Accidental Caustic Exposure from Ingestion of Contaminated Beer: A Case Series

Abstract

Introduction

This report presents three cases of unintentional ingestion of beer line cleaner (BLC), a strongly caustic alkaline solution (pH 13–14). In each incident, unflushed BLC entered the draft system and was served as drinkable beer (pH 4.0–4.5) in different taverns due to deficiencies in regulatory oversight and enforcement.

Case Presentations

A 37-year-old female, a 37-year-old male, and a 40-year-old male presented with esophageal injuries after consuming contaminated beer in unrelated events. Endoscopy revealed findings ranging from erythema and esophageal nodules to benign strictures and very severe Grade D esophagitis. Patients required extended proton pump inhibitor therapy and dietary changes, and they experienced ongoing symptoms, including dysphagia, reflux, taste alterations, and weight loss.

Conclusion

This case series highlights the serious and lasting consequences of BLC ingestion and underscores the need for standardized beer line flushing protocols, tracer dyes, and point-of-use testing to prevent future exposures in commercial establishments where uniform regulations are insufficient. It also demonstrates the underreported health risks associated with accidental BLC ingestion. Greater physician awareness can facilitate earlier diagnosis and treatment and improve outcomes. Enhanced reporting of BLC ingestion can increase identification of caustic hazards and strengthen public health awareness of this largely unrecognized risk.

Introduction

Beer, a beverage widely consumed globally, is produced by fermenting grain-derived sugars with added flavoring compounds [1]. Modern draft beer systems in taverns require consistent maintenance to preserve quality and safety, which depend on proper storage, handling, and dispensing [2]. The Brewer’s Association recommends biweekly alkaline cleaning and quarterly acid cleaning, followed by thorough water rinsing [2]. However, beer line cleaner (BLC), which typically has a pH of 13–14, can persist in lines when inadequately flushed, and create a major hazard to patrons. Industry surveys provide insight on how often draft lines are actually cleaned versus the recommended cleaning schedule. In one survey, only 43% of accounts reported cleaning their draft lines every 2 weeks (the recommended minimum), with 36% reporting a monthly cleaning, and others reporting only sporadic cleaning when time allowed [3].

Caustic ingestions account for 9.28% of poisoning cases in the USA [4]. Esophagogastroduodenoscopy (EGD) is key for diagnosis and is often paired with computed tomography of the chest and abdomen to evaluate upper gastrointestinal tract injury severity [4]. Current recommendations advise performing endoscopy within 24–48 h after accidental ingestion to characterize injuries and optimize outcomes [4].

Over a 3-year period, the 3 patients in this case series, all from the same county, presented with symptoms of caustic ingestion after unintentionally consuming BLC served as beer in local taverns. These individuals sustained injuries to the oral cavity, tongue, and esophagus, including esophageal mucosa scarring. Ingestion resulted in tissue necrosis through saponification of fats and proteins, which disrupts cellular membranes and emulsifies tissue.

Case Descriptions

Patient X: 37-Year-Old Female

A previously healthy 37-year-old female developed acute upper gastrointestinal symptoms after unintentionally ingesting BLC served as draft beer. She noted immediate burning in the esophagus and oral cavity, followed by persistent vomiting, heart palpitations, acid reflux within 24 h, and burning diarrhea daily for 2 weeks. Three months later, she continued to report chronic nausea, an ongoing burning sensation, and a metallic taste when using silverware.

EGD revealed distal esophageal erythema and a 2-mm proximal esophageal nodule (Fig. 1). She was treated with proton pump inhibitors, advised to avoid dietary irritants and metal utensils, and scheduled for annual surveillance endoscopies. At the follow-up, she continued to describe burning and taste disturbances, stating, “It feels like I’ve eaten many hot peppers, and I can’t use metal silverware because everything tastes metallic and causes tingling in my mouth.”

Fig. 1.

The upper third of the esophagus revealing a 2-mm nodule.

Patient Y: 37-Year-Old Male

A previously healthy 37-year-old male ingested ∼3 oz of BLC, immediately experiencing burning of the tongue and esophagus. He described the taste as “an acid banana” and believed he had swallowed poison. Bitters and tonic given by staff exacerbated his symptoms, triggering vomiting, abdominal pain, and diarrhea. Poison Control recommended limited intervention, and he self-treated with water and high-dose 80-mg omeprazole, reporting severe burning “like lava” when a dose was missed. He also developed dysgeusia with heightened sensitivity to salt and spices.

Endoscopy at 1 and 10 months revealed lingual frenulum inflammation, nonbleeding esophageal ulcers, gastritis, and lingual nodular inflammation. He continues to experience dysphagia and altered taste, requiring long-term proton pump inhibitor therapy and dietary restrictions for chronic gastroesophageal reflux disease.

Patient Z: 40-Year-Old Male

A 40-year-old male presented 1 month after drinking a gulp of beer contaminated with residual BLC, describing an immediate “fire” sensation in the esophagus. He experienced vomiting and developed oral mucosal burns and dysphonia, receiving intravenous steroids and lidocaine rinse at urgent care with limited relief. Over the next 3 days, he noted severe pain, dysphagia, abdominal distention, and the sensation of a “pipe down his throat.” He also lost taste and smell, contributing to weight loss because eating was “not pleasurable.”

Initial endoscopy revealed Grade 1 esophagitis, a benign gastroesophageal stricture (Fig. 2), and reactive gastropathy. Follow-up demonstrated progression to a hiatal hernia and Grade D esophagitis (Fig. 3). He remains on high-dose proton pump inhibitors and receives nutritional support, with comorbidities including chronic fatigue syndrome, nonalcoholic fatty liver disease, and hiatal hernia.

Fig. 2.

Stricture in the gastroesophageal junction.

Fig. 3.

Grade D (mucosal breaks which involve at least 75% of the esophageal circumference) esophagitis in the lower third of the esophagus.

Discussion

We present three independent cases of accidental caustic ingestion, resulting in severe injuries that required ongoing endoscopic surveillance (yearly or semiannual depending on injury severity) and prolonged proton pump inhibitor therapy. The cases emphasize that prompt identification of caustic ingestion is essential to guide timely evaluation and treatment.

Inadvertent ingestion of BLC can cause severe, potentially permanent damage to the oral mucosa, esophagus, and gastrointestinal tract. As a strong alkali, BLC induces rapid-onset mucosal injury, including edema, erythema, circumferential ulceration, and focal necrosis, with perforation occurring in severe cases necessitating emergency endoscopic evaluation and intervention [5]. The three cases presented by the same county and clinic show that such injuries can be life-changing and often lead to chronic esophageal pathology.

Accidental BLC ingestion has been reported in the lay press in the UK and the USA (e.g., La Vista, NE, USA; Mishawaka, IN, USA; and Lake County, FL, USA), with a possible fatality noted in Winston-Salem, NC, USA [6–10]. Notably, a 33-year-old female, in Massachusetts, developed ulcerated esophageal mucosa and hyperemia after drinking an Irish car bomb shot; she was monitored via surveillance EGD and outpatient follow-up and continues to experience a metallic taste [11].

In the UK, protocols have not been uniformly enforced, but taverns have implemented additional safety guidelines and checklists to protect patrons. They follow a Line Cleaning Chart [12] to standardize beer line maintenance, conduct Cask Marque Masterclasses to train staff on BLC safety [13], and the British Institute of Innkeeping recommends using litmus paper to test beer pH before serving [14]. Our cases differ from prior reports because each patient presented after drinking at separate taverns, exhibiting symptoms such as a metallic taste, chronic heartburn, dysphagia, and abdominal pain following BLC ingestion.

However, limitations exist in this case report as the small sample size and the paucity of published literature on BLC ingestion restrict the ability to draw broader conclusions. In the absence of a national reporting system, the true incidence and epidemiological trends of caustic ingestions related to BLC remain difficult to quantify. Additionally, variability in BLC products and the amount of product used to clean lines introduces further uncertainty. In this case, the specific cleaning product used and the quantity present at the time of exposure could not be determined, reflecting the lack of standardized protocols and documentation surrounding draft line cleaning procedures.

Conclusion

Incomplete rinsing and the lack of standardized safety protocols during beer line cleaning create a preventable exposure to a well-known chemical hazard. This case series of 3 patients highlights the serious, lasting health consequences of residual BLC ingestion, including chronic esophagitis, benign gastrointestinal strictures, and persistent sensory disturbances. The long-term effects of BLC ingestion reflect the substantial burden of morbidity and represent an underrecognized public health issue. These cases highlight the importance of public and clinician awareness to facilitate prevention and early recognition while ensuring prompt treatment of accidental BLC ingestion. Future research into beer line cleaning methods should be conducted as well as the introduction of monitoring technologies to track epidemiologic trends and prevent further ingestions of contaminated beer.

Acknowledgments

We thank Gia Orsini, Andrea Cortez Mulet, Christine Sylvis, Gabriela Bran, Christopher Saxton, and Tara Edwards for their help and support in editing our case report. We give special thanks to the Southern Nevada Health District for their collaboration and support, making a substantial contribution to our case report.

Statement of Ethics

Written informed consent was obtained from the patients for publication of this case report and endoscopic images (Fig. 1–3). Ethical approval is not required for this study in accordance with local or national guidelines. The CARE Checklist has been completed by the authors for this case report, attached as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000551052).

Conflict of Interest Statement

The authors declare no conflicts of interest regarding the publication of this case report.

Funding Sources

No external funding or financial support was received for this study or the preparation of this case report.

Author Contributions

Each author’s specific contributions to this manuscript are detailed below in accordance with the Contributor Roles Taxonomy (CRediT) guidelines. Frank Nemec: conceptualization, supervision, and project administration. Lauren Canaff: investigation, data curation, writing – original draft preparation, and literature review. Taylor A. Hagans: investigation, literature review, and writing – review and editing. Emily Carter: literature review and writing – review and editing. Each author reviewed and approved the final version of the manuscript and agrees to be accountable for all aspects of the work.

Funding Statement

No external funding or financial support was received for this study or the preparation of this case report.

Data Availability Statement

The information is contained within HIPAA-protected medical records, and patient authorization was obtained for its publication. Additional information may be available through the court system as part of ongoing litigation; however, no information was accessed from litigation for this publication. Further enquiries can be directed to the corresponding author.