Introduction: Ingestion of caustic substances causes injury of the upper GI tract and can lead to significant morbidity and mortality. The pattern and severity of injury correlates to the composition, form, and amount of the substance consumed. Alkaline agents cause injury to the esophagus and acidic substances cause damage to the stomach. Stricture is the most common long-term complication and develops within 8-weeks of initial ingestion in about 80% of patients. To our knowledge, this is the first case of severe esophageal and pyloric stenosis secondary to nitromethane ingestion.
Case Description/Methods: A 48-year-old-man with schizophrenia presented with abdominal pain, dysphagia, and odynophagia 1-week after ingesting nitromethane. As he was outside of the window for evaluation of an acute caustic ingestion injury, EGD was not performed. Supportive management including a PPI was initiated. The patient returned 4-weeks later with continued dysphagia, aspiration pneumonia, and weight loss. EGD demonstrated esophageal stenosis, hematin in the gastric body, diffuse non-bleeding gastric ulcers, and severe pyloric stricture. EGD and NJ tube placement was attempted but unsuccessful secondary to severe pyloric stenosis with inability to pass a guidewire. General surgery performed gastrostomy and jejunostomy tube placement. The patient presented 2-months later with severe malnutrition. CT abdomen revealed a coiled GJ tube in a distended stomach. EGD demonstrated a segment of mid and distal esophageal stricture measuring 12mm in diameter, diffuse gastropathy, and severe narrowing of the pyloric channel. The prior GJ tube had migrated to the stomach so was exchanged for an externally removable gastrostomy tube for venting and NJ tube for nutrition. When the patient’s nutritional status is optimized, he will likely require distal antrectomy and Bilroth II reconstruction for pyloric stenosis.
Discussion: Ingestion of nitromethane has not been reported on to our knowledge and the extent of pyloric stricture demonstrated on EGD was noteworthy. Early contact with the medical system to identify and treat the damage from caustic ingestion is essential and unfortunately this patient’s presentation was delayed. Further management will be targeted at alleviating symptoms, optimizing nutritional status, and engaging a multidisciplinary team to reduce the risk of recurrent ingestion. Potential late complications include esophageal adenocarcinoma or squamous cell carcinoma making ongoing surveillance for malignancy a priority.
