What is the diagnosis and management for a patient with abdominal pain and vomiting after ingesting approximately 5-10 mL of a calcium hypochlorite solution (approximately 5 grams of granules in 250 mL water) with stable vital signs (VS)?

Calcium Hypochlorite Ingestion: Diagnosis and Management

Diagnosis

This patient has acute corrosive gastritis from calcium hypochlorite ingestion, manifesting as chemical injury to the gastrointestinal mucosa. 1

The diagnosis is established by:

• History of ingesting 5-10 mL of calcium hypochlorite solution (approximately 2% concentration based on 5 grams in 250 mL water) 1
• Clinical presentation of abdominal pain and multiple episodes of vomiting (>5 episodes), which are hallmark features of corrosive gastrointestinal injury 1
• Stable vital signs currently, though this does NOT exclude significant mucosal injury or evolving complications 2, 3

Key Diagnostic Considerations

The concentration ingested (approximately 2%) places this in the moderate-to-high concentration range where corrosive injury is likely, though household bleach typically contains 3-6% sodium hypochlorite. 1 Calcium hypochlorite behaves similarly to sodium hypochlorite, causing toxicity through oxidizing capacity and alkaline pH-related corrosive activity upon contact with mucous membranes. 1

Critical caveat: Stable vital signs do NOT exclude severe corrosive injury—patients can have extensive mucosal damage without immediate hemodynamic compromise. 3, 1

Immediate Management Algorithm

Step 1: Initial Stabilization and Assessment (First 30 Minutes)

• Establish large-bore IV access immediately and begin isotonic crystalloid resuscitation at 1000-2000 mL bolus, then maintain at 125-250 mL/hour 2
• Check vital signs every 5-10 minutes initially, monitoring specifically for tachycardia, fever, hypotension, and tachypnea as these predict serious complications 2, 3
• Make patient NPO (nothing by mouth) immediately—no oral intake, no activated charcoal, no attempts at dilution or neutralization 4, 1
• Do NOT induce vomiting or perform gastric lavage, as this increases risk of re-exposure and aspiration 1

Step 2: Laboratory Evaluation (Within First Hour)

Draw blood immediately for:

• Complete blood count, comprehensive metabolic panel (including calcium, sodium, chloride), and arterial or venous blood gas with lactate 2, 3, 1
• Elevated lactate >2 mmol/L would indicate tissue injury and potential ischemia 5
• Monitor for metabolic acidosis, hypernatremia, and hyperchloremia, which can occur with large ingestions 1
• Hypercalcemia may develop from calcium hypochlorite specifically (unlike sodium hypochlorite), requiring monitoring 6

Step 3: Endoscopic Evaluation (Within 12-24 Hours)

Fiberoptic esophagogastroduodenoscopy (EGD) should be performed within 12-24 hours to assess severity of corrosive injury, as this determines prognosis and guides further management. 4, 1

• EGD is indicated because the patient has significant symptoms (multiple episodes of vomiting, abdominal pain) after ingesting a moderate concentration solution 1
• Endoscopy assesses risk of mortality, risk of stricture formation, and extent of mucosal injury 4, 1
• Perform EGD before 24 hours but after initial stabilization—avoid the 5-15 day window when perforation risk is highest due to tissue necrosis 4

Step 4: Imaging Evaluation

Obtain CT chest/abdomen/pelvis with IV contrast if any of the following develop: 4, 1

• Development of peritoneal signs (rebound tenderness, guarding, rigidity) 3
• Hematemesis or signs of gastrointestinal bleeding 1
• Fever, tachycardia, or hemodynamic instability 2, 3
• Severe retrosternal or epigastric pain suggesting transmural injury 1

CT is complementary to endoscopy for assessing transmural injury, perforation, and mediastinal involvement. 4, 1

Step 5: Supportive Care

• Administer IV proton pump inhibitor (e.g., pantoprazole 40 mg IV twice daily) to reduce acid-related secondary injury 1
• Provide antiemetic therapy with ondansetron 4-8 mg IV every 8 hours for persistent vomiting 3
• Maintain adequate hydration with isotonic crystalloids, as vomiting causes significant fluid losses 3
• Monitor urine output targeting >0.5 mL/kg/hour 2

Step 6: Serial Clinical Monitoring

Perform serial abdominal examinations every 4-6 hours to detect development of peritonitis, which would indicate perforation requiring emergency surgery. 2, 3

Monitor continuously for:

• Development of peritoneal signs (rebound, guarding, rigidity) 3
• Worsening abdominal pain or new-onset severe pain 3
• Hemodynamic deterioration (tachycardia, hypotension) 2, 3
• Fever or signs of sepsis 2

Management Based on Endoscopic Findings

Grade 0-I Injury (No injury or superficial mucosal injury)

• Continue NPO for 24-48 hours, then advance diet as tolerated 1
• Discharge with PPI therapy and close outpatient follow-up 1

Grade II Injury (Deep mucosal/submucosal injury without perforation)

• Maintain NPO status for 48-72 hours minimum 1
• Continue IV PPI therapy 1
• Consider total parenteral nutrition if prolonged NPO anticipated 4
• Monitor for stricture development over subsequent weeks to months 1

Grade III Injury (Transmural injury, necrosis, or perforation)

• Immediate surgical consultation for potential emergency laparotomy 4
• Broad-spectrum antibiotics (e.g., piperacillin-tazobactam 3.375 g IV every 6 hours) 4
• Aggressive fluid resuscitation with norepinephrine 0.05-3.3 mcg/kg/min if septic shock develops 2
• Surgical options include primary repair with drainage, esophageal/gastric resection, or damage control surgery depending on extent of injury 4

Critical Pitfalls to Avoid

1. Do NOT give activated charcoal—hypochlorite is not bound by charcoal, and administration risks aspiration and worsens injury 4, 1
2. Do NOT attempt neutralization with acids or dilution with water/milk—this generates heat and worsens injury 1
3. Do NOT delay endoscopy beyond 24 hours in symptomatic patients—early assessment is crucial for prognosis 4, 1
4. Do NOT assume stable vital signs mean absence of serious injury—corrosive damage can be extensive despite initial stability 3, 1
5. Do NOT place nasogastric tube blindly—this risks perforation if severe esophageal injury present; only place under endoscopic guidance if needed 4

Prognosis

Most patients with small-to-moderate household bleach ingestions recover without long-term sequelae, but this patient's significant symptom burden (>5 episodes vomiting, abdominal pain) warrants aggressive evaluation and monitoring. 1 The concentration ingested (approximately 2%) and volume (5-10 mL) place this patient at moderate risk for significant corrosive injury requiring endoscopic assessment. 1

Long-term complications include esophageal or gastric stricture formation, which may require endoscopic dilation or surgical intervention in severe cases. 1, 6