ACMT Toxicology Visual Pearl: Abdominal Bruising

Abdominal Bruising

What could cause this finding three days after ingestion of a concentrated household substance?

Duodenal ulcer
Gastric perforation
Necrotizing enterocolitis
Post-corrosive acute pancreatitis

Reveal the Answer

4. Post-corrosive acute pancreatitis

The above image shows Cullen’s sign, which appears as blotches of superficial ecchymoses in the skin surrounding the umbilicus and is associated with acute pancreatitis [1]. Acute pancreatitis is an unusual complication of corrosive ingestion and when present is generally associated with severe injury and necrosis in the gastrointestinal tract [2,3].

Cullen’s sign results from the spread of retroperitoneal blood into the subcutaneous umbilical tissues through the falciform ligament. Another clinical sign of pancreatitis is Grey Turner’s sign manifested as ecchymosis in the flanks of the abdomen. Approximately 1-3% of patients diagnosed with acute pancreatitis may demonstrate one or two of these signs [1].

What are other possible complications following caustic ingestion? [4-8]

Bleeding
Perforation
Aspiration pneumonitis
Mediastinitis
Systemic complications (renal insufficiency, hepatic dysfunction, and diffuse intravascular coagulation)
Esophageal stricture and fistula
Gastric outlet obstruction
Malignant transformation

What is the management of a caustic ingestion?

Supportive measures with close attention to airway management.
Esophagogastroduodenoscopy (EGD), ideally within 24 hours, is the most effective method for establishing injury severity and for treatment planning following caustic ingestion [4-6].
Computer Tomography (CT) may be necessary to assess for intra-abdominal complications such as perforation and pancreatitis [9 -12].
Surgery may be required in cases of perforation, peritonitis, or hemorrhagic shock.
Monitor for delayed sequelae such as gastric/esophageal stricture or development of malignancy.
For more information about caustic ingestion, refer to ACMT Toxicology Visual Pearl: Swollen Lips.

What is the management of pancreatitis? [9-13]

Treatment for acute pancreatitis is primarily supportive with fluids, electrolyte repletion, and pain management.
Strictly prohibit oral intake initially.
Monitor electrolytes and lipase concentrations.
Prophylactic antibiotics should be reserved for cases with objective signs of infection.
Surgical management may be required for severe cases including extensive necrosis.

Bedside Pearls

Cullen’s sign is a marker of significant injury such as pancreatitis following caustic ingestion.
EGD is the gold standard for identifying, evaluating, and planning the management of caustic injuries. This should ideally be performed within 24 hours of ingestion.
Treatment of pancreatitis is largely supportive although surgical management may be required for severe cases.

The American College of Medical Toxicology hosts this Toxicology Visual Pearls series. The post was peer reviewed on behalf of ACMT by Louise Kao, Kathy Kopec, and Kristine Naňagas.

References

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Nijhawan S, Jain P. Acute pancreatitis as an unusual complication of corrosive ingestion. Journal of Gastrointestinal and Liver Diseases: JGLD. 2007;16(3):345-346.‏ PMID: 17925933.
Cattan P, Munoz-Bongrand N, Berney T, Halimi B, Sarfati E, Celerier M. Extensive abdominal surgery after caustic ingestion. Ann Surg. 2000;231(4):519-23. PMID: 10749612.
Temiz A, Oguzkurt P, Ezer SS, Ince E, Hicsonmez A. (2012). Predictability of outcome of caustic ingestion by esophagogastroduodenoscopy in children. World journal of gastroenterology: WJG. 2012;18(10):1098.‏ PMID: 22416185.
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Temiz A, Oguzkurt P, Ezer SS, Ince E, Hicsonmez A. (2010). Long-term management of corrosive esophageal stricture with balloon dilation in children. Surg Endosc. 2010;24:2287–2292. PMID: 20177917.
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Ismail OZ, Bhayana V. Lipase or amylase for the diagnosis of acute pancreatitis? Clin Biochem. 2017;50(18):1275-1280. PMID: 28720341.
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Arnold M, Numanoglu A. Caustic ingestion in children—a review. Seminars in pediatric surgery. 2017;26(2):95-104. PMID: 28550877.
Soulountsi V, Schizodimos T. Use of antibiotics in acute pancreatitis: ten major concerns. Scandinavian Journal of Gastroenterology. 2020;55(10):1211-1218. PMID: 32805137.
Párniczky A, Lantos T, Tóth EM, Szakács Z, Gódi S, Hágendorn R, et al. Antibiotic therapy in acute pancreatitis: From global overuse to evidence based recommendations. Pancreatology. 2019;19(4):488-499. PMID: 31068256.