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Ferric chloride ingestion with corrosive gastritis

We describe the case of a 25-year-old female who was admitted to hospital after accidentally ingesting a “mouthful” of ferric chloride etching solution which had been inappropriately stored in a drink bottle in the garage. She vomited immediately and experienced ongoing nausea, vomiting, and epigastric pain for several hours. Initial observations on arrival to the Emergency Department were temperature 36.2 C, heart rate 98 bpm, respiratory rate 22 breaths per minute, blood pressure 132/91mmHg, oxygen saturation 100% in room air. Venous blood gas showed metabolic acidosis: pH 7.27, base excess 6.7, bicarbonate 19.8mmol/L, lactate 3.5mmol/L. Blood tests were remarkable for raised white cell count 26.9 10 (4–11), raised C-reactive protein 107mg/L (0–5), raised chloride 112mmol/L (96–104) and raised serum iron concentration 41mmol/L (9–30.4). On examination there were no obvious signs of corrosive injury in the oropharynx. She was initially treated with intravenous (IV) sodium chloride 0.9%, IV omeprazole 80mg, and IV ondansetron 8mg. Urgent CT scan of the abdomen and pelvis performed with intravenous contrast showed a grossly oedematous and distended stomach with enhancing mucosa (Figure 1). Mild free fluid was noted in the abdomen but no evidence of pneumoperitoneum to suggest perforation. The following day she was transferred to a tertiary centre for further management under an upper gastrointestinal surgery team in the same city. She underwent urgent diagnostic laparoscopy and oesophagogastroduodenoscopy (OGD) under general anaesthetic. Laparoscopy confirmed a small amount of free intraperitoneal fluid, the serosa of the stomach looked viable with some inflammation but no ischaemic areas. OGD showed a large area of ulceration of the antrum of the stomach, continuing into the pylorus. The oesophagus, proximal stomach and duodenum were normal. A nasojejunal feeding tube was placed. The patient stabilised over the next 5 days and was allowed to eat and drink normally on day 5 following the ingestion and she was discharged on day 6 post ingestion. At 3months follow-up, she was asymptomatic with no long-term sequelae. Ferric chloride, or iron (III) chloride (FeCl3), is a compound with industrial uses including copper etching and water treatment. It forms a strongly acidic solution with high iron content, and therefore has the potential for severe toxicity to humans, although oral ingestions are rare. A retrospective study which included 13 cases of accidental or intentional oral ingestion of ferric chloride found major symptoms and signs were: nausea and vomiting, sore throat, abdominal pain, oral ulceration, metabolic acidosis, aspiration pneumonia, respiratory failure, diarrhea, and hypotension [1]. Common laboratory findings include leucocytosis, metabolic acidosis, coagulopathy, and elevated serum iron concentration [1,2]. Direct corrosive effects can lead to gastrointestinal tract ulceration and inflammation, with perforation and necrosis in severe cases [1–3]. Desferrioxamine as an iron chelating agent may be indicated if there are features of severe iron toxicity, but supportive care and management of complications remain the mainstay of treatment [1].