Alkali Toxicity

What is Alkali Toxicity?

Alkaline toxicity is a rare health condition that can cause significant problems in both adults and children. This happens when someone swallows, or is exposed to, a substance that is very alkaline or “basic” (the opposite of acidic). This is seen more often in developed countries, and it’s more common for people to accidentally swallow alkaline substances than acidic ones.

Incidents of children accidentally swallowing harmful substances are unfortunately common around the world. Still, usually, because the quantities are small, the effects are generally mild. On the other hand, adults who intentionally swallow these substances for whatever reason tend to consume more, which can lead to more serious health problems. People who do this will need extensive medical help and a long treatment period.

Alkaline toxicity can occur when a person comes into contact with strong alkaline substances like some caustic chemicals or household cleaning agents. This can harm their eyes, skin, or digestive system. If this happens, doctors quickly assess the injured area and rinse it with lots of water to remove the substance. This is followed by immediate medical care. They may need to use a special tool called an endoscope to check for internal injuries, and treatment can involve managing pain, helping with nutrition, and even surgery if needed. Educating people about how to prevent these injuries and handle alkaline substances safely is essential to reduce the risk of this happening.

What Causes Alkali Toxicity?

Caustic substances are materials that can cause harm to any surface they touch, including if they are swallowed. They can affect how something works and what it looks like under a microscope. Anything with a pH higher than 7 is known as alkaline, and those which have a pH more than 11 need special care due to the risk they pose to people. Some household cleaning products contain strong alkalis, which can cause a type of tissue death known as liquefactive necrosis. The damaging effect of alkali substances gets stronger as pH levels increase, and it continues until the alkali is neutralized. This can lead to a lot of harm to human tissue, especially within the food pipe.

Many household or industrial products contain chemicals that have caustic properties. Some common alkaline substances include bleach, sodium hydroxide, potassium hydroxide, ammonia, and dishwashing detergents. Bleach is the most common household alkali with a pH level of 11, and it’s usually found as a solution with 3% to 6% sodium hypochlorite. Household caustics generally have smaller concentrations, which reduces the probability of causing severe injuries. On the other hand, industrial-strength bleach has higher concentrations of sodium hypochlorite and a higher pH level, which raises the risk of serious tissue damage.

Risk Factors and Frequency for Alkali Toxicity

In developed countries, there are lower rates of illness and death due to swallowing or exposure to harmful chemicals, often due to stricter regulations and better public awareness. However, exposure to these harmful substances is still a significant problem in less developed countries. When exposure does happen, it can be intentional, accidental, or occur in a workplace setting.

• Intentional exposure often happens during attempts at self-harm, mainly affecting teenagers and adults, and is usually associated with serious injuries.
• Accidental exposure usually involves young children who ingest these harmful substances out of curiosity, but these cases usually don’t cause severe harm.
• Workplace exposures are common in industries that use these substances and can potentially cause significant injuries.

Developed countries have put measures in place to prevent exposure to these harmful chemicals. These include making chemical containers childproof, regulating highly corrosive substances, improving emergency care, providing better nutrition, and ensuring follow-up care. Despite these efforts, exposure to harmful chemicals is responsible for many calls to poison control centers and visits to emergency departments. For example, in 2019, the American Association of Poison Control Centers reported over 180,000 exposures to household cleaners, with most of these incidents involving children and over 97,000 exposures to a single substance.

The challenges in dealing with exposure to harmful substances are bigger in less developed countries. There, the lack of regulations, delays in getting to care, malnutrition, and cultural tendencies to use harmful substances during attempts at self-harm all contribute to higher rates of illness and death.

Signs and Symptoms of Alkali Toxicity

If someone is suspected of coming in contact with or swallowing a harmful substance, it’s crucial to get a complete history of what happened. This includes finding out what substance was involved, how much was ingested, and the circumstances of the exposure. It’s also essential to figure out if the person did this on purpose or if it was an accident. If it was intentional, more information should be gathered to find out if any other harmful substances were also ingested.

People who have swallowed harmful substances can show a wide range of symptoms. On the other hand, if a person swallowed a harmless substance or only a small amount of a harmful one, they may not show any symptoms. However, people who have ingested a large amount often have symptoms like stomach pain, feeling sick, throwing up, coughing up blood, passing bloody stools, difficulty swallowing, painful swallowing, and chest pain. If the lungs have also come in contact with the harmful substance, the person may feel short of breath.

During a physical check-up, the patient might have a fast heart rate or fast breathing, as well as excessive drooling, difficulty breathing, burns inside the mouth or throat, and swelling. They might also feel tenderness in the stomach. Some other signs of harmful substance ingestion include dribble burns, which are burn marks on the chest and face. Sometimes, air trapped under the skin giving a crackling sensation when the chest is touched, might indicate injury to the mediastinum (the space between the two lungs).

When harmful substances touch the skin, it usually results in redness and localized pain, along with swelling in the affected area. The skin may appear inflamed and irritated, and the patient may report discomfort or tenderness at the exposure site. On the other hand, when the eyes come into contact with harmful substances, patients often complain about eye pain and vision problems, ranging from blurriness to complete blindness.

Testing for Alkali Toxicity

If you’ve accidentally ingested an alkaline substance, your doctors may need to use a procedure called an esophagogastroduodenoscopy (EGD) to check the extent of the damage done to your digestive system. This is because alkaline substances can potentially cause injury to your digestive tract. EGD is an examination done with a small camera that goes down your throat to visualize your esophagus, stomach, and the upper part of your small intestine.

Doctors prefer to do this between 12 to 24 hours after you’ve swallowed the alkaline substance because it’s safer during this window. Some reports suggest that EGD can be safely done up to 96 hours after the incident.

While performing EGD, doctors use the Zargar classification system to understand the kind of damage done in the esophagus after an alkali ingestion.

The Zargar Classification System is as follows:

• Grade 0: Normal esophagus
• Grade 1: Swelling and redness of the inner lining of the esophagus
• Grade 2a: Symptoms such as bleeding, tenderness, abrasions, blisters, whitish secretions
• Grade 2b: Injuries or ulcers around the entire circumference of the esophagus
• Grade 3a: Areas of tissue death (necrosis) that are small or scattered
• Grade 3b: Extensive areas of tissue death (necrosis)
• Grade 4: Perforation or a hole in the esophagus

Alongside an EGD, doctors will also want to perform a series of lab tests like a complete blood count, liver function tests, and others to guide care decisions. The tests might show findings like a high white blood cell count, renal and liver failure, blood clotting disorders, lactic acid buildup, and severe acid-base imbalance. If doctors suspect a co-ingestion (drinking multiple harmful substances), they’ll also test for those specific substances.

An ECG (electrocardiogram) is also performed to look for signs of heart damage or electrolyte imbalances like a high potassium level in your blood.

Doctors can also use imaging tests like X-rays to find if you have what is called a perforated viscus, which is a hole in an organ in your abdomen. They can also use it to check for button batteries that you might have swallowed. A CT scan, which is a more detailed type of imaging test, can help the doctors understand the extent of tissue damage and predict whether or not a scar-like tissue (stricture) would form in the esophagus.

If burns have occurred from battery explosions, for instance from electronic cigarettes or e-cig batteries, the doctors may need to measure the pH of the alkali using something called litmus testing, before washing the burns out (irrigating).

If your eyes have been affected, the doctors will consult with eye doctors (ophthalmologists). The damage to the eyes is classified based on the Roper-Hall classification, which outlines the severity of the eye burn and potential for recovery.

Treatment Options for Alkali Toxicity

When a person accidentally swallows a harmful substance, doctors aim to clear the patient’s airway, deal with any signs of shock, and stabilize the patient. Symptoms like trouble breathing, drooling, vomiting, and a wheezing sound during breathing can indicate severe injury to the airway or food pipe and must not be ignored. Patients presenting with these symptoms will need a tube inserted into their windpipe immediately.

Airway Protection

Clearing and maintaining an open airway after swallowing a harmful substance can be difficult due to swelling and potential bleeding. Therefore, doctors usually use a device that uses light to examine the airway. The patient is then intubated, which means a tube is inserted into their windpipe to help them breathe. In cases where the tube cannot be inserted, or the patient can’t be ventilated, doctors may perform a surgical procedure to establish a secure airway.

Decontamination

Decontamination is crucial when treating patients who’ve been exposed to harmful substances. To protect themselves, doctors, and nurses wear protective clothing, gloves, and masks with shields. If the substance has affected the eyes or skin, these areas should be washed thoroughly with water to dilute and remove the harmful substance, thus reducing further damage. It’s also crucial to remove any clothes that have come into contact with the substance.

Although there’s some debate over the matter, drinking plenty of water or other liquids immediately after ingesting a harmful substance may be considered to dilute the substance. However, substances that cause burns when ingested don’t usually stick well to charcoal, and therefore, treatment methods such as activated charcoal or rinsing of the entire gut is usually regarded as unsuitable. These methods can cause vomiting and potentially worsen the injury. It’s also not advisable to induce vomiting in these cases.

Fluid Resuscitation

Patients presenting with symptoms of shock following swallowing a harmful substance may require fluids. If the patient is bleeding heavily, they may need a blood transfusion, and a central venous line might be inserted for closely monitoring blood pressure if the condition doesn’t improve.

Nasogastric Tube Placement

Inserting a tube from the nose to the stomach after swallowing a harmful substance is a widely debated practice. This tube helps maintain the openness of the food pipe and might reduce the risk of scarring. However, the medical community hasn’t agreed on whether this procedure should be done for all cases. When this procedure is necessary, it is suggested that it is performed under visual guidance, ideally in an endoscopy room rather than the emergency room.

Endoscopy

Urgent endoscopy (a procedure that allows doctors to look inside your body) is necessary to determine the extent of injury in symptomatic patients.
If medical imaging reveals a stuck small metal disc in the food pipe or windpipe, immediate endoscopy is vital to remove it.

Viscus Perforation

Signs that a hollow organ such as the stomach or intestine has been punctured such as air in places it shouldn’t be in the body or clinical findings of inflammation of the inner lining of the abdominal wall, require urgent surgical consultation.

Ocular Burns

Eye burns should receive an immediate assessment by an eye doctor.
Due to the delicate nature of the eye and the possibility of severe harm, a quick assessment and treatment by an ophthalmologist are crucial.

Steroid Use

The use of drugs that lower inflammation in the body (steroids) to treat swallowed harmful substances is controversial. However, in cases where patients present with trouble breathing, dexamethasone, a type of steroid, might be considered to help reduce swelling and inflammation of the airway, thereby easing breathing difficulties.

Alkali Toxicity Grading and Care Levels

All patients who exhibit symptoms of ingesting harmful substances should be admitted to a monitored hospital setting. The level of care required depends on the severity of the injury.

– Grade 1 injuries: Patients with grade 1 injuries, which typically involve superficial damage or inflammation, may be considered for discharge once their condition improves, and they can handle food and drink.

– Grade 2a injuries: Patients with grade 2a injuries, which involve superficial ulcers or erosions without significant scarring require observation for any worsening of the injury. These patients can be given a soft diet and closely monitored.

– Grades 2b and 3 injuries: Patients with grades 2b and 3 injuries, which involve deep ulcers, dead tissue, or strictures require intensive care. These patients should be admitted to the ICU for close monitoring, provided food through their veins or a tube, provided symptomatic treatment, and considered for surgical consultation. These patients are at a high risk of developing immediate complications following ingesting harmful substances and are most likely to develop scarring in the future.

What else can Alkali Toxicity be?

Handling cases of caustic (burning or corrosive) substance ingestion becomes easier once certain factors are identified. These include finding out which substance was consumed, the amount, how long it was exposed to the body for, and whether it was in solid or liquid form. It is also important to figure out if the substance was an acid or alkali, although, this usually has less impact on treatment plans.

Generally, receiving treatment for burning substance exposure is pretty similar whether the substance was an acid or alkali. However, there are a few exceptions like mercuric chloride and zinc chloride. These acids can harm the body significantly, so they often require more specific treatment strategies.

If the harmful substance was taken on purpose, it’s vital to suspect and check for the intake of other substances as well.

Additionally, other health issues can show similar symptoms to those of caustic substance ingestion. These include:

• Asthma or chronic obstructive pulmonary disease (COPD) flare-ups
• Acute coronary syndrome (heart disease)
• Pneumothorax (collapsed lung)
• Appendicitis or cholecystitis (abdominal issues)
• Stomach flu
• Substance intoxication
• Diabetic or alcoholic ketoacidosis (high blood acid levels)
• Sepsis (serious infection)

What to expect with Alkali Toxicity

In cases of caustic burns, which are burns caused by corrosive chemicals, the potential results and risk of the throat narrowing, also known as developing strictures, depend on the severity of the injury to the esophagus (the tube connecting your mouth and stomach). Mild to moderate burns (known medically as Grade 1 and some Grade 2a burns) usually heal well, with the function of the esophagus gradually returning to normal. The chances of developing strictures in these instances are usually low.

However, more severe burns (graded as 2b and 3) can create thick scar tissue, which increases the chances of developing a stricture. When strictures occur, long-term management is needed, which can include regular procedures to widen the esophagus, placement of tubes to keep the esophagus open, and sometimes, surgery.

When determining what a patient’s results might look like, it’s important to take into account several factors. These include severe esophageal injuries, complications associated with swallowing caustic substances, and being 65 or older. All of these are linked to less favorable outcomes.

Eye exposure to corrosive chemicals is often linked to poor outcomes, and many patients can lose their sight. However, there are several possible treatments to address long-term complications and improve vision in those affected. These treatments may include transplanting stem cells to the surface of the eye, keratoplasty (transplanting the cornea) and keratoprosthesis (fitting an artificial cornea).

Possible Complications When Diagnosed with Alkali Toxicity

Swallowing substances with a high pH can lead to the development of narrowings in the esophagus, which may cause discomfort or difficulties in swallowing. If these narrowings are not addressed, they can cause poor nutrition over time.

One of the potential complications of severe esophageal damage due to caustic substances is a type of cancer called squamous cell carcinoma of the esophagus. This cancer may develop many years after the initial injury. However, regular screenings for esophageal cancer are typically not suggested for patients who have had caustic injuries in the past.

If the narrowings in the esophagus do not respond to routine treatment and significantly interfere with the patient’s quality of life, reconstructive surgery might be needed. In some cases, the entire esophagus might need to be removed – a medical procedure known as an esophagectomy. This operation can offer relief from the narrowings by allowing for the reconstruction of the esophagus.

Common Complications:

• Narrowing of the esophagus leading to difficulty in swallowing and discomfort
• Poor nutrition if narrowings are not addressed
• Squamous cell carcinoma of the esophagus

Recommended treatments:

• Routine treatments for esophageal narrowings
• Reconstructive surgery when necessary
• Removal of the entire esophagus (esophagectomy), if required
• Reconstruction of the esophagus following esophagectomy

Preventing Alkali Toxicity

To avoid accidental swallowing, it’s very important to store household cleaning products in a safe place that children can’t reach. If you think someone has swallowed a harmful product, don’t try to make them throw up. This could cause more damage by exposing the stomach and intestines to the harmful substance again. Instead, you could give them milk or water to drink within a few minutes of when they swallowed the substance. When using household products, it’s important to protect yourself by wearing safety equipment such as gloves and safety glasses.