Hydrogen Peroxide Poisoning: An Unusual Cause of Portal
Venous Gas
Poster No.:
R-0021
Congress:
2015 ASM
Type:
Educational Exhibit
Authors:
E. Arnfield, H. Bhardwaj, N. Brown, M. Handy, P. Cleland;
Brisbane/AU
Keywords:
Chemistry, CT, Gastrointestinal tract, Emergency, Abdomen,
Toxicity
DOI:
10.1594/ranzcr2015/R-0021
Any information contained in this pdf file is automatically generated from digital material
submitted to EPOS by third parties in the form of scientific presentations. References
to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any
way constitute or imply RANZCR's endorsement, sponsorship or recommendation of the
third party, information, product or service. RANZCR is not responsible for the content of
these pages and does not make any representations regarding the content or accuracy
of material in this file.
As per copyright regulations, any unauthorised use of the material or parts thereof as
well as commercial reproduction or multiple distribution by any traditional or electronically
based reproduction/publication method ist strictly prohibited.
You agree to defend, indemnify, and hold RANZCR harmless from and against any
and all claims, damages, costs, and expenses, including attorneys' fees, arising from or
related to your use of these pages.
Please note: Links to movies, .ppt slideshows, .doc documents and any other multimedia
files are not available in the pdf version of presentations.
Page 1 of 8
Learning objectives
To examine a case study of hydrogen peroxide poisoning and identify the pertinent
radiographic findings.
Background
Clinical Presentation:
A healthy 21-year-old male unintentionally ingested approximately one mouthful of 3%
Hydrogen Peroxide (H2O2) stored in his relative's fridge. He presented to the emergency
department of Nambour Hospital, Queensland, Australia in December 2014 with vomiting
and pain in his mouth, throat and epigastrium. He was tachycardic (100 beats per
minute) and mildly hypertensive (155/100 mmHg), but not hypoxic (SpO2 97% on
room air). Clinical examination revealed dysphonia with mild erythema and oedema
of the oropharynx and uvula; abdominal and respiratory examinations were otherwise
unremarkable.
A computed tomography (CT) scan demonstrated pneumatosis and mucosal thickening
throughout the stomach and proximal duodenum, as well as extensive portal venous gas
(see Figures 1-2).
Treatment:
The patient was intubated, and conservative treatment with intravenous piperacillin /
tazobactam 4.5g four times daily and intravenous pantoprazole infusion at 8mg per hour
was commenced prior to transfer to The Royal Brisbane and Women's Hospital Intensive
Care Unit.
Outcome:
An upper endoscopy performed three days after the ingestion was normal with no
evidence of mucosal injury. A repeat CT scan at this time revealed interval partial
resolution of the bowel wall thickening and complete resolution of pneumatosis and portal
venous gas (see Figures 3-4). The patient was discharged three days after presentation
on oral pantoprazole and oral antibiotic therapy and made a full recovery.
Images for this section:
Page 2 of 8
Fig. 2: Coronal portal venous phase CT showing mucosal thickening and pneumatosis
of the stomach with portal venous gas.
Page 3 of 8
Fig. 1: Axial portal venous phase CT showing mucosal thickening and pneumatosis of
the stomach with portal venous gas.
Page 4 of 8
Fig. 3: Axial portal venous phase CT with oral contrast showing interval resolution of
pneumatosis and portal venous gas, with partial resolution of gastric mucosal thickening.
Page 5 of 8
Fig. 4: Coronal portal venous phase CT with oral contrast showing interval resolution of
pneumatosis and portal venous gas, with partial resolution of gastric mucosal thickening.
Page 6 of 8
Imaging findings OR Procedure details
1
H2O2 is an oxidising agent available in concentrations ranging from 3%-90%. It is found
in numerous household products including disinfectants, hair dyes, bleaches, and stain
2
removers. It is a clear, colourless liquid at room temperature , allowing it to be mistaken
for water if unlabeled, as in this case. Recently, H2O2 has also been sold for consumption
3
in small volumes following promotion of its purported natural health benefits , despite
2
multiple documented fatalities from its ingestion and no evidence to demonstrate health
benefits of any kind. Upon contact with the enzyme catalase in gastric mucosa, H2O2
4
undergoes rapid decomposition into oxygen and water (2H2O2 # 2H2O + O2 + heat).
If the amount of oxygen liberated exceeds the maximum solubility of blood, bubbles
migrate through the epithelial interstices and gas embolism may occur, manifesting as
3
5
6
7
pneumatosis or gas within the portal venous system , brain and coronary arteries .
Toxicity is also caused by direct caustic injury to gastric mucosa, resulting in gastritis
1
and potential rupture, as well as cytotoxicity from lipid peroxidation. This particular case
is unusual in that gas embolism usually only occurs with ingestion of the stronger 35%
H2O2 solution, with only one other published case report of portal venous gas following
ingestion of the 3% solution.
8
Conclusion
Ingestion of H2O2, a common household item, can have serious sequelae even in low
volumes and low concentrations. Radiographic findings include gastritis, pneumatosis,
perforation, portal venous or arterial gas, and cerebral gas embolism.
Personal information
References
1. Watt BE, Proudfoot AT, Vale JA. Hydrogen peroxide poisoning. Toxicol Rev.
2004;23(1):51-7.
Page 7 of 8
2. Caraccio TR, McGuigan MA. Medical Toxicology. In: RC Dart, editor. Medical
Toxicology. 3rd ed. London: Lippincott Williams & Wilkins; 2004. p. 1253-5.
3. Pritchett S, Green D, Rossos P. Accidental ingestion of 35% hydrogen peroxide. Can
J Gastroenterol. 2007 Oct;21(10):665-7.
4. 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
Mar;15(1):44-50.
5. 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 Jul;48(6):533-8.
6. Rider SP, Jackson SB, Rusyniak DE. Cerebral air gas embolism from concentrated
hydrogen peroxide ingestion. Clin Toxicol (Phila). 2008 Nov;46(9):815-8.
7. Islamoglu Y, Cil H, Atilgan Z, Elbey MA, Tekbas E, Yazici M. Myocardial infarction
secondary to unintentional ingestion of hydrogen peroxide. Cardiol J. 2012;19(1):86-8.
8. Moon JM, Chun BJ, Min YI. Hemorrhagic gastritis and gas emboli after ingesting 3%
hydrogen peroxide. J Emerg Med. 2006 May;30(4):403-6.
Page 8 of 8