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ABSTRACTS: ACCEPTED: CLINICAL VIGNETTES/CASE REPORTS—ESOPHAGUS

Bleach Gargling - An Effective yet Destructive Method to Beat a Drug Test: A Bizarre Case of Caustic Esophageal Injury

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Turk, Issam MD1; Zakaria, Ali MD2; Piper, Marc MD, MSc3; Tesfay, Alula MD4

Author Information
doi: 10.14309/01.ajg.0000596636.67595.ac
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INTRODUCTION:

Caustic alkali ingestion can result in severe esophageal injury. Extensive luminal damage may result in esophageal necrosis and eventually perforation. Historically, caustic ingestion has been seen mostly accidentally in children and in individuals with psychiatric illness. Since the new regulations against opioids, certain individuals have been creative with methods of beating those drugs tests. We present to you a case in which bleach was the culprit in induction of severe mucosal injury.

CASE DESCRIPTION/METHODS:

A 35-year-old male on chronic Oxycodone therapy presented with chest pain, epigastric pain, odynophagia, dysphagia for several months. He denied any history of GERD, EOE, prior EGD or recent new meds. He denied any other GI symptoms such as diarrhea, melena or hematochezia. He reported hemoptysis 3 days prior. Vitals were stable on arrival. His WBC count was 16 and CRP at 100. CT scan revealed diffuse esophageal wall thickening greatest at the upper to mid esophagus. Upon further questioning, he admitted to gargling bleach regularly for several months to falsely pass his opioid drug salivary testing as he had been illegally taking hydrocodone in addition to his prescribed oxycodone. He wasn't aware that bleach may cause any harm as he was not ingesting it. EGD revealed findings consistent with LA grade C esophagitis characterized by esophageal edema, thickening and friability which was most severe at the upper esophagus. Biopsies were taken which came back positive for active esophagitis He was sent home the next day on Protonix 40 mg twice a day with outpatient follow up.

DISCUSSION:

Caustic ingestion in adults can cause severe gastro-esophageal injury. The severity and extent of the damage depends upon: the amount, concentration, form and corrosive property of the agent; along with the duration of contact. Patients will present with oropharyngeal, retrosternal or epigastric pain, dysphagia/odynophagia, or hyper-salivation with or without hemoptosis. In case of perforation the pain will be severe. Initial evaluation includes history, physical examination, lab work and CT scan to determine the depth of involvement. Symptomatic patients should be hospitalized for supportive care. The use of NG tube is contraindicated. Perforation is an indication for emergent surgery, however; In the absence of a perforation EGD should be performed early. Esophageal strictures, bleeding, fistula formation and esophageal squamous cell carcinoma are known complication of caustic ingestion.

Figure 1.
Figure 1.:
Endoscopic image of upper third of esophagus revealing moderate to severe esophagitis.
Figure 2.
Figure 2.:
Moderate to severe esophagitis with edema and friability.
Figure 3.
Figure 3.:
CT chest showing diffuse esophageal thickening.
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