The Journal of Emergency Medicine, Vol. 49, No. 1, pp. e19–e21, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.12.060
Selected Topics: Toxicology
INGESTION OF PORTLAND CEMENT Kyung Ho Kim, MD,* Jang Young Lee, MD,* Seong Eun Yang, MD,† Won Suk Lee, MD,* Won Young Sung, MD,* Sang Won Seo, MD,* and Jung Il Yang, MD* *Department of Emergency Medicine, College of Medicine, Eulji University, Daejeon, Republic of Korea and †Department of Internal Medicine, College of Medicine, Eulji University, Daejeon, Republic of Korea Reprint Address: Jang Young Lee, MD, PHD, Eulji University Hospital, 1306 Dunsan-Dong, Seo-Gu, Daejeon, Republic of Korea
, Abstract—Background: The common toxicities of cement are allergic dermatitis, abrasions, and chemical burns, but reports of cement ingestion are rare. In this study, we report a case of successful treatment of cement ingestion using emergency gastrointestinal endoscopy. Case Report: An 83-year-old female was admitted to the emergency department with altered mental state and abdominal pain. We assumed that she ingested cement based on her medical history and radiologic examination. A previous report recommended surgical removal with gastric lavage. However, we thought that wet cement is highly alkaline, and gastric lavage is contraindicated. We performed emergency gastrointestinal endoscopy, instead of gastric lavage. Why Should an Emergency Physician Be Aware of This?: If a patient ingests cement, the recommendation is to check the status of the upper gastrointestinal tract and remove the cement by emergency gastrointestinal endoscopy as soon as possible. Ó 2015 Elsevier Inc.
mended treating cement ingestion with surgical removal of the cement by gastric lavage (6). That treatment method has been reported to be safe and effective. However, wet cement is highly alkaline, and gastric lavage is contraindicated for the risk of re-exposure to the corrosive agent and additional injury to the esophagus (7). For this case, we performed emergency gastrointestinal endoscopy, instead of the gastric lavage. Here, we report a case of successful treatment of cement ingestion using emergency gastrointestinal endoscopy. CASE REPORT An 83-year-old female was admitted to the emergency department (ED) with an altered mental state and abdominal pain. She was taking medications for diabetes and hypertension. She stated her appearance was normal 8 h before her admission to the ED. The patient’s daughter found gray vomitus, a half bottle of alcohol (approximately 20%), and a ripped bag of Portland cement near the patient 40 min before her admission to the ED. When she arrived at the ED, her blood pressure was 185/93 mm Hg, her pulse rate was 93 beats/min, her respiratory rate was 20 breaths/min, and her body temperature was 36.0 C. Her laboratory findings were all within the normal limits, except for a white blood cell count of
, Keywords—cement; toxicity; endoscopy; gastrointestinal
INTRODUCTION Cement is used as a material for construction in occupational settings and do-it-yourself work, and can be easily obtained (1). Cement’s common toxicities are allergic dermatitis, abrasions, and chemical burns, but reports of cement ingestion are rare (2–5). A previous report recom-
RECEIVED: 18 October 2014; ACCEPTED: 21 December 2014 e19
e20
K. H. Kim et al.
Figure 1. Simple abdominal x-ray (A) and abdominal computed tomography (B) show hyperdense material approximately 7 cm in diameter in the gastrointestinal fundus (arrow).
11.54 103/mL, a C-reactive protein of 0.59 mg/dL, and a creatine kinase of 558 IU/L. There were no abnormal findings in the patient’s brain computed tomography, angiography, or neurologic examination, despite her altered mental state. A simple abdominal x-ray study revealed an oval radiopacity in the left upper quadrant of the abdomen. We performed abdominal computed tomography and found a hyperdense material approximately 7 cm in diameter in the gastrointestinal fundus and a ground glass opacity in both lower lung fields (Figure 1). We assumed she ingested cement and performed emergency gastrointestinal endoscopy. Gray materials were found in the esophagus and gastric fundus, portions of which solid masses (Figure 2). Most materials were carefully washed out with suction, and the solid masses were removed with an endoscopy retrieval net. After 2 days, a follow-up gastrointestinal endoscopy revealed a normal esophagus and duodenum, a mild atrophic change to the stomach, erythema, and intramural bleeding spots in the gastrointestinal body and fundus. No cement materials were visible. She started a pre-
scribed diet and was treated with third-generation cephalosporin and metronidazole for aspiration pneumonia. She was discharged within 7 days of admission. DISCUSSION Throughout the world, Portland cement is the most common type of cement in general use. Portland cement is composed of calcium oxide (64%) and silicon dioxide (21%), with smaller amounts of aluminum, iron, magnesium, potassium, and sulfur oxide (8). Portland cement is easily accessed in the market. If a patient ingests a large amount of cement, it is difficult for an emergency physician to perform suitable emergency management. Visvanathan suggested gastric lavage for the treatment of cement ingestion because Portland cement sets within 3 h and dilution alone delays solidification and can even prevent it from occurring in the stomach (6). However, when Portland cement is mixed with water, it becomes highly alkaline. The hydrogen ion concentration range of wet cement is 10
Figure 2. Emergency gastrointestinal endoscopy shows gray materials in the gastric fundus, portions of which were solid masses, which were removed with an endoscopy retrieval net (arrow).
Cement Ingestion
to 12 and may continue to rise to 12 to 14 (9). Within 2 min of ingestion, the pH of wet cement is 11 to 13, which makes it one million times more alkaline than water (10). In addition, wet cement releases a large amount of heat (11). Cement burns have an insidious onset, a progressive nature, and severely damage tissues (2,12). Therefore, ingested cement should be removed as soon as possible. Gastric lavage is a contraindication of caustic injury because of the risk of esophageal perforation and tracheal aspiration of the stomach contents. Therefore, we recommend gastrointestinal endoscopy for the emergency management of cement ingestion in place of gastric lavage. Additionally delaying cement removal results in the formation of bezoars and complications, such as mucosa ulceration, gastrointestinal hemorrhage, gastrointestinal perforation, outlet obstruction, and protein-losing gastroenteropathy (6). When large bezoars are formed, a surgical operation should be considered (6). In our case, early gastrointestinal endoscopy prevented the formation of large bezoars, and we were able to successfully remove the cement from the stomach. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? When Portland cement is mixed with water, it becomes highly alkaline. Therefore, if a patient ingests cement, we suggest checking the status of the upper gastrointes-
e21
tinal tract and removing the cement using emergency gastrointestinal endoscopy as soon as possible.
REFERENCES 1. Poppe H, Poppe LM, Brocker EB, et al. Do-it-yourself cement work: the main cause of severe irritant contact dermatitis requiring hospitalization. Contact Dermatitis 2013;68:111–5. 2. Mehta RK, Handfield-Jones S, Bracegirdle J, et al. Cement dermatitis and chemical burns. Clin Exp Dermatol 2002;27:347–8. 3. Seyhan N, Keskin M, Savaci N. Contact with wet cement: an unrecognized cause of chemical burn. Ulus Travma Acil Cerrahi Derg 2012;18:189–91. 4. Poupon M, Caye N, Duteille F, et al. Cement burns: retrospective study of 18 cases and review of the literature. Burns 2005;31: 910–4. 5. Palao R, Monge I, Ruiz M, et al. Chemical burns: pathophysiology and treatment. Burns 2010;36:295–304. 6. Visvanathan R. Cement bezoars of the stomach. Br J Surg 1986;73: 381–2. 7. Contini S, Scarpignato C. Caustic injury of the upper gastrointestinal tract: a comprehensive review. World J Gastroenterol 2013; 19:3918–30. 8. Fisher AA. Cement burns resulting in necrotic ulcers due to kneeling on wet cement. Cutis 1979;23:272–4. 9. Pike J, Patterson A Jr, Arons MS. Chemistry of cement burns: pathogenesis and treatment. J Burn Care Rehabil 1988;9:258–60. 10. Chung JY, Kowal-Vern A, Latenser BA, et al. Cement-related injuries: review of a series, the National Burn Repository, and the prevailing literature. J Burn Care Res 2007;28:827–34. 11. Alexander W, Coghlan P, Greenwood J. A ten-year retrospective analysis of cement burns in a tertiary burns center. J Burn Care Res 2014;35:80–3. 12. Alam M, Moynagh M, Lawlor C. Cement burns: the Dublin national burns unit experience. J Burns Wounds 2007;7:e4.
http://dx.doi.org/10.1016/j.jemermed.2014.12.060
Selected Topics: Toxicology
INGESTION OF PORTLAND CEMENT Kyung Ho Kim, MD,* Jang Young Lee, MD,* Seong Eun Yang, MD,† Won Suk Lee, MD,* Won Young Sung, MD,* Sang Won Seo, MD,* and Jung Il Yang, MD* *Department of Emergency Medicine, College of Medicine, Eulji University, Daejeon, Republic of Korea and †Department of Internal Medicine, College of Medicine, Eulji University, Daejeon, Republic of Korea Reprint Address: Jang Young Lee, MD, PHD, Eulji University Hospital, 1306 Dunsan-Dong, Seo-Gu, Daejeon, Republic of Korea
, Abstract—Background: The common toxicities of cement are allergic dermatitis, abrasions, and chemical burns, but reports of cement ingestion are rare. In this study, we report a case of successful treatment of cement ingestion using emergency gastrointestinal endoscopy. Case Report: An 83-year-old female was admitted to the emergency department with altered mental state and abdominal pain. We assumed that she ingested cement based on her medical history and radiologic examination. A previous report recommended surgical removal with gastric lavage. However, we thought that wet cement is highly alkaline, and gastric lavage is contraindicated. We performed emergency gastrointestinal endoscopy, instead of gastric lavage. Why Should an Emergency Physician Be Aware of This?: If a patient ingests cement, the recommendation is to check the status of the upper gastrointestinal tract and remove the cement by emergency gastrointestinal endoscopy as soon as possible. Ó 2015 Elsevier Inc.
mended treating cement ingestion with surgical removal of the cement by gastric lavage (6). That treatment method has been reported to be safe and effective. However, wet cement is highly alkaline, and gastric lavage is contraindicated for the risk of re-exposure to the corrosive agent and additional injury to the esophagus (7). For this case, we performed emergency gastrointestinal endoscopy, instead of the gastric lavage. Here, we report a case of successful treatment of cement ingestion using emergency gastrointestinal endoscopy. CASE REPORT An 83-year-old female was admitted to the emergency department (ED) with an altered mental state and abdominal pain. She was taking medications for diabetes and hypertension. She stated her appearance was normal 8 h before her admission to the ED. The patient’s daughter found gray vomitus, a half bottle of alcohol (approximately 20%), and a ripped bag of Portland cement near the patient 40 min before her admission to the ED. When she arrived at the ED, her blood pressure was 185/93 mm Hg, her pulse rate was 93 beats/min, her respiratory rate was 20 breaths/min, and her body temperature was 36.0 C. Her laboratory findings were all within the normal limits, except for a white blood cell count of
, Keywords—cement; toxicity; endoscopy; gastrointestinal
INTRODUCTION Cement is used as a material for construction in occupational settings and do-it-yourself work, and can be easily obtained (1). Cement’s common toxicities are allergic dermatitis, abrasions, and chemical burns, but reports of cement ingestion are rare (2–5). A previous report recom-
RECEIVED: 18 October 2014; ACCEPTED: 21 December 2014 e19
e20
K. H. Kim et al.
Figure 1. Simple abdominal x-ray (A) and abdominal computed tomography (B) show hyperdense material approximately 7 cm in diameter in the gastrointestinal fundus (arrow).
11.54 103/mL, a C-reactive protein of 0.59 mg/dL, and a creatine kinase of 558 IU/L. There were no abnormal findings in the patient’s brain computed tomography, angiography, or neurologic examination, despite her altered mental state. A simple abdominal x-ray study revealed an oval radiopacity in the left upper quadrant of the abdomen. We performed abdominal computed tomography and found a hyperdense material approximately 7 cm in diameter in the gastrointestinal fundus and a ground glass opacity in both lower lung fields (Figure 1). We assumed she ingested cement and performed emergency gastrointestinal endoscopy. Gray materials were found in the esophagus and gastric fundus, portions of which solid masses (Figure 2). Most materials were carefully washed out with suction, and the solid masses were removed with an endoscopy retrieval net. After 2 days, a follow-up gastrointestinal endoscopy revealed a normal esophagus and duodenum, a mild atrophic change to the stomach, erythema, and intramural bleeding spots in the gastrointestinal body and fundus. No cement materials were visible. She started a pre-
scribed diet and was treated with third-generation cephalosporin and metronidazole for aspiration pneumonia. She was discharged within 7 days of admission. DISCUSSION Throughout the world, Portland cement is the most common type of cement in general use. Portland cement is composed of calcium oxide (64%) and silicon dioxide (21%), with smaller amounts of aluminum, iron, magnesium, potassium, and sulfur oxide (8). Portland cement is easily accessed in the market. If a patient ingests a large amount of cement, it is difficult for an emergency physician to perform suitable emergency management. Visvanathan suggested gastric lavage for the treatment of cement ingestion because Portland cement sets within 3 h and dilution alone delays solidification and can even prevent it from occurring in the stomach (6). However, when Portland cement is mixed with water, it becomes highly alkaline. The hydrogen ion concentration range of wet cement is 10
Figure 2. Emergency gastrointestinal endoscopy shows gray materials in the gastric fundus, portions of which were solid masses, which were removed with an endoscopy retrieval net (arrow).
Cement Ingestion
to 12 and may continue to rise to 12 to 14 (9). Within 2 min of ingestion, the pH of wet cement is 11 to 13, which makes it one million times more alkaline than water (10). In addition, wet cement releases a large amount of heat (11). Cement burns have an insidious onset, a progressive nature, and severely damage tissues (2,12). Therefore, ingested cement should be removed as soon as possible. Gastric lavage is a contraindication of caustic injury because of the risk of esophageal perforation and tracheal aspiration of the stomach contents. Therefore, we recommend gastrointestinal endoscopy for the emergency management of cement ingestion in place of gastric lavage. Additionally delaying cement removal results in the formation of bezoars and complications, such as mucosa ulceration, gastrointestinal hemorrhage, gastrointestinal perforation, outlet obstruction, and protein-losing gastroenteropathy (6). When large bezoars are formed, a surgical operation should be considered (6). In our case, early gastrointestinal endoscopy prevented the formation of large bezoars, and we were able to successfully remove the cement from the stomach. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? When Portland cement is mixed with water, it becomes highly alkaline. Therefore, if a patient ingests cement, we suggest checking the status of the upper gastrointes-
e21
tinal tract and removing the cement using emergency gastrointestinal endoscopy as soon as possible.
REFERENCES 1. Poppe H, Poppe LM, Brocker EB, et al. Do-it-yourself cement work: the main cause of severe irritant contact dermatitis requiring hospitalization. Contact Dermatitis 2013;68:111–5. 2. Mehta RK, Handfield-Jones S, Bracegirdle J, et al. Cement dermatitis and chemical burns. Clin Exp Dermatol 2002;27:347–8. 3. Seyhan N, Keskin M, Savaci N. Contact with wet cement: an unrecognized cause of chemical burn. Ulus Travma Acil Cerrahi Derg 2012;18:189–91. 4. Poupon M, Caye N, Duteille F, et al. Cement burns: retrospective study of 18 cases and review of the literature. Burns 2005;31: 910–4. 5. Palao R, Monge I, Ruiz M, et al. Chemical burns: pathophysiology and treatment. Burns 2010;36:295–304. 6. Visvanathan R. Cement bezoars of the stomach. Br J Surg 1986;73: 381–2. 7. Contini S, Scarpignato C. Caustic injury of the upper gastrointestinal tract: a comprehensive review. World J Gastroenterol 2013; 19:3918–30. 8. Fisher AA. Cement burns resulting in necrotic ulcers due to kneeling on wet cement. Cutis 1979;23:272–4. 9. Pike J, Patterson A Jr, Arons MS. Chemistry of cement burns: pathogenesis and treatment. J Burn Care Rehabil 1988;9:258–60. 10. Chung JY, Kowal-Vern A, Latenser BA, et al. Cement-related injuries: review of a series, the National Burn Repository, and the prevailing literature. J Burn Care Res 2007;28:827–34. 11. Alexander W, Coghlan P, Greenwood J. A ten-year retrospective analysis of cement burns in a tertiary burns center. J Burn Care Res 2014;35:80–3. 12. Alam M, Moynagh M, Lawlor C. Cement burns: the Dublin national burns unit experience. J Burns Wounds 2007;7:e4.
