Kanne et al.

Gastrointestinal Imaging • Trauma Cases from Harborview Medical Center

Gastric
Perforation
Resulting
from
Hydrochlori
c Acid
Ingestion

Delayed Gastric Perforation

Resulting from Hydrochloric
Acid Ingestion
Jeffrey P. Kanne1 Case Report
Martin Gunn A 29-year-old man with schizophrenia pre-
C. Craig Blackmore sented to the emergency department with ab-
dominal pain immediately after ingesting ap-
Kanne JP, Gunn M, Blackmore CC proximately 200 mL of cleaning solution
containing 36% hydrochloric acid. Initial un-
enhanced CT of the chest, abdomen, and pel-
vis showed an intact stomach and a small
amount of free intraperitoneal fluid (Fig. 1A).
Direct endoscopy showed mucosal injury in
the oropharynx, hypopharynx, and supraglot-
tic region, and diffuse caustic injury to the
esophageal mucosa. Because of worsening
clinical status, a contrast-enhanced CT of the
abdomen was performed 2 days later, show-
ing gastric necrosis and perforation (Fig. 1B).
The patient died shortly thereafter.
Discussion
Caustic injury to the upper gastrointesti-
nal tract from acid ingestion is less common
in the United States than ingestion of alka-
line liquids and usually occurs in young chil-
dren or in adults attempting suicide [1]. In
contrast to injury from alkali, which tends to
affect the pharynx and esophagus with gas-
tric sparing, caustic injury from acid inges-
tion typically affects the stomach and spares
the esophagus. However, concurrent esoph-
ageal injury occurs in up to 20% of patients
after acid ingestion [2].
The degree and location of the caustic in-
jury depends on the quantity, concentration,
and nature of the ingested acid, duration of
mucosal contact, and contents of the stomach
at the time of injury, as gastric contents can
buffer the ingested acid [3]. Acute caustic in-
jury is characterized by inflammation and co-
agulation necrosis of the gastric mucosa,
leading to sloughing of the overlying eschar
after several days [1]. This may be accompa-
nied by gastric hemorrhage or perforation.
Late sequelae include fibrosis and gastric out-
let obstruction [1, 2, 4].

Received February 6, 2005; accepted after revision

February 16, 2005.

1All authors:
Department of Radiology, Harborview
Fig. 1—29-year-old man
Medical Center, University of Washington School of
with gastric necrosis
Medicine, 325 Ninth Ave., Box 359728, Seattle, WA 98104- resulting from hydrochlo-
2499. Address correspondence to F. A. Mann ric acid ingestion.
(famann@u.washington.edu). A, Unenhanced CT
shows intact gastric wall
AJR 2005; 185:682–683 (arrows) despite motion
and streak artifacts.
0361–803X/05/1853–682
(Fig. 1 continues on next
© American Roentgen Ray Society page)
A

682 AJR:185, September 2005

 Gastric Perforation Resulting from Hydrochloric Acid Ingestion

Fig. 1 (continued)—29- nation, may underestimate extent of injury.

year-old man with gas- However, when the normally enhancing gas-
tric necrosis resulting
from hydrochloric acid tric mucosa and the underlying submucosal
ingestion. and muscular layers are no longer apparent, ne-
B, Contrast-enhanced CT crosis should be suspected.
2 days later at same level
shows large amount of
Treatment centers on correcting metabolic
fluid in region of gastric imbalances, coagulopathy, and surgical inter-
body (asterisk) without vention for more severe injury and late se-
definable wall and only quelae. Partial or total gastrectomy may be
small amount of remain-
ing intact gastric mucosa necessary, particularly in the setting of trans-
in antrum (arrow). mural necrosis [1, 2, 4]. However, the prog-
nosis is generally poor and worsens with in-
creasing quantity of acid ingestion [4].

The initial clinical presentation may be
misleading and underestimate the severity of
caustic injury, because the patient may have a
normal level of consciousness, normal vital
signs, and no signs of injury to the mouth or
pharynx. This can precede a rapidly develop-
ing coagulopathy, plasma volume depletion,
renal failure, and metabolic acidosis [4].
Imaging, particularly CT, can help in the
immediate and subsequent evaluation of the
References
1. Sugawa C, Lucas CE. Caustic injury of the upper
gastrointestinal tract in adults: a clinical and endo-
B scopic study. Surgery 1989; 106:802–806;discus-
sion 806–807
2. Zamir O, Hod G, Lernau OZ, Mogle P, Nissan S.
gastrointestinal tract after caustic ingestion Corrosive injury to the stomach due to acid inges-
when endoscopy is not available or is limited tion. Am Surg 1985; 51:170–172
by a severe injury. CT has the potential to show 3. Allen RE, Thoshinsky MJ, Stallone RJ, Hunt TK.
abnormalities of the esophageal, gastric, and Corrosive injuries of the stomach. Arch Surg 1970;
duodenal walls and signs of perforation, in- 100:409–413
cluding extraluminal fluid, pneumomediasti- 4. Munoz Munoz E, Garcia-Domingo MI, Rodriguez
num, pneumoperitoneum, or pneumoretroperi- Santiago J, Veloso Veloso E, Marco Molina C.
toneum. Findings on CT depend on the Massive necrosis of the gastrointestinal tract after
severity of injury and time from ingestion. As ingestion of hydrochloric acid. Eur J Surg 2001;
this case shows, early CT, like clinical exami- 167:195–198

F O R YO U R I N F O R M AT I O N

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