ABSTRACT
Accidental ingestion of cleaning substances poses a risk to children all over the world and in our country. In this study, we aimed to investigate the causes of this condition and the clinical problems caused by such serious consequences.
This study was designed as an observational, descriptive, retrospective study. The data were obtained from the hospital electronic medical records. In addition to the demographics, the type of poisoning, presenting complaints, diagnostic tests, medications, treatments and outcomes (results of esophagoscopy and follow-up) were also investigated. The cases were divided into two groups: patients who underwent esophagoscopy and were kept under observation and those kept under observation without esophagoscopy. Patients who underwent esophagoscopy were further divided into two groups as ‘histopathological examination with normal findings ' and ‘histopathological examination with abnormal findings. Hemogram, biochemical parameters and C-reactive protein levels were recorded. The cases with missing or inaccessible data were excluded from the study. The study was approved by the local ethics committee. The SPSS 22.0 program was used for the analysis of the data.
Four thousand three hundred forty five had a diagnosis of poisoning and 295 were exposed to corrosive substances. The most common poisoning agent was bleach (23.7%). Of the patients, 132 (57.9%) underwent only clinical follow-up and 96 (42.1%) underwent esophagoscopy with clinical follow-up. The occurrence rate of esophageal strictures was significantly higher in patients ingesting degreasers (p<0.05). There was a significant relationship between elevated platelet count and amylase level and presence of esophageal pathologies (p<0.05).
Exposure to corrosive substances is a common problem during childhood. It was observed that ingestion of degreasers increased the risk of esophageal stricture formation. Elevated platelet count and amylase level were found to be predictive of esophageal injury.
Keywords: Pediatric emergency, corrosive, caustic, esophagoscopy
Introduction
Accidental exposure to cleaning agents remains a serious problem for childhood throughout the world and especially in developing countries. Most cleaning materials contain corrosive or caustic substances. Caustic means burning or corroding organic tissue by chemical action, typically due to strong acid or alkaline properties. The major caustic agents are household bleaches and oven and drain cleaners which contain sodium hydroxide (NaOH), potassium hydroxide, hydrochloric acid, and nitric acid.1,2 The resulting damage varies according to the type of substance, concentration, amount taken and duration of exposure.1,2 Alkalis and acids produce tissue injury by different mechanisms; alkaline agents tend to cause esophageal injury via liquefactive necrosis if the pH is above 11.5-12.5, however, acids or corrosive agents tend to cause esophageal injury via coagulation necrosis if the pH is less than 2.
Poisoning with corrosive substances is common in childhood. 80% of all cases are child victims. The remaining group consists of adults who are exposed to large amounts of corrosive substances for suicidal purposes. This situation is more dangerous. Low socioeconomic status and low educational level increase the incidence of poisoning with corrosive agents.3,4
Although the actual frequency of such a serious health problem is not known, there are publications reporting the incidence rate of pediatric cases of 5-518 per 100.000 per year.5,6 More than 40.000 child accidental poisonings are reported annually in the UK.7 In the United States alone, the economic burden related with corrosive and caustic substance exposure in 2009 was recorded as $ 22.9 million.8
As a result, caustic poisoning is a condition that causes widespread, serious morbidity and high cost of treatment. We aimed to draw attention to poisoning with domestic cleaning agents, which is a preventable health problem with very simple precautions and family education, and to determine the current situation in our region.
Materials and Methods
This study was designed as an observational, descriptive, retrospective study. All patients, who were admitted to the pediatric emergency department (PED) in a tertiary health center due to ingestion of cleaning and corrosive caustic substances between January 2011 and December 2016, were included in this study. The data were obtained from the hospital automation system. In addition to the demographic information of the cases, the amount of substances, complaints, examination findings, treatments and the results were examined.
We determined the contents of caustic and corrosive substances. The cases are divided into two groups: patients who underwent esophagoscopy and were kept under observation and those kept under observation without esophagoscopy. Patients who underwent esophagoscopy were further divided into two subgroups: histopathological examination with normal findings and histopathological examination with abnormal findings. Hemogram, biochemical parameters and c-reactive protein (CRP) levels were recorded.
Of corrosive and caustic substances included in this study, degreaser agents contain NaOH and potassium hydroxide (KOH), bleaches contain sodium hypochlorite, surface cleaners and dishwasher rinse aids contain acetic acid and citric acid, descalers contain hydrochloric acid (HCl) and clog removers contain sodium bicarbonate.
Our approach to cases with caustic and/or corrosive substance intake is based on the clinical condition of the patient. If the patient suffers from difficulty swallowing, esophagoscopy is planned to determine the level of burn. When stricture formation is developed, surgical intervention is performed. If difficulty with swallowing liquid foods is not observed, the patient is monitored for at least six hours in PED. The cases with missing or inaccessible data were excluded from the study. The study was approved by the local ethics committee.
Statistical Analysis
Mean, standard deviation, median, minimum, maximum, frequency and rate values were used in the descriptive statistics of the data. The distribution of the variables was analyzed by the Kolmogorov-Smirnov test. The Mann-Whitney U test was used in the analysis of independent quantitative data. The chi-square test was used in the analysis of independent qualitative data. Fisher’s exact test was used when chi-square test assumptions were not met. The SPSS 22.0 program was used in the analysis of the data.
Results
In this period, 932.645 patients presented to the pediatric emergency department; 4345 (46.5%) of them were followed up with poisoning diagnosis and 295 (6.8%) of poisonings were related to corrosive substances. Patients whose data were not fully accessible were excluded from the final analysis. Finally, a total of 228 patients [122 (53.5%) boys] were enrolled. The mean age of the patients in the study group was 27±24.9 months (Table 1). The majority of the cases were intoxication related with exposure to non-branded bleaches detected in 54 cases (23.7%) and degreasers in 32 cases (14%) (Table 1).
One hundred thirty two of the cases (57.89%) were only followed up and 96 (42.10%) underwent esophagoscopy. The mean age of the follow-up group was 29.2±27.2 months and the esophagoscopy group was 23.9±20.8 months (p=0.001) (Table 2). There were no differences between follow-up and esophagoscopy groups in terms of white blood cell (WBC) count, platelet count, serum CRP levels and serum amylase levels. Hemoglobin levels were significantly lower in the group undergoing esophagoscopy (p=0.01) (Table 2). Esophagoscopy was performed in 42.7% of the boys and 41.5% of the girls in the study group (p=0.002). There was no significant relationship between the substances and the follow-up and esophagoscopy status (p=0.14) (Table 2). When the duration of hospitalization was examined, the mean duration in the follow-up group and the esophagoscopy group was 55.35±27.16 hours and 68.17±11.70 hours (p=0.001), respectively (Table 2).
Subgroup analysis was performed for esophagoscopy group based on their histopathological reports. When all pathological findings (hyperemic appearance, any degree burn, and stricture formation) were evaluated together, it was determined that ingestion of degreasers caused more damage (p=0.01) (Table 3). When the laboratory parameters and the histopathological findings of esophagoscopy were evaluated, platelet count and amylase level were significantly higher in the group with pathology (p=0.01 and p=0.02, respectively) (Table 3) When we evaluated 38 cases in whom esophageal burns were detected at the end of the esophagoscopic evaluation, it was found that 8 patients had esophageal burn due to exposure to non-branded bleaches, 7 - to dishwasher polisher aid, 6 - to branded bleach, 4 - surface cleaner, 4 - descaling detergent, and 9 patients had burn due to exposure to muriatic acid, stain removers, dishwasher salt, or drain openers (Table 4). The pathological results of the exposure to the substances are shown in Figure 1.
All cases were accidental ingestion of chemical substances. No patient needed pediatric intensive care. There was also no mortality.
Discussion
Exposure to corrosive and caustic substances in children is both serious health and economical problem worldwide.8 While most cases are seen as accidental exposure under the age of four, the frequency of suicidal intake during adolescence is considerable, which can lead to more serious complications.8 In our study, the mean age was 27 months, similar to the literature. In most studies, the male-to-female ratio was found to be high, and 53.5% of the cases were male in our study group.
The degree of damage is closely related to the type, concentration and pH of the chemical substance exposed. It has been reported that 17.2% of patients were admitted to pediatric emergency departments between 1990 and 2006 in the United States due to acid/alkali intake, 8% due to exposure to ammonia compounds and 3.7% due to exposure to bleaches.9 Similarly in our study, bleach-containing sodium hypochlorite, which is a strong alkali, was the most common agent (23.7%) while oil solvents containing KOH were the second (14%) and dishwashing detergents containing trisodium phosphate, descaling agents containing HCl and hypochloric acid were the third most common cause.
In their study, Kucuk et al.10 stated that the most serious burns were with oil solvents and that the severity of injury increased with non-branded and unlabeled ones. In a multicenter study conducted by Betalli et al.11 in Italy, caustic soda (NaOH) was the most irritant substance and 73% of patients needed gastrostomy. In our study, when all the results were evaluated in terms of burn and stricture formation, KOH was found to be the most destructive substance.
In a study by Rigo et al.12 to predict mortality due to caustic substance intake in adults, a WBC higher than 20.000/mm3, serum CRP levels higher than normal, strong acid substance intake, and profound gastric ulcer with necrotic area were found to increase mortality. Since we do not have mortal outcome, we cannot evaluate these parameters, and we observed that CRP and WBC had no value in predicting esophageal burn or stricture. Similarly, in a study conducted by Kaya et al.13 including 134 patients poisoned with corrosive substances who underwent esophagoscopy, it was reported that patients with high-grade esophageal injury had higher WBC compared to those with low-grade esophageal injury, however, WBC but did not have sufficient predictive value.13 This may be due to the fact that adults in the study by Rigo et al. were exposed to more corrosive substances and that the patient group consisted of medically ill patients.12 The reason for the lack of WBC elevation in our cases may be that all of the cases in our study group were accidentally exposed to a small amount of corrosive substances. Therefore, this small amount of corrosive substance may not have caused a systemic response as leukocytosis. It was observed that elevated platelet count and amylase level increased the possibility of tissue damage in patients presenting to emergency clinic immediately after exposure. This may be explained by the fact that platelet count is an acute phase reactant and amylase is secreted from the salivary glands and esophagus.
The gold standard technique for damage assessment is endoscopic assessment. With this examination, the esophagus is evaluated visually and damage and stricture formation can be observed.14-16 It is recommended to be done within the first 12-48 hours and not to exceed 96 hours.17,18 Endoscopic dilatation is recommended 5-15 days after ingestion. According to the study by Kaya et al.13, endoscopic pathologic findings were found in 12% of completely asymptomatic patients without lesions in the mouth. Therefore, indications for performing endoscopy are not clear. While some authors do not recommend endoscopy in patients who do not have a lesion in the oral cavity and can swallow saliva, others recommend it for all patients with spontaneous vomiting.19-22 However, they agree to do it in all patients who attempted suicide.23 In our study, patients with no oral lesions and no swallowing dysfunction were followed up without endoscopy. 132 of 228 cases included in our study (57.89%) were followed up only and 96 (42.10%) underwent endoscopy.
Study Limitations
Since it is a retrospective study, cognitive evaluation of the patients could not be performed and long-term results of the cases could not be reached. Prospective studies on this subject will analyze the situation more clearly.
Conclusion
In conclusion, involuntary use of corrosive-caustic substances and resultant pathological problems are quite common in childhood. Therefore, it is important to ensure that all products containing such substances, especially cleaning products, are equipped with locked mechanisms so that children cannot open them and are kept out of the reach of children. The importance of this matter should be emphasized in prospective randomized controlled trials with more patients.
