Massive noninflammatory periportal liver necrosis following concentrated acetic acid ingestion

Lethal toxicity induced by combined ingestion of dietary acetic acid and carbamazepine

Acetic acid is an organic acid that can be used in the food industry, which normally has an insignificant rate of adverse reactions when used rationally. However, irrational use can cause serious toxic effects and even death. In this context, the case of a death of a 52-year-old woman, involving the suspected voluntary use of food acetic acid, is presented, while toxicological and histopathological aspects were addressed for death mechanism elucidation. In this case, the pH value of 6.75 in blood, has shown severe metabolic acidosis after the ingestion of the large quantity of dietary acetic acid - about a liter. Also, the victim suffers from mental illness, carbamazepine being one of the treatment drugs. Liver damage, demonstrated by histopathological examination may be a consequence of both massive accumulation of carbamazepine in the liver and toxicity of food acetic acid. In conclusion, the hepatotoxicity induced by high level of carbamazepine was suspected of increasing the risk of multiple organ failure, in the context of acetic acid acute toxicity, highlighting the particularities of the case.

Plant and Fungal Hepatotoxicities of Cattle in Australia, with a Focus on Minimally Understood Toxins

Plant- and fungus-derived hepatotoxins are a major cause of disease and production losses in ruminants in Australia and around the world. Many are well studied and described in the literature; however, this is not the case for a number of hepatotoxicities with economic and animal welfare impacts, such as acute bovine liver disease (ABLD), brassica-associated liver disease (BALD) and Trema tomentosa, Argentipallium blandowskianum and Lythrum hyssopifolia toxicity. Additionally, significant overlap in the clinical presentation and pathology of these conditions can present a diagnostic challenge for veterinarians. This review summarizes the current and most recently published knowledge of common plant- and fungus-associated hepatotoxins affecting cattle in Australia, with a focus on the mechanisms of toxicity and distinguishing diagnostic features. Consolidation of the current understanding of hepatotoxic mechanisms in cattle provides insight into the potential mechanisms of lesser-known toxins, including cellular and subcellular targets and potential metabolic pathways. In the absence of specific etiological investigations, the study of epidemiological, clinical and pathological features of hepatotoxicity provides valuable insights into potential toxic mechanisms and is integral for the successful diagnosis and management of these conditions.

Successful management of 70% acetic acid ingestion on the intensive care unit: A case report

Acetic acid is an organic acid available in concentrations from 2 to 80%. Whilst lower concentrations of 2-6% are more commonly used as the table top condiment, vinegar, much stronger solutions are regularly used in Eastern Europe as food preservatives and cleaning solutions. Oral ingestion of greater than 12% has been reported to cause haemolysis, renal failure, shock and death. Most reported cases of deliberate or accidental poisoning are from Russia and Eastern Europe in the 1980s, with very little currently in western publications. We present the case of a female patient who attempted suicide by drinking 250 ml of 70% acetic acid. Her widespread gastrointestinal injuries were managed conservatively, and despite suffering extensive upper airway and renal complications, she was successfully decannulated and discharged home after a prolonged intensive care and hospital stay.

The Damage Pattern to the Gastrointestinal Tract Depends on the Nature of the Ingested Caustic Agent

BACKGROUND

The mechanisms of damage to the gastrointestinal tract after caustic ingestion are conditioned by the nature of the ingested agent. Whether the nature of the ingested agent has a direct influence on patient outcomes is unknown.

METHODS

From January 2013 to April 2015, 144 patients underwent emergency management for caustic injuries at the Saint Louis Hospital in Paris. There were 51 men (51 %) and the median age was 44 years [39, 48]. The ingested agents were soda-based strong alkali in 85 patients (59 %), strong acids in 36 patients (25 %), and bleach in 23 patients (16 %). Emergency and long-term outcomes were compared according to the nature of the ingested agent.

RESULTS

Four patients died (3 %) and 40 patients (28 %) experienced complications. After bleach ingestion, emergency morbidity and mortality were nil, no patient required esophageal reconstruction, and functional outcome was successful in all patients. Acids were more likely to induce transmural gastric (31 vs. 13 %, p =0.042) and duodenal (9 vs. 0 %, p = 0.04) necrosis than strong alkalis, but rates of transmural esophageal necrosis were similar (14 vs. 12 %, p = 0.98). No significant differences were recorded between emergency mortality (9 vs. 1 %, p = 0.15), morbidity (33 vs. 33 %, p = 0.92), the need for esophageal reconstruction (25 vs. 20 %, p = 0.88), and functional success rates (76 vs. 84 %, p = 0.31) after acid and alkali ingestion, respectively.

CONCLUSION

Bleach causes mild gastrointestinal injuries, while the ingestion of strong acids and alkalis may result in severe complications and death. Acids cause more severe damage to the stomach but similar damage to the esophagus when compared to alkalis.

Self-injection of household cleaning detergents into a ventriculoperitoneal shunt reservoir during a suicide attempt: a case report and literature review

Self-injection of household cleaning detergents (more specifically, commercial toilet bowl cleaner) into the reservoir of a ventriculoperitoneal shunt (VPS) has never been reported in the neurosurgical literature. A right-handed 41-year-old female with a past medical history significant for bipolar depression (with multiple prior hospital admissions for suicide attempts) and pseudotumor cerebri (status-post VPS placement from a right frontal approach) successfully injected ∼5 ml of toilet bowl cleaner into her ventricular shunt reservoir during a suicide attempt. She was found unresponsive by a family member 48 h after this event and presented to our hospital in moribund neurological condition (bilaterally fixed and dilated pupils with decerebrate posturing). Head computed tomography (CT) demonstrated marked ventriculomegaly. She was taken emergently to the operating room for placement of a left frontal ventriculostomy. Cerebrospinal fluid (CSF) sampled intraoperatively showed numerous Gram-positive cocci (later determined to be Staphylococcus epidermidis). For this reason, her right-sided shunt system was also removed in its entirety. She was treated with broad-spectrum intravenous and intraventricular antibiotics for her bacterial ventriculitis and her CSF was aggressively drained to treat her hydrocephalus. Once her infection had resolved, the shunt was replaced (using a right parietal approach) and she went on to make an excellent neurological recovery. Here, the authors present the case of a patient who self-injected household cleaning detergents into her VPS reservoir-and, likely, the ventricular system-during a suicide attempt and subsequently developed hydrocephalus and ventriculitis. Following this infrequent clinical scenario, consideration should be given to temporary ventriculostomy placement and shunt removal. Moreover, in patients with a known history of psychiatric co-morbidities-and particularly those patients with prior suicide attempts-the neurosurgeon should give serious consideration to placing the shunt system in an anatomical region which is difficult for the patient to self-access based upon their handedness.

Sudden death due to forced ingestion of vinegar

Vinegar is a clear colorless liquid that commercially consists of 5% acetic acid. It has numerous benefits in everyday use, including culinary, medical, and cleaning. The ingestion of concentrated acetic acid is strongly discouraged and may have detrimental consequences, such as acute pancreatitis, disseminated intravascular coagulopathy, gastric and hepatic complications, upper airway obstruction, or death. We report the first case in the literature of a 5-year-old boy who experienced a sudden death due to ingestion of distilled white vinegar. The manner was homicide. There was evidence of nonfatal blunt force impacts of the head, trunk, and extremities. A pungent aromatic odor of the viscera, gastric/small bowel contents, and cranial cavity was noted at autopsy. A dusky gray discoloration of the gastric mucosa, small bowel, and pancreas was observed. Forensic pathologists should consider ingestion of vinegar when confronted with a compelling history as well as an aromatic odor suggesting vinegar and dusky gray discoloration of the gastric mucosa and small bowel. While vinegar is a common household item and has several advantages, it may prove fatal if ingested in large quantities.

Evaluation of the morphological changes of gastric mucosa induced by a low concentration of acetic acid using a rat model

Oral ingestion of concentrated acetic acid causes corrosive injury of the gastrointestinal tract. To assess the effects of a low concentration of acetic acid on gastric mucosa, we examined the gastric mucosal changes in rats at 1 and 3 days after the injection of 5% or 25% acetic acid into the gastric lumen. The area of the gastric ulcerative lesions in the 25% acetic acid group was significantly larger than that in the 5% acetic acid group. The lesion area was reduced significantly at 3 days after injection in the 5% acetic acid group, whereas no significant difference in lesion area was observed at 1 and 3 days in the 25% acetic acid group. Histologically, corrosive necrosis was limited to the mucosal layer in the 5% acetic acid group, whereas necrosis extended throughout the gastric wall in the 25% acetic acid group. At 3 days post-injection, the 25% acetic acid group showed widespread persistent inflammation, whereas the 5% acetic acid group showed widespread appearance of fibroblasts indicative of a healing process. These results indicate that a low concentration of acetic acid damages the gastric mucosa and that the degree of mucosal damage depends on the concentration of acetic acid.

Factors predicting the hospital mortality of patients with corrosive gastrointestinal injuries receiving esophagogastrectomy in the acute stage

OBJECTIVES

The aim of this study was to identify the preoperative factors that affect the survival of patients who undergo esophagogastrectomy after corrosive ingestion, using analysis of their physiological condition, associated diseases, physical examination, and laboratory data.

METHODS

Between January 1995 and December 2005, 71 consecutive patients who underwent esophagogastrectomy for corrosive ingestion injuries were retrospectively reviewed. Of them, 41 survived and 30 (42.3%) died during the perioperative period. Logistic regression analyses were used to model markers for postoperative mortality, including descriptive data, clinical symptoms/signs, and laboratory data.

RESULTS

There were 35 males and 36 females included in the study, with an average age of 54.7 +/- 14.9 years. After adjustments in the logistic regression model, age of over 65 years (p = 0.021), presence of gross hematuria (p = 0.016), twofold level of serum AST (p = 0.012), blood pH level below 7.2 (p = 0.017), and deficit of blood base over 16 (p = 0.007) were found to be independent risk factors for patient mortality.

CONCLUSIONS

We consider age over 65 years, preoperative pH < 7.2, base deficit >16, twofold level of serum AST, and presence of gross hematuria to be the important factors predicting postoperative hospital mortality in patients presenting with corrosive ingestion injuries who require emergency surgery.

CT Imaging of Gastric and Hepatic Complications After Ingestion of Glacial Acetic Acid

OBJECTIVE

To document the computed tomographic (CT) image features of gastric and hepatic complications after ingestion of glacial acetic acid.

MATERIALS AND METHODS

There were 5 patients (2 men and 3 women; age range, 2-84 years) who had ingested glacial acetic acid to commit suicide or accidentally. Their abdominal and chest CT scans were retrospectively reviewed to detect and evaluate visceral organ injury. Clinical and laboratory data were also reviewed.

RESULTS

Diffuse edematous wall thickening of esophagus and stomach was observed in all patients. Three patients showed nonenhancing, wedge-shaped low densities in the liver on portal venous phase abdominal CT scans. These 3 patients also showed laboratory findings to indicate hepatic failure, hemolysis, metabolic acidosis, and disseminated intravascular coagulation. Two of these patients died despite vigorous supportive treatment.

CONCLUSIONS

Wedge-shaped low densities can be seen in the liver on CT scans after ingestion of glacial acetic acid. They may represent hepatic necrosis caused by the direct effect of toxic materials absorbed into portal circulation.

Ingestion of acid and alkaline agents: outcome and prognostic value of early upper endoscopy

BACKGROUND

Ingestion of caustic substances often leads to severe morbidity and, frequently, death. This study compared complications and survival for patients who ingested an acidic substance, mainly glacial acetic acid, or an alkaline agent.

METHODS

Records for 179 patients hospitalized for ingestion of a caustic agent (85 acid [75 glacial acetic acid], 94 alkali) were reviewed. Mucosal injury, systemic and GI complications, and survival were scored.

RESULTS

Outcome was less favorable for patients who ingested acid compared with those who ingested alkali with respect to mucosal injury (median: grade 2 vs. grade 1; p=0.013), hospital stay (mean: 9.9 vs. 7.2 days; p=0.01), admittance to the intensive care unit (44% vs. 22%; p=0.002), systemic complications (24% vs. 3%; p < 0.001), perforation (6% vs. 0%; p=0.017), and mortality (14% vs. 2%; p=0.003). There was no difference in the development of strictures (acid, 15% vs. alkali, 17%). The grade of mucosal injury at endoscopy was the strongest predictive factor for the occurrence of systemic and GI complications and mortality (relative risk 9: 95% CI[3, 30]). Ten of 29 (34%) patients with strictures were treated by endoscopic dilation alone, whereas the others primarily (n=7) or secondarily (n=11) underwent surgery. One patient with an esophageal stricture died from systemic complications.

CONCLUSIONS

Acid ingestion, particularly glacial acetic acid, is associated with a higher frequency of complications and mortality rate than alkali ingestion. Early endoscopy probably is safe and provides important prognostic information. Endoscopic treatment of caustic-induced strictures is only moderately successful.