A 22-year-old man is brought to the emergency department by paramedics after his mother found him lying on the bathroom floor. Paramedics found him barely conscious with an empty bottle of bleach lying next to him. His mother states that he drank the entire bottle. He had mentioned to his mother that he wanted to end his life after his recent break-up with his girlfriend. He is lethargic, but complains of severe pain and a burning sensation in his throat.
His other medical problems include major depression and post-traumatic stress disorder. His sister also suffers from depression. His medications include nortriptyline and fluoxetine, which he had not been taking for the past several days. He has no known drug allergies.
His temperature is 37.2 C (99.0 F), blood pressure is 90/60 mm Hg, pulse is 104/min, and respirations are 22/min. Examination shows severe pharyngeal erythema/exudates, clear lungs, and normal first and second heart sounds. His abdomen is soft and tender with decreased bowel sounds. There is no rebound tenderness or rigidity.
Intravenous fluids were started. Chest and abdominal x-rays showed no evidence of free air or pleural effusions and were essentially unremarkable.
Which of the following would be the most appropriate next step in management?

Question

A 22-year-old man is brought to the emergency department by paramedics after his mother found him lying on the bathroom floor.  Paramedics found him barely conscious with an empty bottle of bleach lying next to him.  His mother states that he drank the entire bottle.  He had mentioned to his mother that he wanted to end his life after his recent break-up with his girlfriend.  He is lethargic, but complains of severe pain and a burning sensation in his throat.
His other medical problems include major depression and post-traumatic stress disorder.  His sister also suffers from depression.  His medications include nortriptyline and fluoxetine, which he had not been taking for the past several days.  He has no known drug allergies.
His temperature is 37.2 C (99.0 F), blood pressure is 90/60 mm Hg, pulse is 104/min, and respirations are 22/min.  Examination shows severe pharyngeal erythema/exudates, clear lungs, and normal first and second heart sounds.  His abdomen is soft and tender with decreased bowel sounds.  There is no rebound tenderness or rigidity.
Intravenous fluids were started.  Chest and abdominal x-rays showed no evidence of free air or pleural effusions and were essentially unremarkable.
Which of the following would be the most appropriate next step in management?

Quizplus · Accepted Answer

The severity of caustic esophageal injury is dependent upon the ingested substance's corrosive properties, amount and concentration, and duration of contact with the mucosa. Absence of oral injury does not rule out esophageal involvement. Alkali ingestion can cause liquefactive necrosis in the esophagus that spreads within seconds to minutes through the esophageal wall towards the mediastinum. This process can last for 3-4 days with slow healing of the esophageal mucosa taking up to 1-3 months. Patients typically present with dysphagia/odynophagia, retrosternal pain, vomiting, and occasional hematemesis. Serial chest and abdominal x-rays should be obtained to identify any perforation. In the absence of perforation, early endoscopic evaluation within the first 24 hours is recommended in hemodynamically stable patients to assess and grade esophageal involvement. More severe grades of esophageal injury may lead to perforation, strictures, bleeding, or death. Therefore, endoscopy helps to risk stratify these individuals after achieving initial stabilization. Esophagectomy may be indicated in patients with perforation, mediastinitis, or severe strictures. All patients with alkali ingestion should have routine screening for esophageal cancer up to 15-20 years after ingestion. (Choice A) Up to one-third of patients with caustic injury eventually develop esophageal strictures. Barium swallow can be helpful in evaluating these patients; however, it has no role in acute management. (Choice B) Corticosteroids do not prevent the development of esophageal strictures. They may increase the risk of secondary infections and are not indicated in such cases. (Choice C) Nasogastric tube insertion is usually blind and should be avoided in patients with recent corrosive ingestion, as it could induce perforation. (Choice D) Weak acid should not be given orally to patients with alkali ingestions since such reactions usually generate excess heat and cause further damage to the mucosa. Also, the damage from alkali occurs instantaneously with ingestion and would not benefit from weak acid administration. Educational objective: In a case of corrosive ingestion after initial stabilization is achieved, endoscopy should be performed to grade the severity of injury. Steroids are not recommended in such cases. __________ References: Corrosive injury to the GI tract in adults: a practical approach (http://www.ncbi.nlm.nih.gov/pubmed/19929589) Ingestion of strong corrosive alkalis: spectrum of injury to upper gastrointestinal tract and natural history. (http://www.ncbi.nlm.nih.gov/pubmed/1539568)

A 22-Year-Old Man Is Brought to the Emergency Department by Paramedics