Submucosal hematoma: a new distinctive sign during emergency upper digestive endoscopy for ammonia ingestion

Abstract

BackgroundSubmucosal hematoma has never been associated with caustic injuries. Long-term follow-up of patients who ingested ammonia is not well known and ammonia ingestion is rare.MethodsIn a Single-center observational study, prospective data were collected from 2009 to 2013, in patients over the age of 14 years old referred for ammonia ingestion. The emergency and follow-up endoscopic data and the outcome were reported.ResultsAmmonia ingestion occurred in 43 patients. Submucosal hematoma of the gastric wall was a distinctive endoscopic sign observed in 15 (34.8%) cases. Oropharyngeal lesions were present in 30 (69.8%) patients, which was associated with ingestion with suicidal intent in 18 cases. Mild and severe endoscopic lesions (grade IIB to IIIB) were found in 16 (37.2%) cases with 10 (23.3%) cases presenting submucosal hematoma at initial endoscopy. A complete spontaneous gastric healing was frequently observed in 36 (83.7%) cases. In 11 cases with submucosal hematoma, a favourable outcome was observed with a medical treatment, however 6 of these patients had severe endoscopic lesions initially.ConclusionsSubmucosal hematoma of the gastric wall is an endoscopic sign occurring frequently in ammonia ingestion. Submucosal hematoma should be distinguished from necrosis in order to avoid false misclassification in favour of more severe lesions, which would lead to an abusive surgery.Electronic supplementary materialThe online version of this article (10.1186/s12876-018-0809-8) contains supplementary material, which is available to authorized users.

Caustic esophageal injury in clinical settings

“…11 Interestingly, a study conducted in Guadeloupe showed that deliberate ammonia ingestion were more common in older (median: 49 years old) females. 12 An Iranian study also revealed similar older population (average age: 35.38±13.72 years); 88.2% ingested acid. 10 In India, 69% of patients deliberately ingested caustic substances, while 28% ingested caustic substances accidentally or attempted murder (3%).…”

“…Submucosal hematoma usually yielded better outcomes (89.3% suffered no stenosis nor death) although the difference is not significant (p=0.4). 12 Alkali ingestion presented in more serious condition (44% on grade IIIB, 19% on grade IIA, and 13% on grade IIIB), compared to acid ingestion (38% on grade I and IIA each, with only 24% on grade IIIA). 9 Higher grade of esophageal injury was associated with increased mortality; in one study in Iran, 83.3% of grade III patients died compared to lower grades (p=0.021).…”

“…Thus, MRI may be useful to help determine degrees of esophageal injuries due to better soft tissue contrast and non-invasiveness of MRI. 8 Variable outcomes were found, but strictures or stenosis, 6,7,9,12,14 submucosal hematoma, 12 gastric outlet obstruction, 6 mediastinitis, 9 tracheo-esophageal fistula, spondylocystitis, 8 or perforation, and death [6][7][8][9]11,12 could be expected. In a German study, 19% of alkali ingestion cases suffered from esophageal stenosis and mediastinitis (10% and 0% on acid ingestion, p=0.52 and p=0.15).…”

Corrosive substances ingestion: a review

“…Of these 43 patients, oropharyngeal lesions were present in 30 (69.8%) and associated with attempted suicidal ingestions in 18 of these patients. Such submucosal hematomas should be differentiated from gastric necrosis to preclude confusion with gastric necrosis which might be an indication for surgical intervention (Gelu-Simeon et al 2018). Lu et al (2014) conducted a seven-year retrospective study of 108 adult patients who ingested corrosive substances in an attempt to identify predictive factors for the development of esophageal stricture and gastric outlet obstruction utilizing a modified Zargar endoscopic mucosal injury grading scale.…”