Hemorrhagic Pulmonary Edema Associated with Meat Tenderizer Treatment for Esophageal Meat Impaction

doi:10.1378/chest.94.3.640

Chest

Volume 94, Issue 3, September 1988, Pages 640-642

https://doi.org/10.1378/chest.94.3.640 Get rights and content

We describe a case of acute hemorrhagic pulmonary edema caused by aspiration of Adolph's meat tenderizer, used in an attempt to relieve an esophageal meat impaction. We performed an animal experiment in which bronchial instillation of a similar solution reproduced the clinical findings in our patient. This is a previously unreported and potentially lethal complication of a therapy that has never been submitted to clinical trials. We recommend against the use of this therapy for patients with complete esophageal obstruction or in those otherwise at risk for aspiration. (Chest 1988; 94:640-42)

Section snippets

CASE REPORT

A 14-year-old boy was brought to the emergency room complaining of dysphagia and inability to vomit following an attempted three-bite pork chop ingestion. His past medical history was significant only for asthma, which had required intermittent therapy with bronchodilators. He had normal exercise tolerance and normal growth and development. There was no past history of esophageal dysfunction. Physical examination results were within normal limits except for the presence of excessive salivation.

RESULTS

Within 5 min of instillation of the solution, the animal developed frothy hemorrhagic pulmonary edema that reached a total volume of 400 ml in 20 min. Over this time, the lobe underwent rapid loss of volume and increase in weight, with marked subpleural hemorrhage (Fig 4). The dog was sacrificed following a lethal injection of thiopental sodium (Pentothal). Histologic sections showed consolidation and hemorrhagic pulmonary edema without inflammatory infiltrate.

DISCUSSION

Since the original report by Richardson,¹ papain has been recommended as a possible therapy for meat impaction of the esophagus, even though, as pointed out by Cavo et al,⁶ no clinical trials evaluating the various regimens have been carried out. Complications associated with the use of this agent have included esophageal perforation⁷ and severe hyperosmolarity in a woman given Adolph's meat tenderizer for therapy of a bezoar.⁸ Tarlo et al⁹ and Flindt¹⁰ have noted allergic bronchospastic

ACKNOWLEDGMENTS

The authors wish to thank Dr. John Butler for encouragement and the use of his laboratory; Wayne Kirk for assistance with the animal experiment; Dr. Michael Grabowski, Dr. Gerald Garett, and Mr. Paul Anderson, R. Ph., for technical assistance; Dr. Claire Miller for allowing us to study her patient; Drs. Charles Pope, John Butler, David Pierson, Leonard Hudson, Bruce Culver, H. Thomas Robertson, and Robert Seale for review of the manuscript; and Barbara Geffert, medical transcriptionist.

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Perforation of the esophagus after use of a digestant agent
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There are more references available in the full text version of this article.

Cited by (20)

Use of Proteolytic Enzymes in the Treatment of Proteinaceous Esophageal Food Impaction
2016, Journal of Emergency Medicine
Citation Excerpt :
Other reported adverse effects are based on two separate case reports. They include aspiration pneumonitis and hemorrhagic pulmonary edema (5,6). In addition to the safety issues raised by these reports, papain's intrinsic ability to break down meat bolus was also called into question by the results of an animal model study performed by Goldner and Danley (7).
Proteinaceous esophageal food impaction typically requires endoscopic intervention. An alternative approach is the use of proteolytic enzymes. Concerns regarding the use of proteolytic enzymes include the risk of perforation and aspiration pneumonitis.
We retrospectively reviewed our series of 69 patients treated with papain to determine the safety and efficacy of proteolytic enzymes.
Patients were retrospectively reviewed if treated for an esophageal food impaction from 1999 through 2008.
Median age was 56 years (range 19–91 years), with 46 male and 23 female patients. In 27 patients (39%) this was their first presentation, in 14 (20%) it was the second, and 28 (41%) had multiple previous episodes. Meat was the cause in 49 (71%), chicken in 6 (9%), fish in 3 (4%), and unspecified in 11 (16%). All patients presented with dysphagia for solids, 56 (81%) could not tolerate liquids. Papain solution, 1 tsp in 8 oz of water, was given to patients in an unlimited quantity. Papain was successful in relieving the obstruction in 60 patients (87%). The remaining 9 patients (13%) underwent endoscopy with successful retrieval. No patient suffered a perforation, either with papain ingestion or endoscopy. There were no episodes of pneumonitis or pneumonia.
We have used proteolytic enzymes with a high success rate and with minimal complication. Further, if proteolytic enzymes fail, endoscopy can be performed safely and effectively. We recommend the use of proteolytic enzymes as the initial management in all patients with proteinaceous food impaction of the esophagus.
Gastric bezoar treated endoscopically with a carbonated beverage: Case report
2004, Gastrointestinal Endoscopy
Citation Excerpt :
However, oral ingestion of papain (in the form of meat tenderizer) also has resulted in hyperosmolar hypernatremia, and one patient developed a gastric ulcer.3,8 In addition, aspiration of papain has resulted in hemorrhagic pulmonary edema.12 Thus, medical management of bezoars has significant limitations, and the effectiveness of this approach is debatable.
Persimmon bezoars: A successful combined therapy
2002, Gastrointestinal Endoscopy
Citation Excerpt :
Treatment with enzymes such as papain and cellulase has also been proposed.11,12 This has been of little benefit and complications may occur such as hyperosmolar hypernatremia, hemorrhage, aspiration, or gastric ulcers in the case of treatment with papain.13,14 A number of endoscopic techniques for the management of diospyrobezoars have been described including extraction with or without previous breakage with biopsy forceps, polypectomy snares, or foreign body forceps.15-18
Background: Persimmon phytobezoar, although an infrequent entity, is not rare in some countries. Because of their particular features, management of diospyrobezoars is difficult. A number of surgical, endoscopic, and pharmacologic treatments have been proposed with variable success. This is a description of our experience with 10 patients with a new combination therapy. Methods: Ten patients (7 men, 3 women; mean age 46.4 years) were treated with a new fragmentation technique consisting of a saw-like effect with a large polypectomy snare followed by administration of cellulase, cysteine, and metoclopramide. Results: Resolution was achieved in 8 patients. Complications (intestinal obstruction) developed in 2 patients. Conclusions: Our combined therapy is safe and highly efficacious but caution must be exercised because intestinal obstruction can occur if large fragments pass through the pylorus. A more extensive study is required to assess these clinical observations.
A new endoscopic technique for the removal of gastric phytobezoars
2000, Gastrointestinal Endoscopy
Citation Excerpt :
Oral ingestion of papain (in the form of Adolph's Meat Tenderizer) has itself caused hyperosmolar hypernatremia.6 Aspiration of papain has resulted in hemorrhagic pulmonary edema.7 Madsen et al.8 reported bezoar removal by means of a 36F gastric lavage tube after endoscopic disruption of the bezoar with jet sprays of water.
Background: There is no standardized method for the evacuation of gastric phytobezoars. Prior endoscopic attempts have used injected cellulase and various devices to disrupt bezoars. The efficacy of directed, large-channel suction using an endoscope for the removal of large gastric phytobezoars is the subject of this study. Methods: Three consecutive patients with large gastric bezoars were examined. Phytobezoar removal using a standard endoscope (GIF-100, Olympus) was attempted but unsuccessful. Each phytobezoar was successfully evacuated by directed suction through an endoscope with a large-diameter accessory channel (GIF-XT30, Olympus). Each patient was followed up for bezoar recurrence. Results: Rapid, complete bezoar evacuation was achieved at one session in all patients. Aspirated volumes were 500, 700, and 1000 mL. There were no procedure-related complications. Conclusions: Endoscopic suction removal of gastric phytobezoars using a large-channel endoscope is efficacious and safe. Coupling directed endoscopic suction with other endoscopic techniques might be efficacious for removal of more complex bezoars.
Foreign Bodies in the Pediatric Patient
1998, Current Problems in Surgery
Foreign bodies in the gastrointestinal tract
1996, Emergency Medicine Clinics of North America

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Chest

Selected ReportsHemorrhagic Pulmonary Edema Associated with Meat Tenderizer Treatment for Esophageal Meat Impaction

Section snippets

CASE REPORT

RESULTS

DISCUSSION

ACKNOWLEDGMENTS

Lancet

A new treatment for esophageal obstruction due to meat impaction

Ann Otol Rhino Laryngol

Foreign bodies in the gut

Foreign bodies in the air and food passages

Ann Surg

Meat impaction in the esophagus treated by enzymatic digestion

JAMA

Enzymatic treatment of steak house syndrome

Drug Intell Clin Pharmacol

Use of enzymes for meat impactions in the esophagus

Laryngoscope

Perforation of the esophagus after use of a digestant agent

Ann Otol

Bezoar therapy: complications using Adolphs meat tenderizer and alternatives from literature review

Arch Intern Med

Selected Reports
Hemorrhagic Pulmonary Edema Associated with Meat Tenderizer Treatment for Esophageal Meat Impaction