Case Reports

Case Studies in Toxicology: Tiny Bubbles (Or, the Dangers of Cleaning Your Fruit)

Emergency Medicine. 2013 December;45(12):34-37

References

Ukuku DO, Bari ML, Kawamoto S, Isshiki K. Use of hydrogen peroxide in combination with nisin, sodium lactate and citric acid for reducing transfer of bacterial pathogens from whole melon surfaces to fresh-cut pieces. Int J Food Microbiol. 2005;104(2):225-233.
35% H₂O₂ hydrogen peroxide food grade certified benefits. The One Minute Miracle Web site. http:// www.theoneminutemiracleinc.com/pages/h2o2- benefits/. Accessed November 20, 2013.
FDA warns consumers against drinking high-strength hydrogen peroxide for medicinal use: ingestion can lead to serious health risk and death [news release]. Silver Spring, MD: US Food and Drug Administration; July 27, 2006. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ 2006/ucm108701.htm. Accessed November 20, 2013.
Shaw A, Cooperman A, Fusco J. Gas embolism produced by hydrogen peroxide. N Engl J Med. 1967;277(5):238-241.
Cina SJ, Downs JC, Conradi SE. Hydrogen peroxide: a source of lethal oxygen embolism. Case report and review of the literature. Am J Forensic Med Pathol. 1994;15(1):44-50.
Rider SP, Jackson SB, Rusyniak DE. Cerebral air gas embolism from concentrated hydrogen peroxide ingestion. Clin Toxicol (Phila). 2008;46(9):815-818.
French LK, Horowitz BZ, McKeown NJ. Hydrogen peroxide ingestion associated with portal venous gas and treatment with hyperbaric oxygen: a case series and review of the literature. Clin Toxicol (Phila). 2010;48(6):533-538.
Bassan MM, Dudai M, Shalev O. Near-fatal systemic oxygen embolism due to wound irrigation with hydrogen peroxide. Postgrad Med J. 1982;58(681):448-450.
Henry MC, Wheeler J, Mofenson HC, et al. Hydrogen peroxide 3% exposures. J Toxicol Clin Toxicol. 1996;34(3):323-327.
Papafragkou S, Gasparyan A, Batista R, Scott P. Treatment of portal venous gas embolism with hyperbaric oxygen after accidental ingestion of hydrogen peroxide: a case report and review of the literature. J Emerg Med. 2012;43(1):e21-e23.

Do all patients presenting with H₂O₂ ingestion require imaging to assess for the presence of portal venous air?

Figure. Abdominal computed tomography reveals extensive portal venous gas in the liver.

Reportedly, ingestion of as little as a “sip” or “mouthful” of 35% H₂O₂ has resulted in venous and arterial gas embolism,⁶ occasionally with severe consequences, but no current consensus guidelines exist regarding imaging requirements. Some toxicologists and hyperbaric physicians believe that the presence of portal venous air does not adversely impact a patient’s prognosis or necessitate treatment, and therefore a workup is unnecessary. Others, however, suggest that the presence of portal venous air indicates oversaturation of oxygen in the blood, placing the patient at increased risk for cardiac and cerebral air embolism. Neither one of these theories is well supported in the literature. Although practice patterns vary by institution, it is reasonable that all patients presenting with abdominal complaints after ingestion of H₂O₂ undergo CT imaging to assess for portal venous air.

If portal venous air is detected, do patients require hyperbaric oxygen therapy?

The management of patients with portal venous gas following H₂O₂

Hyperbaric therapy increases the amount of oxygen that can be dissolved in the blood, thereby decreasing bubble formation and allowing transport of dissolved oxygen to the lungs where it can be exhaled. Some patients with portal venous air experience significant pain and portal venous hypertension, which may respond rapidly to this therapy.¹⁰ Based on available literature, hyperbaric therapy is reasonable for patients with significant abdominal pain and portal venous air following H₂O₂ ingestion; less controversial is the role of hyperbaric therapy in those with cerebral air embolism. Multiple case reports of patients with significant neurologic findings demonstrate resolution of symptoms following hyperbaric therapy.⁶

Case conclusion

Hyperbaric oxygen therapy was recommended for the patient in this case, but transfer to a hyperbaric facility was not possible. He was instead admitted to the hospital for continuous monitoring. Over the next 12 hours, his symptoms gradually resolved, and a repeat CT scan the following day showed complete resolution of the portal venous gas. The patient was subsequently discharged without any sequelae.

Case Studies in Toxicology: Tiny Bubbles (Or, the Dangers of Cleaning Your Fruit)

References

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