Harpic, a well-known sanitary cleaning agent, poisoning incidents for which is increasing day by day. It contains Hydrochloric Acid (10%) as the active ingredient along with Butyl Oleyl amine and others in an aqueous solution. 

Caustic substances are merchant all around the countries and popularized with extensive advertising. Although they are hazardous and may cause serious injury to the respiratory and gastrointestinal tract. Children usually ingest it accidentally whereas adult swallow in a larger amount intentionally for suicidal attempt. 

Severity of injury and long-term complications depend on amount and mode of intake. After caustic ingestion patients complain burning sensation of mouth and throat, retrosternal chest pains, nausea, vomiting, often with bloody content. These symptoms may develop immediately after caustic ingestion, or be delayed for few hours after ingestion and they may last days and weeks. Hypersalivation, difficulty in swallowing with edema, ulceration or whitish plaques in the oral cavity, palatal mucosa and pharynx are common phenomena.1 The most common late complications are esophageal strictures and stenosis, gastric stenosis of the antrum and pylorus, esophageal and stomach cancer.2,3

Several methods are used to estimate and evaluate lesions caused by caustic ingestion. Simple radiography in suspicious cases of perforation, radiography with contrast, CT scan with and without contrast, nuclide radio scan and endoscopy because of sensitive and accurate information in the acute phase after ingestion, were the selected methods for the estimation of severity and extent of the burns.4

This case made us realize that, after primary management early establishment of nutrition plays a crucial role in the management of caustic injury. Subsequently we can plan routine follow-up and surgical management if any long-term complications arise.

A 19-year-old lady was in familial disharmony. She had a fight with husband and decided to end her life and drunk a bottle of Harpic. Immediately after drinking she felt burning at her throat chest and abdomen but nobody could notify this until 3hours. She was taken to emergencies of different hospital and brought to our hospital after 48 hours. 

Immediately endoscopy was performed that reveal 3rd degree esophageal burn. After initial symptomatic management feeding jejunostomy done for nutritional support as patient could not even swallow saliva. Patient was discharge thereafter and was on regular follow-up.

After 2 months check endoscopy was done which showed lower esophageal stricture and on Gastrograffin swallow X-ray Esophageal stricture and Gastric hold up found. (Figure 1).

Contrast enhanced CT Chest and Abdomen revealed long segment esophageal stricture 2 cm above the Carina to lower end and Pyloric stricture. Then, we planned for surgical intervention. Preoperative nutritional improvement attempted by both parenteral (TPN) & Enteral (Feeding Jejunostomy) route. On table Colonoscopy reveal normal Colon.

During laparotomy, Colon mobilized (Figure 2 A, B, C). after omentectomy and colonic vasculature assessed (Figure 3), then stomach mobilized. Cervical incision was made and esophagus mobilized, Esophagectomy (Figure 4) followed by Colonic pull up (Isoperistaltic, based on ascending ending branch of left & middle colic artery) performed. Then,Pharyngocolonic anastomosis, Cologastric & Colocolic anastomosis was made. Finally, Roux-en-Y Gastrojejunostomy with Feeding Jejunostomy performed.

Postoperative period was uneventful, no anastomotic leakage and no strictures. Feeding Jejunostomy tube were removed after one & half month. Patient was in follow-up for the last 1.5 years.

Accidental swallowing of caustic materials can cause serious damage to the gastrointestinal tract. This damage occurs in the esophagus because it is the most delicate and defenseless tissue and at the same time, has the greatest contact with ingested caustic substances. 5 

Esophageal injury also tends to be most severe at areas where the lumen is smaller, and consequently the transit speed is lower. The most optimal timing for esophago gastro duodenoscopy is the first 48 hours post-ingestion. Since inflammatory changes, vascular thrombosis and the healing process of the post-corrosive injuries begin the 4th and are most intensive until the 14th day, it is suggested to avoid this diagnostic procedure during this period.6 

It is important not to administer emetics because this will re-expose the esophagus to the caustic agent.t Gastric lavage is also contraindicated, owing to the risk of esophageal perforation and aspiration of gastric contents.

Early dilatation & stenting can prevent esophageal stricture. Early indication of surgery includes esophageal perforation, transmural necrosis, grade 2 or 3 injury. Late indications are complete stenosis in which all attempts are failed, perforation after dilatation, esophageal carcinoma, fistula formation. Options for reconstructive surgery with conduits includes platysma myocutaneous flap Jejunal interposition, Gastric pull up, Gastric tube, reversed gastric tube, Colonic pull up. Advantages of Jejunum as conduit are its availability and reliable transport of food. The diameter & wall thickness of the Jejunum closely resembles that of the esophagus. Its isoperistaltic placement provides some defense against gastroesophageal reflux. Major disadvantage is its arterial supply variations in the Jejunal arcades may limit the amount of length that can be gained when the Jejunum is used as an interposition or roux limb. 7 Colon has a number of attributes that make it an excellent option for esophageal replacement. It has several key advantages, including long length, acid resistance, typically excellent blood supply, and the potential for a wide gastric resection margin for patients with cancers of the gastroesophageal junction.In most patients the graft is placed in the posterior mediastinum in the bed of the native esophagus, and this route tends to produce the best functional result. Long-term problems with colon interposition are reported to occur in approximately one third of patients. The majority of these consist of, Graft redundancy, aspiration, bile reflux

In most patients the graft is placed in the posterior mediastinum in the bed of the native esophagus, and this route tends to produce the best functional result. Long-term problems with colon interposition are reported to occur in approximately one third of patients. The majority of these consist of, Graft redundancy, aspiration, bile reflux

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2. Atiq M, Kibria RE, Dang S, Patel DH, Ali SA, Beck G, Aduli F. Expert Rev Corrosive injury to the GI tract in adults: a practical approach. Gastroenterol Hepatol. 2009;3:701–709. [PubMed] 

3. Berthet B, Bernardini D, Lonjon T. Treatmen of caustic stenoses of the upper digestive tract. Chir (Paris) 1995;132:447–450. [PubMed] 

4.Shahbazzadegan B, Samadzadeh M, Feizi I, Shafaiee Y. Management of Esophageal Burns Caused by Caustic Ingestion: A Case Report. Iran Red Crescent Med J. 2016 Nov; 18(11): e12805. 

5. Najafi M, Asgar shirazi M, Farahmand F, KHodadad A, Falahi G. Year following the Accidental Caustic Ingestion and Esophageal mucosal damage in children resulting from it. Child Health J. 2007;17(1):205–10. 

6. Poley JW, Steyerberg EW. Ingestion of acid and alkaline agents:outcome and prognostic valve of early upper endoscopy. Gastrointest Endosc. 2004;60:372–377. [PubMed] 

7. William A. Cooper and Joseph I. Miller, Jr. Jejunal interposition for esophageal replacement. Operative Techniques in Thoracic & Cardiovascular Surgery, Vol 4, No 3 (August), 1999: pp 239-251.