A 24-year-old male presented to the ED after an accidental ingestion of hydrogen peroxide. The patient worked at a lab and ingested about 250 mL of 35% hydrogen peroxide thinking it was water. Almost immediately after the ingestion, he had multiple episodes of hematemesis. He denied suicidal ideation. He denied ingestion of anything else. He had no past medical history.

 

Initial VS: HR 97, BP 126/91, T 36.5 °C (97.7 °F), SpO2 89% on RA

 

Physical exam was significant for a male in moderate distress with persistent vomiting. The airway seemed patent, but he was only intermittently protecting. Breath sounds were equal and clear bilaterally. Abdomen was soft, non-tender, and non-distended.

 

The patient was intubated with RSI given his inability to protect his airway and persistent hematemesis.

 

The team taking care of the patient was concerned that the hematemesis could represent an esophageal perforation given the large amount of gas that hydrogen peroxide can produce, and they performed a FAST exam after intubation. There was no pleural effusion, pneumothorax, or free fluid in the abdomen noted, however, the liver was seemingly hard to image. See clip below:

The team noted that the liver appeared hyperechoic.

 

They continued to image the liver. See the 2 additional clips below:

 

If you look closely, you can see air bubbles present. The liver was hard to image because there was portal venous air present. But why?

 

In the ED, GI was consulted for possible esophagoduodenoscopy. The regional poison center was also contacted, and the patient was taken for a CT of his chest, abdomen, and pelvis. See images from the CT below:

Screen Shot 2015-05-28 at 10.41.55 AM

 

Screen Shot 2015-05-28 at 10.39.24 AM

 

Screen Shot 2015-05-28 at 10.39.54 AM

The CT scan was significant for pneumatosis throughout the esophagus and stomach with a large amount of portal venous air. There was no free air present to suggest perforation. There was also a small amount of air noted in the right ventricle and main pulmonary artery. It was unclear weather the focus of air in the RV and pulmonary artery were from the ingestion or from air associated with the power injector for CT contrast through the peripheral IV.

 

He was admitted to the MICU for ongoing care. Hyperbaric Medicine was consulted for the air seen in the RV and pulmonary artery, and they recommended proceeding with hyperbaric oxygen therapy.

 

EGD on the day of admission showed Grade 1 caustic injury to the mid and lower esophagus with mucosal edema and exudate. There was Grade 2A caustic injury to the entire stomach with superficial ulceration and mucosal bleeding.

 

He underwent one hyperbaric oxygen dive and was extubated the day after admission. He had no neurologic deficits. On follow-up imaging, the pneumatosis and portal venous air had completely resolved.

 

Follow-up EGD 2 weeks later revealed no stricture present in the esophagus.

 

Hydrogen Peroxide Poisoning

  • Hydrogen peroxide is a colorless and odorless liquid.
  • Hydrogen peroxide that is sold for household use is generally a 3%-9% concentration. In this case, 35% hydrogen peroxide was ingested, which is used for industrial purposes usually.
  • Concentrations <10% are felt to be benign if ingested.
  • More concentrated solutions are known to be caustic.
  • Ingesting 30 mL of 35% hydrogen peroxide can yield up to 3,000 mL of oxygen.
  • Portal venous gas is thought to be created by a chemical reaction in the stomach that releases large amounts of oxygen. This excessive amount of oxygen exceeds the amount of oxygen that can be dissolved in the blood and gas bubbles are formed. The gas is not related to corrosive effect on the gastric mucosa.
  • Neurological impairment, caustic gastritis, respiratory failure, pneumomediastinum, seizures, portal venous gas, air in the right ventricle, acute myocardial infarction, and death have all been reported after ingestion of 35 % hydrogen peroxide.
  • Management is generally supportive.
  • French et al. published a case series of 11 people with highly concentrated hydrogen peroxide ingestions that underwent hyperbaric oxygen therapy for portal venous air. The portal venous air resolved after therapy in 9 of the 11 cases. In the other two cases, the air nearly resolved. All of the patients were discharged from the hospital alive.

 

 

References

  1. French L, et al. Hydrogen peroxide ingestion associated with portal venous gas and treatment with hyperbaric oxygen: a case series and review of the literature. Clin Toxicol. 2010; 48:533–538
  2. Indorato F, et al. Fatal accidental ingestion of 35% hydrogen peroxide by a 2-year-old female: case report and literature review. Forensic Sci Med Pathol. 2014; 10:443-447.
  3. Manning EP, et al. Images in emergency medicine. Young woman with epigastric pain and vomiting. Ingestion of 35% hydrogen peroxide. Ann Emerg Med. 2014 ;64(3):330, 333.
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