Severe gastrointestinal burn with hydrochloric acid
Herewith, we report the case of a 49-year-old male patient who had attempted suicide by drinking about 800 mL of 25% hydrochloric acid, and was in the Ankara Güven Hospital, Ankara, Turkey, in 2009. The patient was admitted to the Emergency Department within 30 minutes of ingestion of the corrosive liquid, with severe abdominal pain, agitation, and respiratory discomfort. Due to subsequent psychological problems, he had attempted to commit suicide. The patient, with a history of no previous systemic disorder, was evaluated by Gastroenterology, General Surgery, and Emergency Department practitioners, as also the İntensive Care Unit (ICU) team. On admission to the ICU, his consciousness was delirious in nature and he was confused. His blood pressure was 130/90 mmHg, heart rate 115/minute, oxygen saturation (SpO2) 90%, and respiratory rate 25 per minute. In the physical examination of the respiratory system, wheezing and prolonged expirium existed, together with fine rales. There were increased abdominal irritability and peritoneal irritation signs, but no pathological findings in the thoracoabdominal tomographic examination. There were ulcerative lesions, and bloody and dirty material in his mouth. His initial leucocyte count was 20.600 cell/uL, creatinine 1,68 mg/dL, aspartate aminotransferase 455 U/L, alanine aminotransferase 175 U/L, lactate dehydrogenase 701 U/L, gamaglutamyl transferase 110 U/L, sodium 152.1 mEq/L, potassium 3.21 mEq/L, pH 7.29, pO2 71 mmHg, pCO2 43 mHg, HCO3- 17.4 mmol/L, and SpO2 89%. Intravenous hydration, meperidine, antibiotics, nonsteroidal anti-inflamatory agents, methylprednisolone, and proton pump inhibitors were given for his symptoms. After admission to the Emergency Department, the patient was moved to the ICU and sedated with opioids and benzodiazepines, because of his agitative state. With nasal oxygen delivery his SpO2 was 98%. Nine hours after ingestion, due to gradually increasing metabolic ascidosis and respiratory deterioration, the patient was intubated and connected to the mechanical ventilator. Arterial, central venous, and urinary catheterization were performed. His Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 27 and estimated mortality rate was 61%. At the forty-eighth hour, because of extensive abdominal pain and serious respiratory discomfort, the thoracoabdominal computerized tomography (CT) was repeated []. An urgent surgical intervention was made because free abdominal fluid was detected on CT. During the operation, six liters of intra-abdominal fluid with infected material was aspirated. Total gastrectomy, duodenal resection, partial jejunectomy, and partial pancreatectomy were performed. Due to splenic hemorrhage, splenectomy was also applied [Figures - show pictures of the resected material]. Histopathological analysis of the surgical material revealed stage IIIb necrosis, which was also called ‘black necrosis’. Hemogram and electrolyte levels were closely followed up during the perioperative period. The blood components were given and fluid replacements were administered when needed.\nThe patient was extubated eight days after the operation, without deterioration of oxygenation. However, he had abdominal infections and / or serious metabolic problems in common, such as, lactic ascidosis or low serum sodium bicarbonate levels, due to abdominal low perfusion andrenal insufficiency. After surgery, antibiotherapy, parenteral nutrition, and palliative care were applied to the patient for 140 days, 105 of which passed in the ICU. Nine complemantary or intra-abdominal debridement and clean-up surgeries were performed during this period. Oral nutrition was started on the one hundred and twenty-fifth day of hospitalization. Parenteral nutrition was gradually stopped and he was discharged with recommendations for Psychiatry, Gastroenterology, General Surgery, and Physical Therapy Departments on the one hundred and fortieth day. After six months, he came for a follow-up without any further complication.