Surgical Science, 2011, 2, 338-340
doi:10.4236/ss.2011.26072 Published Online August 2011 (http://www.SciRP.org/journal/ss)
Isolated Full Thickness Jejunal Necrosis Following
Sulphuric Acid Cocktail Ingestion—A Clinical Case Report
—Isolated Corrosive Jejunal Necrosis
S. S. Pankaja, George J. Valooran, Sri Aurobindo Prasad Das, L. Suvasini, R. Aravind,
Vikram Kate, Pankaj Kundra*
Departments of Surgery and Anaesthesiology, Jawaharlal Institute of Postgraduate Medical
Education and Res earch, Puducherry, India
Received February 16, 2011; revised March 24, 201 1; acce p te d Ma y 16, 2011
Abstract
Isolated involvement of the lower gastrointestinal tract with relative sparing of the oesophagus and the
stomach is extremely rare following corrosive agent ingestion. We report a case of isolated full thickness
jejunal necrosis following sulphuric acid cocktail ingestion. A 42 year old man presented with history of
consuming 200 ml of sulphuric acid mixed with alcohol, with suicidal intent. On exploration there were mul-
tiple, full thickness necrotic areas in the proximal jejunum with minimal congestion of the oesophagus,
stomach and duodenum. Inversion of the jejunal necrotic areas with feeding jejunostomy was carried out.
However postoperatively patient developed progressive pulmonary insufficiency with features of sepsis and
expired on the nineteenth day following a bout of massive haematemesis. Corrosive agents when taken in
considerable amount mixed with other fluids can lead to full thickness small bowel necrosis with relative
sparing of the proximal gastrointestinal tract.
Keywords: Corrosive Injury, Acid Ingestion, Bowel Necrosis
1. Introduction
Accidental or suicidal ingestion of sulphuric and hydro-
chloric acids, leading to esophagogastric injury is not
uncommon [1-3]. The site, extent and intensity of dam-
age depend on the multiple factors related to the caustic
agent, duration of contact and the victim [4]. Concomi-
tant acid injury of the lower gastrointestinal tract is a rare
occurrence due to acid induced pylorospasm with con-
sequent gastric pooling, and neutralizing effect of the
bile [1,5-7]. However, isolated necrosis of the lower gas-
trointestinal tract with relative sparing of the proximal
gastrointestinal tract is extremely rare with limited re-
ports [2,4,5]. Here we present a case of isolated full
thickness jejunal necrosis with relative sparing of the
proximal gastrointestinal tract following sulphuric acid
cocktail ingestion.
2. The Case
A 42 year old manual labourer presented to emergency
department with history of having consumed battery
sulphuric acid mixed with alco hol, around 200 ml, under
the influence of alcoh ol with suicidal intent 3 hours prior
to presentatio n. Fo llowing inge stion p atien t h ad v omiting
which had both fresh and altered blood and developed
severe burning pain in epigastric and retrosternal regions.
At presentation patien t was severely agitated. Abdominal
examination revealed mild epigastric guarding, tender-
ness and normal bowel sounds. As patient had mild epi-
gastric guarding upper gastrointestinal endoscopy was
not performed as there was a likely risk of perforation
due to inflation for endoscopy. Initial arterial blood gas
analysis revealed severe metabolic acidosis. Skiagram of
the chest, electrocardiogram and other biochemical tests
including serum amylase were normal. Patient was re-
suscitated, started on antibiotics and shifted to surgical
intensive care unit.
Two days later, patient developed abdominal disten-
sion with peritoneal signs for which he was posted for an
exploratory laparotomy. Considering the patient being
full stomach and scheduled for emergency laparotomy,

S. S. PANKAJA ET AL. 339
an awake, orotracheal fibreoptic tracheal intubation was
performed under local anaesthesia. On exploration there
were multiple areas of full thickness necrosis in the
proximal jejunum (Figure 1) starting fr om duodeno-j eju-
nal flexure for a leng th of two feet. As the necrotic areas
were in close proximity to the duodeno-jejunal flexure
and there were no obvious large areas of full thickness
necrosis, resection of the involved was not carried out.
The lower end of oesophagus, stomach, duodenum were
minimally congested whereas the rest of the intestine and
colon were appearing normal. There was saponification
of the omentum and two litres of blood stained fluid in
the peritoneal cavity. 18 size Ryle’s tube was inserted
intra operatively into the stomach successfully. All the
necrotic areas were inverted in two layers by seromuscu-
lar sutures and a feeding jejunostomy was carried out.
Postoperatively ventilatory support was continued. Pa-
tient continued to deteriorate developing features of sep-
sis, multi-organ dysfunction and expired on 19th postop-
erative day following a massive bout of haematemesis.
Autopsy findings included a congested oesophageal and
gastric mucosa with evidence of grade I/II oesophageal
varices, multiple necrotic areas over jejunum without
evidence of free perforation, and features of cirrhosis in
the liver.
3. Discussion
Accidental or suicidal ingestion of caustic substances is
common as they are presen t in many household products
such as toilet cleansers, antirust compounds, battery fluid
etc. [3,4]. Self poisoning is associated with higher grade
of injury. Characteristic features in acid ingestion include
severe injury to the stomach, particularly antropyloric
region and relative sparing of the oesophagus. However
following gastric surgeries involving pyloric ablation,
Figure 1. Full thickness necrotic area in the jejunum with-
out perforation.
ingested acid can enter the small intestine rapidly and
can cause significant inju ry [8]. Due to contact burn s and
bitter taste concentrated acids are usually vomited out
thereby producing lesser damage whereas dilute acids
will be ingested in relatively larger amount and can lead
to significant injury of the digestive tract [4]. In the pre-
sent case dilution of acid with alcohol has lead to a sig-
nificant corrosive injury to the proximal jejunum rather
when compared to the oesophagus or the stomach.
However it has been reported that strong acids when
taken in considerable amount can lead to injury beyond
the stomach causing extensive necrosis of the small in-
testine and colon [5,6].
Diagnosis can be made by clinical examination, imag-
ing and endoscopy in stable cases whereas in unstable
cases clinical examination and imaging are used for the
diagnosis. Although antibiotics and steroids are used,
their role is still controversial. Early su rgical interven tion,
performed when indicated, has been reported to improve
the prognosis. In the present case there were no early
clinical signs or imaging finding necessitating emergent
laparotomy at presentation. At exploration resection of
all the necrotic tissues is recommended [5]. However, in
the present case resection was not done as patient had
very small but multiple necrotic patches just distal to th e
duodeno-jejunal flexure. There are reports of successful
management of corrosive jejunal perforation with simple
closure [7].
This case highlights that although corrosive acid injur y
commonly involves oesophagus and stomach, when
taken in considerable amount mixed with other fluids, it
can enter the small bowel in significant amount causing
full thickness necrosis with relative sparing of the
proximal gastrointestinal tract.
4. References
[1] J. P. Thornton, “Surgical Management of corrosive Gas-
tric Injuries,” Journal of the National Medical Associa-
tion, Vol. 66, No. 1, 1974, pp. 53-55.
[2] J. B. Dilawari, S. Singh, P. N. Rao and B. S. Anand,
“Corrosive Acid Ingestion in Man—A Clinical and En-
doscopic Study,” Gut, Vol. 25, No. 2, 1984, pp. 183-187.
doi:10.1136/gut.25.2.183
[3] K. Ramasamy and V. V. Gumaste “Corrosive Ingestion in
Adults,” Journal of Clinical Gastroenterology, Vol. 37,
No. 2, 2003, pp. 119-124.
doi:10.1097/00004836-200308000-00005
[4] S. Sharma, P. R. Debnath, L. D. Agarwal and V. Gupta,
“Gastric Outlet Obstruction without Esophageal In-
volvement: A Late Sequelae of Acid Ingestion in Chil-
dren,” Journal of Indian Association of Pediatric Sur-
geons, Vol. 12, No. 1, 2007, pp. 47-49.
doi:10.4103/0971-9261.31094

S. S. PANKAJA ET AL. 340
[5] P. Cattan, N. Munoz-Bongrand, T. Berney, B. Halimi, E.
Sarfati and M. Celerier, “Extensive abdominal surgery
after caustic ingestion,” Annals of Surgery, Vol. 231, No.
4, 2000, pp. 519-523.
doi:10.1097/00000658-200004000-00010
[6] Q. Zeng, H. Zhou, X. Zheng, Z. Li, M. Zhou, S. Han, et
al., “Total Gastrointestinal Tract Necrosis after Ingesting
a Considerable Amount of Hydrochloric Acid,” Journal
of Gastrointestinal Surgery, Vol. 13, No. 3, 2009, pp.
578-80. doi:10.1007/s11605-008-0524-9
[7] O. Boybeyi, I. Karnak, F. C. Tanyel and M. E. Senocak,
“Management of Unusually Extensive Esophagogastric
Corrosive Injuries: Emergency Measures and Gastric
Reconstruction,” Journal of Pediatric Surgery, Vol. 44,
No. 5, 2009, pp. 1022-1026.
doi:10.1016/j.jpedsurg.2009.02.001
[8] J. M. Chang, M. H. Wu, W. W. Lai, M. Y. Lin, Y. F. Tsai,
I. L. Hsu, et al., “Acid Corrosive Injury in Patients with a
History of Partial Gastrectomy: Outcome Analysis,” Di-
gestive Surgery, Vol. 24, No. 3, 2007, pp. 202-207.
doi:10.1159/000102900