Abstract
Caustic ingestion usually carries superficial burns to extensive necrosis in the upper gastrointestinal tract and might cause complications, especially esophageal stricture. One of the dangerous substances accidentally ingested in large quantities is sodium lauryl sulfate, despite this being an alkaline substance commonly available in homes due to its used cleaning properties. Management of esophageal stricture with recurrence lumen stenosis may be required endoscopic dilation combined with stenting. Selecting stent material was crucial in minimizing post-installation losses and elevated nutritional intake.
Keywords: Caustic Ingestion, Endoscopic Dilation, Esophageal Stricture, Sodium Lauryl Sulfate
Introduction
Caustic ingestion is a medical emergency that may lead to serious consequences despite prompt and appropriate treatment.1 Ingestions, in most cases, are deliberate as suicide attempts in adolescents and adults.2 Previous studies showed that alkaline properties are the most common cause of upper gastrointestinal tract injury (60.3%).3 Caustic ingestion may be devastating in terms of individual suffering and disability.2,4 Esophageal stricture is one of the problems caused by caustic ingestion. This management is esopagheal dilation, generally without an acute inflammatory response.5 Meanwhile, data and studies of Indonesia on caustic ingestion and stricture esophageal are lacking.4,6 The study aimed to report an accidental caustic ingestion with delayed management in an Indonesian man.
Case Report
A 36-year-old Indonesian man ingested an alkaline substance (sodium lauryl sulfate (SLS)) accidentally 3 months ago. He complained of inadequate intake of nutritional because he constantly vomited within 10–60 minutes after eating. He also lost 26 kg in the 3 months, from 66 kg to 40 kg. After 5 minutes of ingestion, he developed nausea and vomiting despite was not brought to the hospital. The patient and family had no past medical history, which included alcoholism, anxiety, depression, and prior suicide attempts.
Clinical examination revealed stable vital signs, absence of fever, decreased peristaltic sound, and epigastric and left hypochondriac area tenderness with a pain scale of 6. There were no remarkable findings in the laboratory examination. Radiological imaging showed a normal limit, which included an x-ray and computed tomography scan with contras. The endoscopic performed showed an esophageal stricture complexity (Figure 1). On the second endoscopic performed, the stricture was dilated with a controlled radial expansion (CRE) balloon (Figure 2). The endoscopic result showed corrosive damage type IIIA according to Zargar's classification in the esophageal and pyloric areas. On the third endoscopic performed, refractory stenosis of the esophageal lumen, accompanied by an antrum and pylorus, was obtained. Therefore, dilatation was performed with a CRE balloon combined with Triamcinolone acetonide injection at 4 points area similar to 3, 6, 9, and 12 in the o'clock template (Figure 3).
Figure 1.
The first endoscopic performed showed severe stenosis of the lumen at the esophageal sphincter proximal and a front of the esofageal junction.
Figure 2.
The second esophageal endoscopy showed a complex esophageal stricture with pyloric stricture and corrosive injury type IIIA according to Zargar's classification.
Figure 3.
The third esophageal endoscopy showed refractory esophageal lumen stenosis.
The endoscopy showed that a recurrence of esophageal and pyloric strictures; therefore, clinicians must utilize a CRE balloon dilation combined with Triamcinolone acetonide injection in the fourth and sixth endoscopy. The time interval between the fourth and fifth endoscopy was approximately 2 weeks. The sixth endoscopy performed showed esophageal and pyloric recovery. He has a recurrence of lumen stenosis in 30 cm from the cavum Oris at the seventh endoscopy, approximately 30 days from the last endoscopic. Clinicians repeat dilations CRE balloon and Savary Gilliard for lumen patent. He was monitored with an endoscopy every 2 weeks for up to 7 sessions utilizing the CRE balloon and Savary Gilliard dilation, accompanied by Triamcinolone acetonide injection when stenosis lumen recurrence. Stent implanted due to stenosis lumen recurrence issues after 14 times Savary Gilliard dilation performed.
Discussion
Esophageal stricture management aims to alleviate dysphagia symptoms while also reducing stenosis lumen from recurring. Esophageal dilatation, temporary stenting, intralesional steroid injection, and surgical are all alternatives for treating benign refractory strictures.7 Endoscopy may be required to examine the degree and extent of gastrointestinal injury in the first 48 hours and treat strictures that develop in the esophageal and stomach. Corrosive injuries cause esophageal strictures that may be efficiently and safely treated with endoscopic balloon dilation.8 The cause of esophageal stricture is SLS ingestion incidentally in this case. SLS is a moderately toxic material that penetrates the skin and causes cutaneous irritation. Meanwhile, ingesting it in large amounts may be harmful.9 Based on a study in Turkey, it was revealed that SLS contributed 8.1% of caustic ingestion and 83.3% of accidental cases.3
The primary treatment for strictures is gradual dilatation at 10–14-day intervals for 6–12 months after the initial occurrence, or until the fibrosis stops progressing. Therapeutic dilatation should begin promptly if a stricture is detected.10 Chronic patients require repeated endoscopy dilatation performed to maintain a patent lumen diameter. Esophageal dilatation often includes esophageal bougination, balloon dilatation, and stenting. Endoscopic balloon dilatation may be accomplished via direct endoscopy, and the risk of perforation is lower than that of esophageal bougination since pressure is not given to the stricture zone's longitudinal axis while radial pressure is fully applied.5
Stenting may be performed using metal, plastic, or biodegradable stents.11,12 Stent complications include stent migration, tissue development, which may induce recurrent dysphagia and impede stent removal, fistula formation, and tumor growth. Plastic stenting is superior to metal stenting because it reduces the incidence of recurrent dysphagia and cases fewer complications from stent migration. More prospective trials with high sample sizes are required to examine the effectiveness, safety, cost, and patient satisfaction of managing metal, plastic, and biodegradable stents.13,14
Esophageal stricture is one of the complications of caustic ingestion (alkaline property) that requires lengthy treatment due to the high risk of recurrence of a stenosis lumen incident. Esophageal stenting may considered when endoscopic dilation with steroid injection does not have a significantly improved prognosis. The esophageal stent materials consist of metal, plastic, and biodegradable, and the selection of materials is significant to minimize post-installation losses and increase nutritional intake.
Footnotes
Acknowledgments: The authors would like to thank “Fis Citra Ariyanto” as a translator and assistant in the study.
Conflicts of Interest: The authors disclose no conflicts.
Funding: The authors report no funding.
Ethical Statement: Ethical approval is exempt/waived at our institution for individual reports. However, we must strictly implement appropriate ethical measures to ensure that individuals cannot be identified. The individual also approved publishing this case report and accompanying images via written informed consent signing.
Reporting Guidelines: CARE.
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