Investigating the
predictive factors of gastrointestinal lesions due to consumption of household
sodium hypochlorite in pediatric and adult Rasht referral hospitals
Alireza
Badsar 1, Morteza Rahbar Taramsari 1, Mirsaeed Attarchi 2,
Hamid Mohammadi Kojidi 1*, Shohreh Maleknejad 3, Ehsan
Kazemnezhad Leyli 4, Erfan Badsar 5, Masihollah
Khayatzadeh 5
1 Department of
Forensic Medicine, School of Medicine, Social Determinants of Health Research
Center, Razi Hospital, Guilan University of Medical Sciences, Rasht, Iran
2 Department of
Forensic Medicine, School of Medicine, Inflammatory Lung Diseases Research
Center, Razi Hospital, Guilan University of Medical Sciences, Rasht, Iran
3 Department of
Pediatrics, School of Medicine, 17 Shahrivar Hospital, Guilan University of
Medical Sciences, Rasht, Iran
4 Department of
Biostatistics, School of Nursing and Midwifery, Road Trauma Research Center,
Guilan University of Medical Sciences, Rasht, Iran
5 Razi Clinical
Research Development Unit, Razi Hospital, Guilan University of Medical
Sciences, Rasht, Iran
*Corresponding
Author: Hamid Mohammadi Kojidi
* Email: h_mohammadi8778@yahoo.com
Abstract
Abstract
Introduction: Sodium hypochlorite is a corrosive substance with an alkaline nature
that can lead to intoxication. This study aimed to evaluate the demographic,
clinical, and endoscopic findings of swallowing this substance and to
investigate the predictive factors for the incidence of gastrointestinal
lesions in these patients.
Materials and Methods: In a retrospective study, all records of patients who were admitted to
Razi and 17 Shahrivar Hospitals in Rasht during the years 1386-96 were
evaluated by Endoscopy. Subsequently, the results were analyzed by SPSS v21
software including age, sex, cause of ingestion, volume of fluid swallowing,
referral time, clinical manifestations, and endoscopic findings.
Results: Of the 173 patients under study, there were 33 pediatric patients and
140 adult patients. 101 cases (58.4%) were female and 72 cases (41.6%) were
male. As reasons of swallowing, 102 cases (59%) were deliberate and 71 cases
(41%) were accidental. The most common treatment was proton pump inhibitor and
anti-vomiting. The most common symptom was nausea, seen in 135 patients (78%).
Coughing was the most common sign in 51 of the cases (29.5%). In adults, 51
cases were less than or equal to 0.5 glass, 64 cases were between 0.5 glass to
2 glasses and 25 were higher.
Conclusion: The results show that in volumes less than 1.5 glasses, damage has
either not been present or mild. Therefore, in volumes of less than 1.5
glasses, it is not necessary to perform endoscopy, and medical treatment and
patient monitoring are recommended.
Keywords: Caustics, Digestive system injuries, Endoscopy-digestive system,
Endoscopy-gastrointestinal, Sodium hypochlorite
Introduction
Sodium hypochlorite, known in Iran
as the WHITEX brand, is a corrosive substance with an alkaline nature that can
deliberately or accidentally lead to intoxication and damage to the digestive
tract. Sodium hypochlorite poisoning is one of the more common causes of acute
poisoning (1).
The damage done to the oral cavity
as well as the gastrointestinal tract, following ingestion, is a major cause
for concern as it can vary from mild inflammation of the esophagus to
perforations or necrosis (2, 3). Endoscopic
examinations are a routine part of assessing the damage done in the cases of
corrosive agent ingestion since it can provide a better management plan as well
as a treatment course for the physician (4-6). Among the
sign and symptoms with which the patients are presented, nausea and vomiting
are more common. Although, findings suggest that gastrointestinal damage may be
present as well. These include but are not limited to, dysphagia, drooling, and
epigastric pain (the latter indicates more severe damage). In extreme cases,
shock and ARDS (Acute Respiratory Distress Syndrome) have been reported (7-11). Many authors
and researchers believe that there is a rather weak correlation between
clinical manifestations of the patients and endoscopic findings. Therefore,
despite the fact that performing an endoscopic examination in patients with
sufficient indications is recommended, it is not part of the routine management
protocol (12-14).
The aim of this study was to
evaluate the demographic, clinical, and endoscopic findings of swallowing of
this substance and to investigate the predictive factors for the incidence of
gastrointestinal lesions in these patients.
Materials and Methods
In this
retrospective cross-sectional
study,
all documents of patients with Bleach poisoning admitted in Razi and 17
Shahrivar hospitals of Rasht
from March 2007 to March 2017 were assessed. These included both adult
and pediatric cases. This study was initiated after approval by the ethical committee of Guilan
University of Medical Sciences.
Variables such as age, gender,
cause of exposure, estimated ingested volume, duration between exposure and admission, time of
hospitalization, management,
signs and symptoms (abdominal pain, tenderness, guarding, nausea,
vomiting, drooling, skin burn, oral orifice burn, dysphonia, dyspnea, upper GIT
complications, erythema, dysphagia, retrosternal pain, etc.) and endoscopic
findings were extracted
and surveyed. Inclusion criteria were clinical manifestations such as upper GIT burns or nausea, accompanied
by a history of
exposure to bleach during the past 24 hours. Zargar's classification was used
to categorize the damage done to the esophagus, the stomach, and the duodenum.(13) In this classification, the grades
are as follows: normal mucus is 0, edema and swollen mucus is 1, erosion,
shallow ulceration, bleeding and a white membrane is 2a, should the findings of
grade 2a be accompanied by deep or annular ulcerations it was labeled 2b, in
cases of necrosis and multiple ulcerations it was 3a and lastly, massive
necrosis was graded 3b.
All patients received standard care.
Airway management and intravenous fluid resuscitation were the priorities.
Treatment with a proton pump inhibitor (pantoprazole) was the most common method
followed by the use of Metoclopramide (Plasil) but steroids and prophylactic
antibiotics were used In a few of the cases as well. Pantoprazole was initiated
at a dosage of 40 mg twice daily for all patients. If gastrointestinal bleeding
occurred, the dosage would change to 80 mg bolus followed by 8 mg per hour. At
the time of admission, ECG was taken and pulse oximetry was done, then blood
samples were drawn for arterial blood gas, complete blood count, serum
electrolytes, blood urea nitrogen, and creatinine. Frequency was used for
descriptive statistics regarding the characteristics of the patients, clinical
manifestations, and complications the patients faced. The severity of damage
done based on the volume of Sodium Hypochlorite ingested, age and gender of the
patients, as well as the duration of time spent prior to arrival in the
hospital, were compared through the use of mean ± standard deviation. Kruskal Wallis test
and Mann-Whitney U test were used to specify the most predictive factor in
gastrointestinal damages following sodium hypochlorite ingestion. The Spearman
correlation test and multiple logistic regression analyses were used to assess
the necessity of endoscopic evaluation in every case. Collected data were
analyzed with SPSS
software (version 21) and variables were presented as frequency and mean ± standard deviation (SD).
All the participants or their legal
proxies signed written informed consent. The patient's identity as well as
other information remains confidential and is not disclosed. The results of the
research are reported in the form of groups and should there be a need for
individual results, it is done without disclosing the patient's name. This study was approved by the Ethics
committee of Guilan University of Medical Sciences with the ethics code of "IR.GUMS.REC.1396.522".
Results
In our study, 177 cases were
evaluated (33 were pediatric cases). 72 (41.6%) of the cases were male patients
and the rest (58.4%) were females. The most frequent age group with sodium
hypochlorite poisoning were patients between 21-30 years of age (26.6%),
followed by patients who were between the ages of 13-20 (23.7%). In the
majority of cases (59.0%), Sodium hypochlorite was ingested with suicidal
intent and the rest (41.0%) was accidental. All of the pediatric cases were
accidental. The most frequent treatment option was the use of proton pump
inhibitors (PPIs e.g. Pantoprazole) alongside anti-nausea agents such as
Metoclopramide. PPIs were used in 161 of the cases (93.1%) and Metoclopramide
(Plasil) was used in the treatment of 95 patients (54.9%). The most common
symptom was nausea (135 of the cases or 78.0%), followed by vomiting in 120
patients (69.4%) and the third most common symptom was epigastric pain (56.6%).
The most frequent signs observed in the cases of this study were coughing
(29.5%), oral erythema (24.3%), hoarseness (3.5%), and hematemesis (2.9%). No
other clinically significant sign was recorded.
The ingested volume was measured
relative to a medium-size glass. 6 groups were devised to classify the patients
on that basis. Ingested volumes of between 0.5 and 1 glass were the most
frequent with 64 cases (37.0%), followed by ingested volumes less than 0.5 a
glass with 51 (29.5%). In all the pediatric cases (33) the volume of ingestion
was unknown. The volume of ingestion had a strong correlation (p<0.001) with
2+ grade damage in the esophagus as well as the stomach and the duodenum in
which an increase in volume intensified the severity of tissue damage. Other
than nausea, no other symptom had a statistically significant correlation with esophageal
damage. Nausea, vomiting, loss of appetite, burning sensation in the mouth, and
fatigue all had a connection to gastric damage. In the duodenum, nausea and
vomiting were correlated with duodenal damage. Signs of hematemesis and oral
erythema were also linked to the deterioration of the esophagus. Stomach
injuries had a statistically significant correlation with coughing and oral
erythema. There was also an association between hoarseness, oral erythema, and
hematemesis, and duodenal tissue damage.
According to the statistics,
referral time had no statistically significant effect on GI disturbances. On
the contrary, the ingested volume crucially affected how severe the damage in
the esophagus, stomach, and duodenum was (p<0.001, p<0.001, and p<0.001
respectively). Our data shows that the most frequent site of damage was the
stomach (63.6%), followed by the esophagus (52.6%) and lastly the duodenum
(9.2%). Tables 1 and 2 show the frequency and prevalence and the similarity of
distribution, respectively. Furthermore, the correlation between the severity
of damage done to each part and the signs and symptoms present was evaluated.
The severity of damage in the esophagus was associated with nausea, vomiting,
epigastric pain, and orodynia (p<0.05). The severity of damage in the
stomach was correlated with nausea, vomiting, dysphagia, abdominal pain, and
orodynia (p<0.05) and the duodenal damage intensity was statistically
correlated with vomiting and orodynia. The more severe the damage, the more
frequent the signs and symptoms became. Lastly, our data suggests that both
hoarseness and oral erythema are associated with grade 2+ damage in all 3 parts
of the gastrointestinal tube (p<0.001). However, hematemesis was only
associated with grade 2+ damage in the stomach and duodenum (p<0.001),
whilst coughing was exclusively associated with stomach damage (p<0.001).
Table
1. Frequency and prevalence of endoscopic findings in the upper
gastrointestinal tract.
|
|
Grade 0 |
Grade 1 |
Grade 2A |
Grade 2B |
Grade 3A |
Grade 3B |
Total |
|
|
Esophagus |
Frequency |
82 |
73 |
18 |
0 |
0 |
0 |
173 |
|
Percentage |
47.4% |
42.2% |
10.4% |
0.0% |
0.0% |
0.0% |
100.0% |
|
|
Stomach |
Frequency |
63 |
73 |
31 |
5 |
1 |
0 |
173 |
|
Percentage |
36.4% |
42.2% |
17.9% |
2.9% |
0.6% |
0.0% |
100.0% |
|
|
Duodenum |
Frequency |
157 |
11 |
5 |
0 |
0 |
0 |
173 |
|
Percentage |
90.8% |
6.4% |
2.9% |
0.0% |
0.0% |
0.0% |
100.0% |
|
Table 2. The similarity of distribution of
the upper gastrointestinal endoscopic findings in patients with bleach
poisoning.
|
Duodenal endoscopic findings |
Gastric endoscopic findings |
Total |
||||||||
|
Grade 0 |
Grade 1 |
Grade 2A |
Grade 2B |
Grade 3A |
||||||
|
Grade 0 |
Esophageal endoscopic findings |
Grade 0 |
Frequency |
41 |
31 |
9 |
0 |
|
81 |
|
|
Percentage |
50.6% |
38.3% |
11.1% |
0.0% |
|
100.0% |
||||
|
Percentage of all |
26.1% |
19.7% |
5.7% |
0.0% |
|
51.6% |
||||
|
Grade 1 |
Frequency |
21 |
33 |
9 |
1 |
|
64 |
|||
|
Percentage |
32.8% |
51.6% |
14.1% |
1.6% |
|
100.0% |
||||
|
Percentage of
all |
13.4% |
21.0% |
5.7% |
0.6% |
|
40.8% |
||||
|
Grade 2A |
Frequency |
1 |
2 |
8 |
1 |
|
12 |
|||
|
Percentage |
8.3% |
16.7% |
66.7% |
8.3% |
|
100.0% |
||||
|
Percentage of all |
0.6% |
1.3% |
5.1% |
0.6% |
|
7.6% |
||||
|
Total |
Frequency |
63 |
66 |
26 |
2 |
|
157 |
|||
|
Percentage |
40.1% |
42.0% |
16.6% |
1.3% |
|
100.0% |
||||
|
Percentage of
all |
40.1% |
42.0% |
16.6% |
1.3% |
|
100.0% |
||||
|
Grade 1 |
Esophageal endoscopic findings |
Grade 1 |
Frequency |
|
7 |
0 |
1 |
|
8 |
|
|
Percentage |
|
87.5% |
0.0% |
12.5% |
|
100.0% |
||||
|
Percentage of all |
|
36.6% |
0.0% |
9.1% |
|
72.2% |
||||
|
Grade 2A |
Frequency |
|
0 |
2 |
1 |
|
3 |
|||
|
Percentage |
|
0.0% |
66.7% |
33.3% |
|
100.0% |
||||
|
Percentage of
all |
|
0.0% |
18.2% |
9.1% |
|
27.3% |
||||
|
Total |
|
Frequency |
|
7 |
2 |
2 |
|
11 |
||
|
Percentage |
|
36.6% |
18.2% |
18.2% |
|
100.0% |
||||
|
Percentage of all |
|
36.6% |
18.2% |
18.2% |
|
100.0% |
||||
|
Grade 2A |
Esophageal
endoscopic findings |
Grade 0 |
Frequency |
|
|
1 |
0 |
0 |
1 |
|
|
Percentage |
|
|
100.0% |
0.0% |
0.0% |
100.0% |
||||
|
Percentage of
all |
|
|
20.0% |
0.0% |
0.0% |
20.0% |
||||
|
Grade 1 |
Frequency |
|
|
1 |
0 |
0 |
1 |
|||
|
Percentage |
|
|
100.0% |
0.0% |
0.0% |
100.0% |
||||
|
Percentage of all |
|
|
20.0% |
0.0% |
0.0% |
20.0% |
||||
|
Grade 2A |
Frequency |
|
|
1 |
1 |
1 |
3 |
|||
|
Percentage |
|
|
33.3% |
33.3% |
33.3% |
100.0% |
||||
|
Percentage of
all |
|
|
20.0% |
20.0% |
20.0% |
60.0% |
||||
|
Total |
|
Frequency |
|
|
3 |
1 |
1 |
5 |
||
|
|
|
Percentage |
60.0% |
20.0% |
20.0% |
100.0% |
||||
|
Percentage of all |
60.0% |
20.0% |
20.0% |
100.0% |
||||||
|
Total |
Esophageal
endoscopic findings |
Grade 0 |
Frequency |
41 |
31 |
10 |
0 |
0 |
82 |
|
|
Percentage |
50.0% |
37.8% |
12.2% |
0.0% |
0.0% |
100.0% |
||||
|
Percentage of
all |
23.7% |
17.9% |
5.8% |
0.0% |
0.0% |
47.4% |
||||
|
Grade 1 |
Frequency |
21 |
40 |
10 |
2 |
0 |
73 |
|||
|
Percentage |
28.8% |
54.8% |
13.7% |
2.7% |
0.0% |
100.0% |
||||
|
Percentage of all |
12.1% |
23.1% |
5.8% |
1.2% |
0.0% |
42.2% |
||||
|
Grade 2A |
Frequency |
1 |
2 |
11 |
3 |
1 |
18 |
|||
|
Percentage |
5.6% |
11.1% |
61.1% |
16.7% |
5.6% |
100.0% |
||||
|
Percentage of
all |
0.6% |
1.2% |
6.4% |
1.7% |
0.6% |
10.4% |
||||
|
Total |
Frequency |
63 |
73 |
31 |
5 |
1 |
173 |
|||
|
Percentage |
36.4% |
42.2% |
17.9% |
2.9% |
0.6% |
100.0% |
||||
|
Percentage of all |
36.4% |
42.2% |
17.9% |
2.9% |
0.6% |
100.0% |
||||
Discussion
The ingestion of caustic agents may
be life-threatening depending on the type of corrosive agents ingested (NaClO
vs other corrosives), clinical manifestations (hoarseness, orodynia, dysphagia,
skin burns, drooling, hematemesis, retrosternal pain, and epigastric pain), and
high-grade endoscopic findings (15). Based on the
information obtained from this study and statistical analysis; A significant
correlation was found in the esophagus, stomach, and duodenum between the
degree of injury and the volume of WHITEX consumed (p <0.001). According to
the findings, larger consumption volumes of WHITEX were directly linked to the
more detrimental damage in all three areas. As in consumptions larger than 1.5
cups, gastrointestinal damage was grade A2 or worse which was consistent with
the findings of a study by Kim et al. (16) in 2006 in South Korea. Based on
the aforementioned retrospective study, consuming less than 100 ml. was
significantly related to low degree findings in endoscopy. Overall, the study
suggested follow-up during hospitalization in patients who consumed less than
100 ml. of WHITEX because there were few signs or symptoms. The study found
emergency endoscopy unnecessary in such cases.
In the study conducted by Nikpour et
al. (17), the
correlation between the volume of consumption and the endoscopic findings
wasn't significant which can be attributable to studying the effects of both
acidic and basic solutions. According to the statistics, there was a
significant correlation between esophageal injury and the sign of vomiting (p
<0.023). Yet, other signs weren't significantly correlated. In other words,
of all the signs, only vomiting is related to the severity of damage to the
esophagus. Nausea, vomiting, loss of appetite, heartburn, weakness, and lethargy
were significantly associated with the injury in the stomach. Nausea, vomiting,
and abdominal pain were associated with the injury to the duodenum (p
<0.05). In the study of Ghoochani et al.(18), a significant correlation was
found between signs and the degree of injury, which was consistent with the
results of the present study in this regard. Furthermore, they reported a
statistically meaningful connection between the endoscopic findings and frequency
of hoarseness (p = 0.04), nausea and vomiting (p = 0.007), and sialorrhea (p =
0.044). A significant correlation was
found between the severity of damage to the esophagus and the signs of nausea,
vomiting, epigastric pain, and mouth burning in the aforementioned study. The
higher the degree of damage, the more frequent appearance of these signs (p
<0.05). Also, a significant connection was found between the severity of the
gastric injuries and signs of nausea, vomiting, Dysphagia, abdominal pain, and
heartburn in the statistical analysis (p <0.05). There was a significant
relationship between the degree of duodenal injury and vomiting and heartburn
(p <0.05). The symptom hoarseness was also significantly associated with the
degree of injury in all three areas (p <0.001). This means that in patients
with hoarseness, the frequency of grade 2 injury or worse is higher than the
patients without hoarseness. Also,
coughing was significant only in the severity of gastric injuries (p
<0.002). The presence of oral erythema was also significantly associated
with the degree of damage in all three areas (p <0.001). Hematemesis was
also associated with the degree of gastric and duodenal damage (p <0.001).
Ghoochani et al. (19) in a study in 2014 in Tehran on
patients with sodium hypochlorite poisoning reported a finding consistent with
the present study. The correlation between hoarseness (p = 0.04), nausea and
vomiting (p = 0.007), and sialorrhea (p = 0.044) were also reported to be
significant in this study.
In the present study, a significant
relationship was found between the volume of fluid consumed and the severity of
the damage, as in volumes of 1.5 glasses or above, gastrointestinal damage was
graded A2 or worse in most of the patients. In a study conducted by Quingking
et al. (20) in 2013, they also reported a
significant connection between the volume of consumed fluid and the degree of
injury, as well as the frequency of signs and symptoms in 36 patients with
sodium hypochlorite poisoning which was consistent with the results of the
present study. Besides, they reported that there was no significant correlation
between the degree of damage grading and leukocytosis. According to this study,
there was no significant connection between the severity of injury and referral
time in any of the areas investigated. In other words, the referral time did
not affect the severity of complications. This finding is consistent with the
2017 study by Nikpour et al. (17) as they also
did not report a significant link between the referral time and the degree of
injuries.
Conclusion
For patients without clinical
symptoms, emergency endoscopy is not required due to the lack of severe
complications in the study. In patients with clinical symptoms (at least three),
upper endoscopy and further examination are recommended. In patients with a
history of consuming more than 1.5 glasses, upper endoscopy and further
examinations are recommended. It is recommended that in all patients with a
history of ingestion of caustic agents, fixation with the time interval between
swallowing and referral should be avoided and more attention should be paid to
clinical signs, the volume ingested, and patient history. It is suggested that
a similar study be performed in a higher statistical population and a wider age
range on different types of acidic or alkaline corrosives. Also, in an accurate
history taking, the history of neurological problems, as well as a more
detailed examination of the signs and symptoms should be noted.
Author contributions
AB, MRT, MSA, SM,
EKL, EB, and MKh wrote and completed the article. HMK designed and edited the
manuscript. All authors confirmed the
final edited version.
Acknowledgment
We would like to thank to all hospital staff and specialists for
assistance with conforming and recording cases.
Conflict of
interest
The authors declare that they have no conflict of interest.
Funding
There is no funding.
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