Management of Extrahepatic Biliary Disease of Pregnancy: A Continuous Dilemma

Case Series

Austin Surg Case Rep. 2016; 1(1): 1004.

Management of Extrahepatic Biliary Disease of Pregnancy: A Continuous Dilemma

Li C¹, Kamine TH², Howell K³ and Odom SR4*

¹Department of Surgery, Harvard Medical School, USA

²Department of Surgery, Harvard Medical School, USA

³Harvard Medical School, USA

4Department of Surgery, Harvard Medical School, USA

*Corresponding author: Stephen R Odom, Department of Surgery, Beth Israel Deaconess Medical Center, 110 Francis Street, Suite 2-G, Boston, USA

Received: December 04, 2015; Accepted: February 03, 2016; Published: February 04, 2016


Caustic ingestions are uncommon clinical encounters. We present three cases of intentional severe alkali ingestion in adults and discuss management and treatment of these complex and unusual lesions. Clinical presentation depends on the agent used, the quantity ingested, affected tissue and time to presentation. Airway is an initial concern and should be addressed promptly. Initial workup should include chest x-ray to rule out pneumomediastinum or pneumothorax. Staging requires upper endoscopy and sometimes, computed tomography. Viscous perforation or peritonitis requires urgent surgery. Evidence of full thickness necrosis generally warrants exploration. Operative intervention can include esophageal, gastric or, less commonly, small bowel resection. Feeding access should be obtained at the first operation. Steroids and antibiotics are not recommended. Definitive reconstruction is more complex and can be accomplished once the acute inflammatory reaction has resolved. Often, psychiatric treatment will be needed in intentional injuries of this nature.


CT: Computed Tomogram; OR: Operating Room; EGD: Esophagogastroduodenoscopy; ICU: Intensive Care Unit; POD: Post Operative Day; HIV: Human Immunodeficiency Virus; HBV: Hepatitis B Virus; NGT: Nasogastric Tube


There are between 5000-15000 cases of acid or alkaline caustic ingestions per year in the United States [1]. Most cases occur in the pediatric population as accidents and occasionally as a result of child abuse. In the adult population, ingestions most often occur in patients with a psychiatric background, such as those with depression, schizophrenia or more commonly in those who attempt suicide [2]. The severity of injury depends on several factors including corrosive properties of the agent, concentration, amount and duration of contact, as well as the intent of the patient [1,3]. Short-term outcomes include perforation and death, whereas long-term complications include dysphagia, strictures or even esophageal carcinoma [1].

Caustic agents causing the most significant damage often have a pH less than 2 or greater than 12, with a range of injuries from mucosal burns to esophageal or gastric perforations to death [4]. The most frequently documented alkaline agents involved are common household cleaners such as drain or dishwater cleaners and batteries [1]. In this review, we highlight management of the adult ingestion patient and three alkaline agents: household bleach, sodium hydroxide, and potassium hydroxide.

Case Series 1 (Potassium Hydroxide)

A 46year-old male with history of depression and 3 previous suicide attempts presented after being found down and agitated at home. A 62 fluid-ounce bottle of potassium hydroxide 45% was found next to him with 30 ounces left in the bottle. He was intubated in the field and brought to the emergency room. At admission, he was afebrile with normal vital signs. His physical exam was notable for partial thickness chemical burns of the bilateral posterior lower legs and bilateral buttocks. His labs were significant for a leukocytosis of 19.1 K/uL. A Computed Tomogram (CT) scan of his torso showed no obvious extravasation of oral contrast.

The patient was taken to the Operating Room (OR) for laryngoscopy, bronchoscopy, and upper endoscopy. The laryngoscopy revealed significant erythema and edema of the posterior oropharynx, but the mucosa appeared intact. The remainder of the bronchoscopy was normal. The Esophagogastroduodenoscopy (EGD) revealed severe caustic injury to the entire esophagus beginning with level 3a injury at 18cm and worsening to level 3b injury by the Gastroesophageal (GE) junction. The stomach similarly showed grade 3b injury concentrated near the antrum, characterized by disrupted mucosa without frank perforation. The duodenum appeared uninjured. A laparotomy was performed, and the stomach was noted to be thickened with some areas of necrosis. A total gastrectomy was performed, and the patient’s abdomen was temporarily left open. The following day, the patient returned to the OR and underwent repeat esophagoscopy which noted worsening burns and full-thickness necrosis of the esophagus. He then underwent right thoracotomy with esophagectomy and cervical esophagostomy as well as a feeding jejunostomy.

He was initially transferred to the Intensive Care Unit (ICU) and was extubated on hospital day 2, and tube feeds were started on the following day. He was seen by the psychiatry service. His cutaneous chemical burns were noted to be partial thickness and were managed with non-adherent dressings. He tolerated advancement in tube feeds and was discharged to the inpatient psychiatric service on hospital day 14. Six weeks after surgery, he developed retching and was noted to have a stricture at the esophagostomy site. He subsequently underwent dilation with symptomatic improvement. He treated in an inpatient psychiatric unit for 2 months postoperatively and was discharged on lithium for bipolar disorder II. Twelve months after initial injury, he underwent reconstruction with a colonic conduit. Since the reconstruction, he has developed dysphagia; however, he has been able maintain oral intake and gain weight.

Case Series 2 (Sodium Hydroxide)

A 53 year-old male without medical or psychiatric history presented to the emergency room following a suicide attempt where he consumed 12 ounces of Liquid Plumr® (0.5-2% sodium hydroxide and 5-10% sodium hypochlorite) and slashed his abdomen and thorax more than 30 times with a box cutter. He was found after an unknown down time and Emergency Medical Services was called. A chest radiograph showed no effusion, pneumothorax or pneumomediastinum. His electrolytes on admission were significant for sodium 150mEq/L, chloride 117mEq/L and bicarbonate 23mEq/L.

Urgentlaryngoscopy, bronchoscopy, and EGD were performed in the OR. Laryngoscopy revealed hyperemic mucosa. Bronchoscopy was normal. EGD revealed significant mucosal necrosis (grade 3b) of the distal esophagus and patchy necrosis in the cardia and the antrum. The duodenum was found to have Zargar grade [1] injury with superficial hyperemia but no necrosis. Since the necrosis appeared localized to the distal esophagus, a left thoracoabdominal incision was made. The stomach had multiple patchy areas of fullthickness necrosis. An esophagogastrectomy was performed with a Roux-en-Yesophagojejunostomy for primary reconstruction, with feeding jejunostomy.

He was unable to be extubated postoperatively due to significant airway edema. On hospital day 5 he underwent percutaneous tracheostomy placement. The following day, he was weaned to tracheostomy collar, and psychiatry was consulted. Lower extremity ultrasounds performed for leg swelling revealed a deep venous thrombosis for which he was started on heparin, which was bridged to Coumadin on discharge. On the seventh postoperative day, he underwent a barium swallow study, which showed an intact anastomosis. He was discharged to the psychiatry inpatient service on hospital day 15. He was discharged from the inpatient psychiatry unit after one month on bupropion and haloperidol for depression with psychotic features and has been doing well in follow up.

Case Series 3 (Sodium Hypochlorite)

A 50 year-old male with a history of Human Immunodeficiency Virus (HIV) and Hepatitis B Virus (HBV) presented to the ER following a suicide attempt in which he drank a half gallon of household bleach (5-10% sodium hypochlorite). An EGD was performed which revealed significant erythema of the esophagus (Figure 1a) along with friability, erythema, and focal necrosis of the stomach (Figure 1b - grade 3a injury). A CT scan showed thickening of the stomach and esophagus but no evidence of perforation. The following day he developed hematemesis, worsening abdominal pain, hiccups, and sinus tachycardia to the 140s. His electrolytes were significant for sodium 142mEq/L, chloride 116mEq/L and bicarbonate 17mEq/L.

Citation: Li C, Kamine TH, Howell K and Odom SR. Alkali Ingestion in Adults: A Case Series. Austin Surg Case Rep. 2016; 1(1): 1004.