ACMT Toxicology Visual Pearl: Swollen Lips

Answer

4 – Potassium hydroxide

Background

The markedly swollen lips and drooling in this photo are seen following a caustic ingestion. Potassium hydroxide, also known as potash, is a caustic substance found in fertilizers, cleaning supplies, and some hair products. As a strong alkali, it causes deep mucosal damage through liquefactive necrosis [1]. In comparison, acid agents cause coagulative necrosis. Whether a caustic agent is acid or alkaline, the overall clinical picture and management are similar. Caustic injuries remain a common public health issue despite efforts to raise public awareness about the safe handling of household products. Unfortunately, many of these injuries worldwide involve children [2].

What are possible signs and symptoms of a caustic ingestion? [1-6]

• Pain
  • Occurs immediately in the lips, mouth, throat, and possibly chest and abdomen.
• HEENT
  • Erythema, swelling, and burns to the lips and oral cavity
  • Drooling
• Respiratory
  • Laryngeal edema
  • Stridor
  • Voice hoarseness
  • Respiratory distress
• Gastrointestinal
  • Dysphagia and odynophagia (esophageal injury)
  • Epigastric pain and hematemesis (gastric injury)

CAUTION: Patients may still have a severe injury despite few initial signs and symptoms.

What are possible complications?

Long-term complications in survivors may include gastrointestinal strictures, stenoses, and fistula formation. The severity and extent of symptoms depend on the concentration, dosage, and form of caustic ingested.

Deaths following caustic ingestion typically result from perforation, hemorrhage, mediastinitis, peritonitis, or sepsis.

What diagnostic testing should be obtained? [1-6]

• CBC, basic metabolic panel, venous blood gas
  • Serial hemoglobin levels may be useful to evaluate for hemorrhage
  • Metabolic acidosis is commonly seen with acid ingestions and GI tract necrosis
• Upright chest xray or abdominal xray
  • Can assess for pneumomediastinum or pneumoperitoneum
• CT scan
  • Can assess for perforation and hemorrhage and may be of utility to detect burns

What is the management of a caustic ingestion? [1-6]

Contraindication: Gastric lavage, activated charcoal, or attempts to neutralize the acid or alkali

• Standard supportive measures with close attention to airway management
• Decontamination with removal and bagging of clothing and copious irrigation with normal saline if exposure to eyes or on skin
• Esophagogastroduodenoscopy (EGD) – ideally performed within 24 hours of a caustic ingestion
  • Recommended for all intentional ingestions
  • Recommended for patients with stridor
  • Recommended for patients with 2 of the following symptoms:
    • Drooling
    • Pain
    • Vomiting
• Antibiotics
  • If signs of infection
• Steroid therapy
  • Recommended for patients with respiratory compromise from upper airway edema
  • May be considered for grade IIb burns
• Surgical intervention may be required in cases of perforation, hemorrhage, necrosis, or shock.

Bedside Pearls

• Decontamination should occur if indicated with attention to preventing secondary exposure to caregivers
• Patients may have few initial symptoms with a severe gastrointestinal tract injury
• Watch carefully for respiratory compromise due to upper airway edema.
• CT imaging may be useful to evaluate for perforation, hemorrhage, and burns.
• EGD is the gold standard to identify, evaluate, and plan for management for the caustic injury. This should ideally performed within 24 hours of ingestion.  

References

1. Wightman RS, Fulton JA.  In: In: Nelson LW, Howland MA, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS Eds. Goldfrank’s Toxicologic Emergencies. 11th edition. New York: McGraw-Hill Education, 2019, 1388-96.
2. De Lusong MAA, Timbol ABG, Tuazon DJS. Management of esophageal caustic injury. World J Gastrointest Pharmacol Ther. 2017 May 6;8(2):90-98. doi: 10.4292/wjgpt.v8.i2.90. PMID: 28533917; PMCID: PMC5421115.
3. Kumar NB, Aditya Chowdary TV, Thirunavukkarasu S, et al. IDDF2018-ABS-0049 Management of caustic consumption injuries – a multidisciplinary effort for a successful outcome. Gut 2018;67:A39.
4. Mamede RC, De Mello Filho FV. Treatment of caustic ingestion: an analysis of 239 cases. Dis Esophagus. 2002;15(3):210-3. doi: 10.1046/j.1442-2050.2002.00263.x. PMID: 12444992.
5. Cheng HT, Cheng CL, Lin CH, et al. Caustic ingestion in adults: the role of endoscopic classification in predicting outcome. BMC Gastroenterol. 2008 Jul 25;8:31. doi: 10.1186/1471-230X-8-31. PMID: 18655708; PMCID: PMC2533005.
6. Contini S, Scarpignato C. Caustic injury of the upper gastrointestinal tract: a comprehensive review. World J Gastroenterol. 2013 Jul 7;19(25):3918-30. doi: 10.3748/wjg.v19.i25.3918. PMID: 23840136; PMCID: PMC3703178.