A lethal cocktail: gastric perforation following liquid nitrogen ingestion

Abstract

We report a case of gastric perforation in an 18-year-old girl as a result of ingesting an alcoholic drink containing liquid nitrogen. The drink was purchased in licensed premises. The extent of the injury necessitated total gastrectomy with Roux-en Y reconstruction. We review the literature, discuss the mechanism of injury and consider the implications for medical services. The authors believe this case is of educational interest to professionals working in emergency medicine, general surgery and public health fields. It raises awareness of a rare injury, but one that may be more commonly encountered because of developing social trends. It informs surgeons confronted with this type of injury that trauma to the gastrointestinal tract can be extensive and preoperative contact with oesophago-gastric colleagues is advisable. Public health bodies must be aware of, and monitor, the use of liquid nitrogen in this way and consider regulation to prevent further injuries.

Background

Liquid nitrogen is being used as an additive to alcoholic drinks to create an aesthetic ‘smoking’ effect. Recipes are available on the internet and such drinks are increasingly sold in some licensed premises. Use in this way requires no training and sales are unregulated. We report this case to raise awareness among the public and medical services of the potential dangers of using liquid nitrogen in this way.

Case presentation

An 18-year-old girl presented to the emergency department following ingestion of an alcoholic drink containing liquid nitrogen purchased in licenced premises. She complained of sudden onset of severe abdominal pain and shortness of breath immediately after ingestion. She had no medical history. On examination she was tachycardiac and tachypnoeic. Her abdomen was distended, tympanic and peritonitic.

Investigations

Her white cell count was raised at 30.7×109/l and an erect chest x-ray (figure 1) showed a large volume pneumoperitoneum. A CT scan of her abdomen confirmed the presence of both a large volume pneumoperitoneum and free intrabdominal fluid but was unable to identify the site of perforation.

Figure 1.

Erect chest x-ray showing a large pneumoperitoneum.

Treatment

After initial resuscitation and broad spectrum antibiotics, an emergency laparotomy with on table oesophagogastroduodenoscopy (OGD) was performed.

At operation a 4 cm linear perforation was identified in the anterior wall of the stomach overlying the lesser curve. Surrounding this was an area of necrosis and haemorrhage extending around the posterior wall of the stomach and superiorly towards the gastroesophageal junction (figure 2). There was also some erythema affecting the fundus of the stomach. The rest of the abdominal contents were normal. OGD did not show any oesophageal injury but identified extensive tearing of the mucosa along the lesser curve (figure 3). extending up to the gastroesophageal junction (figure 4). Owing to the extent of the injury advice from a specialist oesophago-gastric surgeon was sought.

Figure 2.

Operative view of the perforation over the lesser curve of the stomach with the area of necrosis and haemorrhage extending towards the cardia.

Figure 3.

Endoscopic view showing mucosal tearing over the lesser curve of the stomach.

Figure 4.

Retroflexed view showing the mucosal tearing extending superiorly towards the gastroesophageal junction.

The perforation could not be safely closed primarily due to the extent of the necrotic area and hence a total gastrectomy with Roux-en Y reconstruction was undertaken. Proximal gastrectomy was rejected because of the risk of poor function of the remaining gastric remnant. A feeding jejunostomy was sited to provide nutrition during the postoperative period. The patient was transferred to the critical care unit, ventilated and requiring vasopressor support.

Outcome and follow-up

The patient was extubated the next day and enteral feeding commenced via jejunostomy. She was transferred to the surgical ward on the fourth day postoperatively. Oral intake was commenced on the sixth postoperative day. She was discharged 15 days post-operatively.

Discussion

With a boiling point of −195°C liquid nitrogen can cause severe thermal burns to the skin and the mucosal membranes. It has an expansion ratio of 1:694 on vaporisation leading to a rapid increase in volume.

Cases of ingestion resulting in gastric perforation are reported in the literature.^1–4 In all these cases the clinical presentation is similar to the case we report, namely a rapid onset of abdominal pain associated with shortness of breath. In three cases, the site of perforation was identified as being over the lesser curve of the stomach, the same site as in our case.^1–3 In one case an OGD was performed which did not show any thermal injury to the oesophagus,³ again a finding similar to this case.

The absence of injury to the oesophagus does not seem to support thermal injury as the major cause of visceral perforation, although it may have contributed to the gastric mucosal injury and subsequent perforation. The consistent finding of a large volume of gas within the peritoneum, would suggest barotrauma to the stomach, resulting from rapid increase in volume on vaporisation of the liquid, as the primary mechanism of injury. The consistent site of perforation may indicate that this part of the stomach is the most susceptible to barotrauma. Evidence from compressed air diving accidents would seem to support this, with the lesser curve commonly identified as the site of gastric perforation.⁵

Learning points.

• Staff working in emergency departments and acute surgical units need to be aware of the potential for such injuries to occur.

• Surgeons facing this type of injury need to be aware of the potential for major upper gastrointestinal trauma and consider preoperative involvement of specialist oesophago-gastric colleagues.

• Public health bodies must monitor the increasing use of liquid nitrogen in alcoholic drinks and alert the public to the potential dangers.

• We believe regulators must take action to end use of liquid nitrogen in this way and look at restricting its sale to only those properly trained in its use in order to prevent future incidents such as this.