S4357 Hydrogen Peroxide Ingestion Causing Portal Vein Thrombosis and Esophageal Perforation

Introduction: Hydrogen peroxide is simple household item that when ingested can lead to life-threatening events. This case highlights two complications of hydrogen peroxide ingestion; directly related to oxygen gas embolism and direct caustic injury. While gastrointestinal necrosis and pneumatosis are common after consumption, portal vein thrombosis (PVT) and esophageal perforation are rare. We present a case of hydrogen peroxide ingestion resulting in both of these complications, requiring diverse multidisciplinary management. Case Description/Methods: A 23-year-old woman with no past medical history, presented after Hydrogen Peroxide ingestion; notable associated symptoms of nausea, vomiting, and severe odynophagia. Initial computed tomography abdomen revealed diffuse gastric/duodenal wall thickening with adjacent inflammatory fat stranding. The patient underwent an esophagogastroduodenoscopy which was notable for esophagitis with severe stenosis, duodenitis and superficial necrotic changes at the level of D1, D2 and D3. Due to extensive esophageal damage, she underwent stenting to protect the friable mucosa after severe caustic injury. The patient resumed proton pump inhibitors and sucralfate regimen. Throughout the course of the hospitalization, she developed worsening dyspnea and right upper quadrant pain. Repeat computed tomography imaging now revealing a new onset PVT extending into the superior mesenteric vein; this event likely occurring in the setting of oxygen gas embolism, prompting immediate anticoagulation. This imaging was also able to identify a distal esophageal perforation subsequently treated with an esophagectomy, cervical esophagostomy and feeding jejunostomy. Four months later, the patient's intestinal continuity was restored via transverse colonic interposition graft. Discussion: This case highlights two rare complications of hydrogen peroxide ingestion. PVT likely occurred due to hydrogen peroxide intoxication; high levels of oxygen exceeded the maximum blood solubility, developing a venous embolism responsible for portal venous gas and pneumatosis. The perforation found on serial imaging demanded immediate surgical intervention due to irreversible tissue damage. Of note, given the endoscopic stenting failure to protect the fragile mucosa, one should keep in mind the limitations of minimally invasive procedures in advanced caustic injury. Given these complications, this case encourages clinicians to consider caustic ingestion in the differential for any unexplained PVT and acute esophageal injury, specifically in the young and healthy patient population.