PYLORIC STENOSIS: AN UNUSUAL COMPLICATION OF ALKALINE CORROSIVE POISONING*

Transcription

1 NOVEMBER, 1968 PYLORIC STENOSIS: AN UNUSUAL COMPLICATION OF ALKALINE CORROSIVE POISONING* By VIVIAN J. HARRIS, M.D.t COLUMBUS, T HE swallowing of an alkaline corrosive, such as sodium hydroxide (lye), although frequently causing esophageal narrowing, seldom results in pyloric or antral stenosis. By neutralizing ingested alkali, the gastric acid secreted by the stomach protects the stom 27 8, 9, 13 In contrast, the ingestion of an acid corrosive often leads to pyloric or antral stenosis. The purpose of this paper is to report 2 patients who developed severe stenosis of the gastric antrum as an unusual complication of alkali ingestion. In addition, a third patient is reported who acquired a similar lesion after swallowing acid. REPORT OF CASES CASE I. After accidentally ingesting Drano (54.2 per cent sodium hydroxide), L.L., a 22 year old white man, experienced esophageal burns and stricture. Upon improving in the hospital, he was discharged on a regimen of esophageal self-dilatations. He re-entered University Hospital 6 weeks after the initial episode complaining of weight loss, postprandial vomiting, and esophageal pain. An upper gastrointestinal series showed moderate pyloric obstruction and esophageal stricture (Fig. I; and 2). Laparotomy revealed gastric dilatation and a shortened, scarred pylorus. The gastric antrum was resected and a Billroth I anastomosis done. The patient did well postoperatively. CASE II. B.R., a 41 year old white woman swallowed a teaspoonful of lye while attempting suicide. Her buccal mucosa, tongue and pharynx became markedly inflamed. Nine days later, except for showing edematous gastric mucosa, the esophagogram and upper gastrointestinal series were normal (Fig. 3). Ten days after these studies, however, a repeat upper gastrointestinal series showed that the lower esophagus was narrowed and the gastric antrum markedly stenosed (Fig. 4). A month after she was admitted, laparotomy OHIO revealed the distal half of her stomach to be narrowed and fibrosed, grossly resembling linitis plastica. After a gastrostomy and jejunostomy were done, the patient improved and was discharged. CASE III. L.W., a 40 year old white woman, attempted suicide by drinking Sno-Bowl toilet cleaner ( per cent hydrogen chloride) and antifreeze. Soon after ingesting the acid, she felt severe burning of the mouth and pharynx. She entered University Hospital the next day complaining of painful swallowing. Indirect laryngoscopy showed burns of the hypopharynx and epiglottis. Direct esophagoscopy revealed esophageal burns, although the esophagogram was normal. After being treated for 2 weeks with adrenal corticosteroids and * From the Department of Radiology, Ohio State University College of Medicine, Columbus, Ohio. t Assistant Professor of Radiology. 594

2 \OL. 104, No. 3 Pvloric Stenosis 595 esophageal dilatations, she was able to swallow soft foods and was discharged from the hospital. She re-entered a week later because she had begun to vomit a half-hour after meals. An upper gastrointestinal series now showed a stricture of the distal end of the stomach, although the esophagus again appeared normal (Fig. ). Laparotomy revealed an indurated stomach, with scarring of its lesser curvature and thickening, fibrosis, and stenosis of its distal inches. The patient, after undergoing a subtotal gastrectomy, recovered completely. FIG. 2. Case i. Upper gastrointestinal examination made 6 weeks after Drano was ingested shows pyloric stenosis. DISCUSSION Since Robert described the first case in 1828, over 200 cases of pyloric stenosis caused by ingestion of corrosives have been reported. Gray and Holmes reviewed the literature up to 1948 in detail. In 1959, a further survey by Nevin and co-workers brought the total number of reported cases to 170. Usually lye ingestion fails to cause pvloric stenosis. Heindl6 found that pyloric stenosis occurred in only 20 per cent of 116 patients who had esophageal stricture due i ic. 3. Case II. Nine days after the patient ingested lye, a posteroanterior roentgenogram of the stomach shows edema of the gastric mucosa. to lye ingestion. In general, alkaline corrosives attack the squamous epithelium of the esophagus while acid corrosives attack the columnar epithelium of the stomach. The passage of alkaline corrosives tends to stop or slow down at or before the cardioesophageal junction. Once alkaline corrosives have entered the stomach, however, they usually are quickly neutralized.2 0 Testa 4 used fluoroscopy to follow a mixture of caustic soda and barium that he introduced into the esophagus of dogs. The alkaline corrosive mixture flowed along the lesser curvature of the stomach Fic.. Case ii. Ten days after the study shown in Figure 3. The upper gastrointestinal roentgenogram now shows marked narrowing of the gastric antrum.

3 596 Vivian J. Harris NOVEMBER, 1968 l ic. #{231}. Case III. Three weeks after acid ingestion. The outlet of the stomach is markedly narrowed. The proximal portion of the antrum is retracted upwards. to the pylorus where severe antral spasm occurred. When ingested corrosives injure the stomach, the site and severity of the lesion are influenced by several factors including the amount of stomach contents, the occurrence of spasm, the dependent position of the gastric antrum and even the presence of suicidal intent. If the stomach is full, ingested acid follows along the lesser curvature to the gastric outlet, producing pyloric stenosis through direct contact. Less frequently, mu cosal erosion immediately proximal to the spastic segment results in an hourglass deformity.4 If the stomach is empty, so that neutralization by food is absent, the ingested acid may destroy the lower half of the stomach. If either acid or alkaline corrosives have been ingested, the dependent position of the gastric antrum favors localization of the lesion to the outlet of the stomach. A suicidal intent leads to more extensive scarring of the stomach. The suicidal patient, feeling a severe pain in the mouth, swallows quickly; this causes the corrosive material to pass more rapidly into the stomach, where it can affect the pylorus. #{176} After ingestion, caustic substances cause mucosal swelling, followed by inflammation and necrosis of both the mucosa and submucosa and the formation of local venous thrombi. Eventually, healing takes place through fibrosis and scarring. As happened in our 3 patients, symptoms of gastric obstruction are usually delayed until I to 4 weeks after the ingestion of corrosives SUMMARY i. Pyloric stenosis is common after acid ingestion. It seldom occurs after alkali, or lye, ingestion. 2. In patients who have swallowed corrosives, the gastric outlet may become obstructed several weeks after the initial acute reaction has subsided. 3. The site of obstruction depends not only on the kind of corrosive ingested, but also on the condition of the stomach when the corrosive is swallowed. Department of Radiology Ohio State University College of Medicine 410 West ioth Avenue Columbus, Ohio REFERENCES I. BERRY, W. B., HALL, R. A., and JORDAN, G. L., JR. Necrosis of entire stomach secondary to ingestion of corrosive acid: report of patient successfully treated by total gastrectomy. Am. 7. Surg., 1965, 109, BOIKAN, W. S., and SINGER, H. A. Gastric sequelae of corrosive poisoning. Arch. mt. Med., 1930, 46, BOLSTAD, D. S. Pyloric obstruction and stricture of esophagus following ingestion of lye (sodium hydroxide mixed with sodium carbonate). Arch. Otolaryng., 1948, 47, I 8o-i GRADMAN, R., GERBER, S. T., and KAISER, J. Corrosive pyloric stenosis. Illinois M. 7., 1951, zoo,

4 VOL. 104, No. 3 Pyloric Stenosis 597 g. GRAY, H. K., and HOLMES, C. L. Pyloric stenosis caused by ingestion of corrosive substances: report of case. S. Clin. North America, 1948, 28, HEINDL, D. Quoted by W. S. Boikan and H. Singer.2 7. HERRINGTON, J. L., JR. Stenosis of gastric antrum and proximal duodenum resulting from ingestion of corrosive agent. Am. 7. Surg., 1964, 107, MARKS, I. N., BANK, S., WERBELOFF, L., FARMAN, J., and Louw, J. H. Natural history of corrosive gastritis: report of five cases. Am. 7. Digest. Dii., 1963, 8, MCLANAHAN, S. Pyloric occlusion following ingestion of corrosive liquids. 7.A.M.A., 1934, 102, MILEwICz, Z. Radiologic picture of burns of upper alimentary tract by corrosive poisons. Polish Rev. Radiol. & Nuclear Med., 1964, 28, II. NEVIN, I. N., TURNER, W. W., and GARDNER, H. T. Early and late roentgenologic findings in corrosive gastritis: report of case. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1959, 8!, 6o3-6o POTESHMAN, N. L. Corrosive gastritis due to hydrochloric acid ingestion: report of case. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1967, 99, SCHULENBERG, C. A. R. Corrosive stricture of stomach: without involvement of esophagus. Lancet, 1941, 2, TESTA, G. F. Quoted by Schulenberg.

5 This article has been cited by: 1. Maulana Mohammed Ansari, Shahla Haleem, Syed Hasan Harris, Roobina Khan, Iqbal Zia, Mohammed Hanif Beg Isolated corrosive pyloric stenosis without oesophageal involvement: An experience of 21 years. Arab Journal of Gastroenterology 12:2, [CrossRef] 2. Lowell Livingston Davis, John Raffensperger, Gertrude Martha Novak Necrosis of the Stomach Secondary to Ingestion of Corrosive Agents. Chest 62:1, [CrossRef]