Clinical Toxicology (2009) 47, 689–690 Copyright © Informa UK, Ltd.ISSN: 1556-3650 print / 1556-9519 onlineDOI: 10.1080/15563650903095221

LCLTIMAGES

Gastric stricture following zinc chloride ingestion

Zinc chloride ingestionRAED TAYYEM, TAMIM SIDDIQUI, KHALED MUSBAHI, and ABDULMAJID ALI

Ayr Hospital, Ayr, UK

Aim. We present the case of an adult who ingested soldering fluid containing zinc chloride (ZC) in a suicide attempt. He developed agastric stricture that was managed successfully by laparoscopic Roux-en-Y gastrojejunostomy. An extensive literature review shows thatthere are few reports of ZC ingestion. Furthermore, management of corrosive gastrointestinal tract injury is debatable. The evidence issummarized in this case report. Results. ZC is a strong corrosive agent, which, following ingestion, is capable of producing widespreaddamage locally and systematically with long-lasting morbidity and significant mortality. The mainstay of treatment is supportive.Esophago-gastro-duodenoscopy is the diagnostic procedure of choice in the absence of perforation. Strictures that cannot be dilatedendoscopically may require surgery. Emergency surgery is required for patients with evidence of perforation. Early and aggressive surgicalresection in patients with high-grade burns may improve mortality and morbidity. Conclusion. Because of the lack of data, it remainsdebatable as to the optimal management strategies following ZC ingestion. Our patient was managed conservatively throughout the acutephase. However following recognition of the gastric stricture, surgical intervention ensued and he underwent successful laparoscopic Roux-en-Y gastrojejunostomy and was subsequently discharged having made an excellent recovery.

Keywords Zinc chloride ingestion; Management; Gastric stricture; Laparoscopic gastrojejunostomy

A 39-year-old male with a background of severe depressionand recently discharged from a psychiatric hospital wasadmitted following a suicide attempt by ingestion of 30 mLof soldering fluid containing 30–60% zinc chloride (ZC) and10% ammonium chloride (pH 3.9). He presented withabdominal pain and vomiting. His pulse and blood pressurewere normal, as was physical examination. His blood testswere unremarkable apart from hyperamylasemia (240 mg/L)and plain abdominal and chest X ray were unremarkable. Hewas initially managed conservatively without early esoph-ago-gastro-duodenoscopy (OGD). During the initial stage ofthe admission, he developed a candidial infection of the oralcavity which was managed by topical nystatin and oral flu-conazole. His recovery was subsequently complicated byaspiration pneumonia. By day 21 following admission, hewas complaining of worsening dysphagia and vomiting.OGD showed widespread inflammation and ulceration of theesophagus, the stomach, and the duodenum. He had a pyloricstenosis which was dilated. Repeat OGD performed on day24 showed persistence of the inflammation in the esophagusthrough the stomach to the duodenum. Repeat OGD in thefollowing week showed improvement in the inflammation ofthe esophagus; however, the stomach was still inflamed andulcerated with stenosis of the pylorus. The pylorus wasballoon dilated to 18 mm. Despite these measures, he was

still vomiting. His nutrition was thus maintained parenterally.Barium meal demonstrated obstruction to the flow of contrastat the level of the body of the stomach (Fig. 1) and so he wasreferred to the surgical department 6 weeks following theincident. On table OGD prior to the diagnostic laparoscopydemonstrated that the fundus was the only remaining patentpart of the stomach. The laparoscopy showed a densely scarredand cicatrized stomach. Gastrectomy was hazardous becausethe stomach was fixed to the nearby structures. Thereforelaparoscopic Roux-en-Y gastrojejunostomy was performed.The post-operative recovery was routine and the patientresumed normal diet on the sixth post-operative day and wasdischarged on the ninth post-operative day.

ZC is a strong corrosive agent which, following ingestion,is capable of producing widespread damage locally and system-atically with long-lasting morbidity and significant mortalityparticularly in concentrations exceeding 20%.1 Literaturereview shows that there are few reports of ZC ingestion andits management is debatable. The mainstay of treatment issupportive. In the acute phase, perforation and necrosis mayoccur, necessitating emergency surgery. Long-term compli-cations include gastrointestinal tract (GIT) stricture formationand carcinoma. OGD is the diagnostic procedure of choice inthe absence of perforation. OGD can classify GIT corrosiveburns into grades 0–3 (Table 1). Zargar found that earlymajor complications and deaths were confined in grade 3.Grade 3 survivors and the majority of grade 2b developedesophageal or gastric strictures.2 Esophageal and antral stric-tures that cannot be dilated endoscopically may require sur-gery.3 Our patient was managed conservatively throughout

Received 25 April 2009; accepted 5 June 2009.Address correspondence to Raed Tayyem, Ayr Hospital, Dalmel-

lington Road, Ayr KA7 3QP, UK. E-mail: rtayyem@yahoo.com

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the acute phase. However, following recognition of the gas-tric stricture, surgical intervention ensued and he underwentsuccessful laparoscopic Roux-en-y gastrojejunostomy andwas subsequently discharged having made an excellentrecovery.

References

1. Barceloux DG. Zinc. J Toxicol Clin Toxicol 1999; 37:279–292.2. Zargar SA, Kochhar R, Mehta S, Mehta SK. The role of fiberoptic endo-

scopy in the management of corrosive ingestion and modified endo-scopic classification of burns. Gastrointest Endosc 1991; 37:165–169.

3. Ramasamy K, Gumaste VV. Corrosive ingestion in adults. J Clin Gastro-enterol 2003; 37:119–124.

Fig. 1. Barium meal demonstrates obstruction to the flow ofcontrast at the level of the body of the stomach.

Table 1. Upper gastrointestinal endoscopy classifies corrosiveinjury into four grades

Grade OGD findings

0 Normal1 Mucosal edema and hyperemia2a Friable, blisters, erosions, superficial ulcers, and hemorrhage2b Deep or circumferential ulcers3a Small scattered areas of necrosis3b Extensive necrosis

Upper gastrointestinal endoscopy classifies corrosive injury into four grades.

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