The Effects of Large Volume Ingestion of Concentrated Household Bleach

Introduction: Caustic ingestion remains a significant hazard throughout the world. Despite ongoing efforts toward restricting the access, concentration and handling of these chemicals, a substantial amount of the population is affected every year. In cleaning products, worse outcomes are associated with more basic solutions with a pH >12. Here we describe the interesting case of a 38-year-old man who ingested 0.5 gallons of household bleach. Case Description/Methods: A 38-year-old man with a history of psychotic disorder presented to the hospital as a transfer from an outside hospital for evaluation of intentional bleach ingestion 24 hours prior. The patient admitted to consuming about 50% of a 128oz bottle of household bleach. Shortly thereafter, he experienced multiple episodes of frank hematemesis prompting a visit to the hospital. Laboratory data upon transfer was unremarkable and the patient’s hematemesis resolved with ondansetron administration. Computed tomography (CT) revealed grade 2-3 esophagitis (Figure 1-1). On endoscopy, the oropharynx was ulcerated with mucosal sloughing (Figure 1-2) and moderate esophagitis distally (Figure 1-3). The stomach suffered a third-degree injury with multiple areas of deep ulcers and necrotic tissue (Figure 1-). Sucralfate and viscous lidocaine were used for analgesia until the patient was able to transition to a clear liquid diet after 48 hours. The patient made an uneventful recovery without evidence of an esophageal stricture at 6 weeks follow-up. Discussion: Apart from oven and grill cleaners (pH 13.5-14), bleach is one of the most corrosive household substances due to its alkalinity. The concentration of sodium hypochlorite in the most household bleach products is 5%-6%. The typical volume of intentional caustic ingestions range from 200-500 mL. Our patient ingested ∼1800 mL of bleach with a concentration of 7.5% (pH of 12.5), owing to the significant symptoms he experienced. Guidelines for the ingestion of corrosive substances are vague but ultimately suggest close monitoring while the patient remains NPO. Following a high-grade injury, a significant risk remains for stricture formation in the upcoming weeks-months. This is coupled with a 3000-fold increase in the risk of developing esophageal carcinoma. In summary, this case illustrates the toxic effects of a large volume ingestion of household bleach that is not commonly encountered. Close attention towards evidence of perforation or airway compromise should be a pertinent consideration for every provider.Figure 1.: 1. CT scan revealing grade 2-3 esophagitis (arrow). 2: Granulation tissue with erythema, congestion and swelling in the oropharynx. 3: Grade 2A esophageal injury (Zagar classification). 4: Focal necrosis and hyperemia in the gastric body.