Article, Toxicology

Intentional cyanoacrylate ingestion: A rare cause of delayed gastric perforation requiring gastric wedge resection

a b s t r a c t

Cyanoacrylate (LOCTITE(R) 401(TM)) is a fast-acting adhesive available nationwide, with medical and household uses. Most cases of cyanoacrylate exposure are accidental and occur in children less than 5 years old. Various routes of exposure have been reported including the dermal, oral, ocular, otic, nasal, and urethral routes; howev- er, very few result in serious complication and mortality. Although a few cases of airway obstruction related to cyanoacrylate ingestion have been reported, intentional cyanoacrylate ingestion-induced Gastrointestinal tract injury has scarcely been reported. In addition, there have been no reports of serious complications following in- tentional cyanoacrylate ingestion requiring surgical intervention. Herein, we report a case of intentional inges- tion of cyanoacrylate in a 70-year-old man who required gastric wedge resection due to delayed gastric perforation.

A 70-year-old man visited the emergency department (ED) complaining of sore throat. He had ingested 50 g of cyanoacrylate one hour prior to presentation in a suicidal attempt. He did not complain of dyspnea, hoarseness, chest pain, or abdominal pain. The initial vital signs showed hypertension with tachycardia (172/100 mmHg-110 beats/min-24 breaths/min-36.5 ?C-97%). On physical examination, he was mentally alert, and had pharyngeal injection with slightly swollen tonsils, but without signs of respiratory distress. Breathing sound was clear, and his abdomen was soft and flat with normoactive bowel sounds. The initial chest X-ray image was unremarkable (Fig. 1A). Lab- oratory tests performed showed normal findings for white blood cell count (6860/uL), hemoglobin (13.1 g/dL), hematocrit (49.1%), platelet count (163,000/uL), blood urea nitrogen (13 mg/dL), creatinine (0.7 mg/dL) and C - reactive protein level (0.3 mg/dL).

To evaluate the GI tract injury, an emergent Esophagogastroduodenoscopy was performed which showed multiple foreign bodies in the esophagus and stomach (Figs. 1B-D). Despite attempts to remove the foreign bodies during EGD, an approx- imately 4-cm sized foreign body retained in the stomach wall (Fig. 1E) was too adhesive. After EGD, the patient did not show any procedure- related complication. He was admitted for close observation. On post-admission day 3, he suddenly complained of abdominal pain with epigastric tenderness and a rigid abdomen. An abdominal X-ray showed a pneumoperitoneum (Fig. 2A). An emergency exploratory

* Corresponding author.

E-mail address: [email protected] (S.J. Yun).

laparotomy was performed to remove the foreign body, during which a tiny perforation was identified on the part of the stomach wall to which the remaining foreign body was adhered (Fig. 2B). Thus, surgical removal of the foreign body via gastric wedge resection was performed (Fig. 2C). One week postoperatively, he was discharged without any complications.

Cyanoacrylate (LOCTITE(R) 401(TM)), which is well known as “super glue”, is a fast-acting adhesive available nationwide, with medical and household uses [1]. Cyanoacrylate exposure is mainly accidental, but a small number of exposures (approximately 2.5%) have been due to inten- tional misuse (such as trying to stop a bleeding cut) or malicious intent (such as purposefully gluing a person’s eyes shut as a prank). It is com- mon among children less than 5 years old. Various routes of exposure have been reported including the dermal, oral, ocular, otic, nasal, and ure- thral routes [2]. The increasing use of cyanoacrylate adhesives as glue and surgical material has raised concern about their potential toxicity [3].

Toxic cyanoacrylate substances are released from the glue, which are toxic to human fibroblast cells [4]. This release of substances may persist for at least two weeks. Thus, it can harden upon contacting the moist surfaces of the upper gastrointestinal (GI) and upper respiratory tract and cause airway obstruction [3]. There have been a few reports of air- way obstruction following cyanoacrylate ingestion [3,5,6].

Until now, there cyanoacrylate-related GI tract injury has scarcely been reported [7]. In this report [7], EGD revealed multiple foreign bod- ies with extensive erosive gastritis and mucosal laceration of the stom- ach. Endoscopic removal was attempted, but some foreign bodies could not be removed endoscopically. New erosions were observed in the area

https://doi.org/10.1016/j.ajem.2017.10.017

169.e6 S.H. Lee et al. / American Journal of Emergency Medicine 36 (2018) 169.e5-169.e7

Fig. 1. Chest X-ray and endoscopic gastroduodenoscopy (EGD) findings of the patient. (A) Posteroanterior chest X-ray reveals unremarkable finding. (B, C) Multiple foreign bodies are attached to the walls of the esophagus and stomach. (D) Most foreign bodies are removed under EGD. (E) A large foreign body remained in the gastric antrum.

in contact with the remaining foreign bodies. Our patient presented with similar findings.

However, the associated morbidity was somewhat different be- tween the previously reported case [7] and ours. Generally, most cases of cyanoacrylate exposure do not result in significant morbidity. In a previous literature review of 893 cases [2], major effects according to the criteria set by the American Association of Poison control centers (symptoms that are life-threatening or that result in significant residual disability or disfigurement) [8] or death related to the complication of cyanoacrylate exposure, were not seen. In contrast, gastric perforation

was a new development in the contact area with the remaining foreign bodies in our case.

We hypothesize is that the foreign bodies caused no obstruction of the GI tract, but remained in the stomach wall, and led to mucosal inju- ry, which might have led to the delayed perforation. Papatheofanis et al.

[9] demonstrated that the mechanism of cytotoxicity of cyanoacrylate adhesives may be due to the generation of lipid hydroperoxides that ac- tivate prostaglandin and thromboxane biosynthesis, which participate in membrane oxidation and lysis. Such a mechanism may contribute to our understanding of the thrombotic events associated with necrosis

S.H. Lee et al. / American Journal of Emergency Medicine 36 (2018) 169.e5-169.e7 169.e7

Fig. 2. Abdominal X-ray and surgical findings of the patient. (A) Erect abdominal X-ray reveals small amount of both subphrenic air (arrows), presumed to be pneumoperitoneum. (B) On Exploratory laparotomy, small perforation at the gastric antrum (arrow) is shown. (C) Wedge resection of stomach wall was performed with foreign body removal.

observed on application of these adhesives to tissues in vivo. Based on this, Intentional ingestion can lead to the formation of large, irregular foreign bodies that can cause gastric perforation [7]. Thus, patients who ingest cyanoacrylate might need admission and surgical observa- tion; if signs of peritoneal irritation occur, emergent diagnostic laparos- copy is needed.

As emergency physicians, we should kept in mind that patients who ingest cyanoacrylate require endoscopic foreign body removal as soon as possible, as well as surgical observation for delayed perforation of the GI tract because this might lead to significant morbidity and even mortality in the patients.

Grant or other financial support. None.

Previous presentation. None.

Conflicts of interest

None declared.

References

AJEM

Intentional cyanoacrylate ingestion: A rare cause of delayed gastric perforation requiring gastric wedge resection

a b s t r a c t

Carstairs SD, Koh C, Qian L, Qozi M, Seivard G, Cantrell FL. Sticky situations: cyanoac- rylate exposures reported to a poison control system. Clin Toxicol (Phila) 2017;55: 1001-3.

Chang YH, Chang H, Tsai MJ. Cyanoacrylate glue ingestion with formation of a laryn- geal cast. Resuscitation 2011;82:507.

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