHCO3 (AC/B, n=3) in the drinking water for 12 weeks. Following 9 weeks of drinking water treatment, we observed a significantly higher hemoglobin A1c in our bicarb treated group compared to vehicle and AC/B treated groups (Bicarb 4.6 ± 0.1 vs Veh 4.2 ± 0.3 vs AC/B 4.2 ± 0.2; One‐way ANOVA, p=0.05). Following another 3 weeks of drinking water treatment, we performed blood gas measurements to assess plasma K+. In contrast to our hypothesis we observed the highest levels of plasma K+ in our bicarb treated animals compared to our vehicle or AC/B groups (Bicarb 5.18 ± 0.28 vs Veh 4.48 ± 0.66 vs AC/B 4.5 ± 0.21; One‐way ANOVA, p=0.16). Our data show that oral NaHCO3 could worsen blood glucose control in the setting of high tubular flow. Additionally, plasma K+ may not be a reliable measure for assessment of K+ status in CKD patients supplemented with NaHCO3. As the majority of K+ is stored intracellularly, further studies characterizing the effect of chronic alkali ingestion on total body K+ are warranted to assess the impact of NaHCO3 on K+ depletion in this patient population.Support or Funding InformationNIH PO1H134604 and DK099548

The role of endoscopy in caustic ingestion in the pediatric population: experience in a tertiary center.

caustic ingestion in children is rare but has potentially serious consequences. to analyze the clinical and endoscopic features and the type of caustic ingested in our population. the upper endoscopies performed in this setting, as well as the characteristics of patients and caustics, were analyzed from 2010 to 2018. fifty-one endoscopies were performed (48 cases of witnessed intake or high suspicion and three with a low suspicion) in patients with a mean age of 2.55 years. Alkali ingestion was more frequent (88.2 %) and 56.9 % of the endoscopies were normal, which was more frequent among those who ingested bleach (72 %). Alkali tended to produce more esophageal injuries (31.1 %) and acids tended to produce esophageal (20 %) and esophageal-gastric injuries (20 %). Four patients developed esophageal stenosis during follow-up. even though more than half of the studies were normal, endoscopy is important in the diagnosis and prognosis of these patients.

2868 A Single Academic Institution Experience With Caustic Ingestion to the Gastrointestinal Tract

INTRODUCTION: Patients with caustic ingestion present with a range of gastrointestinal (GI) manifestations. The severity of injury depends on the type of substance ingested, its concentration, and duration of contact with the GI mucosa. Apart from usual supportive care, esophagogastroduodenoscopy (EGD) performed within 24 hours of ingestion is generally recommended. This study reports clinical, endoscopic features and hospital outcomes in patients presenting following ingestion of a caustic agent at a single large academic center. METHODS: A retrospective chart review was performed at two academic hospitals between January 2000 and October 2018 in adult patients presenting with caustic ingestion. Demographic data, type of ingestion, endoscopy and computed tomography (CT) findings, in-hospital mortality and length of stay (LOS) was collected. (Table 1). RESULTS: A total of 89 patients were included in the study. Suicidal ingestion occurred in 49.4% cases compared to accidental. The mean age was 43 ± 20 years with 50.6% males. Ingestion of alkalis (81.0%) was higher than acids (15.7%). The most common presenting symptom was vomiting (31.5%). Endoscopy was performed in 54 patients (60.7%) with 45 (83.3%) performed within 24 hours. Endoscopic findings are summarized in Table 2. Patients undergoing endoscopy had a longer duration of hospitalization (5.58 vs 1.67 days, P &lt; 0.001). Patients with Zargar grade 0 had shorter hospitalization compared to those with grade IIA-IIB esophagitis (2.87 vs. 7.53 days, P &lt; 0.001). However, there was no difference in LOS when comparing grade II to III esophagitis (8.4 vs. 11.2 days, P = 0.238). All patients with grade IIA-IIIB were started on a PPI during hospitalization. Only 19.1% of patients had a CT with the majority (70.6%) being normal. Death occurred in 3 patients. CONCLUSION: In this single center cohort, patients mainly presented with alkali ingestion with varying symptoms. An endoscopy was performed in about 60% patients, most within 24 hours and the majority of patients demonstrated Zagar scores of 0 or 1. Despite recent data suggesting cross-sectional imaging as a triage tool, its utilization in this academic center was limited. Implementing a CT-first strategy prospectively may provide additional data and may minimize the utilization of inpatients endoscopy. To our knowledge, this is one of the largest samples to date on caustic ingestion in the United States.

1776 Bleach Gargling - An Effective yet Destructive Method to Beat a Drug Test: A Bizarre Case of Caustic Esophageal Injury

INTRODUCTION: Caustic alkali ingestion can result in severe esophageal injury. Extensive luminal damage may result in esophageal necrosis and eventually perforation. Historically, caustic ingestion has been seen mostly accidentally in children and in individuals with psychiatric illness. Since the new regulations against opioids, certain individuals have been creative with methods of beating those drugs tests. We present to you a case in which bleach was the culprit in induction of severe mucosal injury. CASE DESCRIPTION/METHODS: A 35-year-old male on chronic Oxycodone therapy presented with chest pain, epigastric pain, odynophagia, dysphagia for several months. He denied any history of GERD, EOE, prior EGD or recent new meds. He denied any other GI symptoms such as diarrhea, melena or hematochezia. He reported hemoptysis 3 days prior. Vitals were stable on arrival. His WBC count was 16 and CRP at 100. CT scan revealed diffuse esophageal wall thickening greatest at the upper to mid esophagus. Upon further questioning, he admitted to gargling bleach regularly for several months to falsely pass his opioid drug salivary testing as he had been illegally taking hydrocodone in addition to his prescribed oxycodone. He wasn't aware that bleach may cause any harm as he was not ingesting it. EGD revealed findings consistent with LA grade C esophagitis characterized by esophageal edema, thickening and friability which was most severe at the upper esophagus. Biopsies were taken which came back positive for active esophagitis He was sent home the next day on Protonix 40 mg twice a day with outpatient follow up. DISCUSSION: Caustic ingestion in adults can cause severe gastro-esophageal injury. The severity and extent of the damage depends upon: the amount, concentration, form and corrosive property of the agent; along with the duration of contact. Patients will present with oropharyngeal, retrosternal or epigastric pain, dysphagia/odynophagia, or hyper-salivation with or without hemoptosis. In case of perforation the pain will be severe. Initial evaluation includes history, physical examination, lab work and CT scan to determine the depth of involvement. Symptomatic patients should be hospitalized for supportive care. The use of NG tube is contraindicated. Perforation is an indication for emergent surgery, however; In the absence of a perforation EGD should be performed early. Esophageal strictures, bleeding, fistula formation and esophageal squamous cell carcinoma are known complication of caustic ingestion.

Rapid Resolution of Symptomatic Hypercalcaemia

Rapid Resolution of Symptomatic Hypercalcaemia Abstract. Milk-alkali syndrome consists of the triad of hypercalcaemia, metabolic alkalosis, and renal insufficiency associated with the ingestion of calcium and absorbable alkali. Older patients, those at risk for volume depletion and those on medications that reduce glomerular filtration rate are at increased risk for the development of this syndrome. Most affected patients are postmenopausal women with chronic kidney disease who take an excessive amount of calcium carbonate. The incidence of milk-alkali syndrome is increasing due to the common supplementation of calcium carbonate. Nowadays, it is the third most common cause of hypercalcaemia. As shown in this case, hypercalcaemia may occur even with small amounts of calcium carbonate in patients with the given risk factors.

SUN-LB031 An Atypical Case of Diabetic Keto-Alkalosis with Severe Hypernatremic Hyperosmolarity in a Patient with Amphetamine Abuse

Introduction- Acid base disturbances have a complex interplay in Diabetic Ketoacidosis (DKA). Substance abuse in DKA is associated with more severe metabolic acidosis with higher acidosis-ketosis gap. Severe hypernatremia and alkalosis are rare in DKA but were exhibited in our case. Case- A 31-year-old female with Type 1 diabetes and schizophrenia was hospitalized after she was found to be minimally responsive at home. She had abdominal pain and polyuria since few days and wasn’t compliant with her medications. There was no history of vomiting, diarrhea, alkali ingestion, laxative or diuretic use. On admission, she was severely dehydrated, obtunded and only responsive to painful stimuli. Initial biochemical findings: serum glucose 1323 mg/dl (n 70-140 mg/dl), sodium 135 mEq/L (n 136-148 mEq/L, corrected sodium 154, bicarbonate 32 mEq/L (n 22-28 mEq/L), serum osmolality 379 (n 275-295 mOsm/Kg), beta hydroxybutyrate 62.56 mg/dl (n <=4.17 mg/dl), anion gap 30 (n 12-16) and delta gap of 24. Venous blood gas showed: pH-7.40 (n 7.31-7.41), pCO2-62 (n 41-51), HCO3-38.4 (23-27). She was adequately managed and was fully awake and alert with closed anion-gap within 24 hours of admission. Serum sodium initially peaked to 163 but normalized over the next 36-42 hours. She was also admitted with HHS (Hyperglycemic Hyperosmolar State) 3 months before and 1 month after this admission. Urine drug screen was positive for amphetamines in all 3 admissions. Discussion- Our patient exhibited mixed metabolic acidosis (elevated anion gap, ketonemia), metabolic alkalosis (elevated bicarbonate, elevated delta gap) and compensatory respiratory acidosis. Osmotic diuresis due to glycosuria and amphetamine abuse led to severe volume depletion and bicarbonate reabsorption leading to severe contraction alkalosis. Studies have shown that methamphetamine use leads to elevated plasma cortisol and corticosterone levels via hyper-activation of the hypothalamic-pituitary-adrenal axis. Ecstasy use has been shown to cause an acute increase in cortisol levels of around 150% in sedentary humans and 800% in dance clubbers. Excess glucocorticoids promote Hᶧ secretion from kidneys via mineralocorticoid receptors contributing to alkalosis. DKA/HHS patients usually present with eunatremia/hyponatremia. Adult schizophrenics who receive psychostimulants have been shown to develop polydipsia and hyponatremia. Ecstasy intoxication can precipitate both DKA and hyponatremia in Type1 diabetics. Combined DKA/HHS and hypernatremic hyperosmolarity has been reported due to huge intake of sugar-rich carbonated beverages to quench thirst especially in pediatric population. There is frequent association between decompensated diabetes and illicit drug use. Substance abuse should be suspected in young Type 1 diabetics presenting with recurrent hyperglycemic emergencies especially with atypical biochemical features. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.