A 40-year-old man is brought to the emergency department due to retrosternal and epigastric pain after ingesting an unknown amount of sodium hydroxide-based drain cleaner 45 minutes ago. He has a history of major depressive disorder and a prior suicide attempt. The patient has difficulty swallowing his saliva and is drooling. Temperature is 36.8 C (98.2 F), blood pressure is 120/70 mm Hg, pulse is 110/min, and respirations are 20/min. Examination shows oropharyngeal erythema and mild edema. The lungs are clear to auscultation. Abdominal examination shows tenderness at the epigastrium without rebound or guarding. Chest x-ray reveals no abnormalities. Intravenous normal saline infusion is initiated. Which of the following is the most appropriate next step in management of this patient?

Question

A 40-year-old man is brought to the emergency department due to retrosternal and epigastric pain after ingesting an unknown amount of sodium hydroxide-based drain cleaner 45 minutes ago.  He has a history of major depressive disorder and a prior suicide attempt.  The patient has difficulty swallowing his saliva and is drooling.  Temperature is 36.8 C (98.2 F), blood pressure is 120/70 mm Hg, pulse is 110/min, and respirations are 20/min.  Examination shows oropharyngeal erythema and mild edema.  The lungs are clear to auscultation.  Abdominal examination shows tenderness at the epigastrium without rebound or guarding.  Chest x-ray reveals no abnormalities.  Intravenous normal saline infusion is initiated.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d1cf_6754_bc81_4337170c4395_MD0003_00 This patient who ingested sodium hydroxide (a strongly caustic alkaline solution) now has pain, dysphagia, and erythema of the oropharynx, which is concerning for caustic esophageal injury. This injury can be caused by ingestion of: acidic substances, which cause coagulation necrosis (eg, protein denaturation) that results in an eschar, thereby preventing further acid penetration and injury. alkaline substances (eg, many cleaning supplies), which cause liquefactive necrosis (eg, cell membrane dissolution) that often leads to deeper penetration of tissues and therefore more severe injuries. Mucosal injury results from contact with the caustic substance (rather than from systemic absorption); therefore, patients often have immediate oropharyngeal, retrosternal, or epigastric pain as well as dysphagia and hypersalivation (eg, drooling). Vomiting and hematemesis may also occur. Patients should initially undergo assessment and stabilization of the airway, breathing, and circulation. Serial chest and abdominal x-rays should be obtained to identify any signs of perforation, such as pneumomediastinum, pleural effusions, or subdiaphragmatic air (none of which are seen in this patient). An upper gastrointestinal x-ray study with water-soluble contrast should be performed in patients with suspected perforation. The severity of esophageal injury cannot be predicted by either clinical symptoms or the extent of oral injury seen on physical examination. Therefore, in the absence of perforation or severe respiratory distress, endoscopic evaluation within the first 24 hours is recommended to assess the severity of esophageal damage. (Choice A) Activated charcoal can decrease the systemic absorption of poisons; however, caustic ingestions cause immediate local damage on contact with the esophagus. In addition, charcoal would obstruct the view during endoscopy. (Choice B) Inducing vomiting with ipecac is not appropriate because it would reexpose the esophagus to the caustic agent and potentially cause further injury. (Choice C) Corticosteroid therapy has been hypothesized to reduce the risk of late complications (eg, stricture) but has not been shown to be effective. In addition, it may increase the risk of secondary infections. (Choice D) Because esophageal damage occurs instantaneously, neutralizing agents are not effective. In addition, acid-base reactions are exothermic and could cause further injury. Educational objective: Caustic alkali ingestion causes immediate esophageal injury with liquefactive necrosis. In stable patients with no evidence of perforation, endoscopy should be performed within the first 24 hours to assess the severity of the injury and guide further management. References: Corrosive injury to the GI tract in adults: a practical approach. (http://www.ncbi.nlm.nih.gov/pubmed/19929589) Caustic ingestion in adults: the role of endoscopic classification in predicting outcome. (http://www.ncbi.nlm.nih.gov/pubmed/18655708) Endoscopic findings and outcome in caustic ingestion of acidic and alkaline agents in adults: a retrospective analysis. (http://www.ncbi.nlm.nih.gov/pubmed/31464902)

A 40-Year-Old Man Is Brought to the Emergency Department Due