Postgraduate Medicine

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Barotrauma after liquid nitrogen ingestion: a case

report and literature review

Yuemei Zheng, Xiaoxia Yang & Xinli Ni

To cite this article: Yuemei Zheng, Xiaoxia Yang & Xinli Ni (2018) Barotrauma after liquid nitrogen
ingestion: a case report and literature review, Postgraduate Medicine, 130:6, 511-514, DOI:
10.1080/00325481.2018.1494492

To link to this article: https://doi.org/10.1080/00325481.2018.1494492

Accepted author version posted online: 12

Jul 2018.
Published online: 16 Jul 2018.

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POSTGRADUATE MEDICINE
2018, VOL. 130, NO. 6, 511–514
https://doi.org/10.1080/00325481.2018.1494492

CLINICAL FEATURE
CASE REPORT

Barotrauma after liquid nitrogen ingestion: a case report and literature review
Yuemei Zheng, Xiaoxia Yang and Xinli Ni
Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China

ABSTRACT ARTICLE HISTORY

A 25-year-old man developed a gastric perforation after ingesting a homemade drink containing liquid Received 27 April 2018
nitrogen. Surgical repair had to be postponed to seek consultations with experts because the available Accepted 26 June 2018
practitioners in this case, including emergency physicians, surgeons, and anesthesiologists, had little KEYWORDS
experience and knowledge about the source of the patient’s pneumothorax and subcutaneous emphy- Barotrauma; liquid nitrogen
sema. The patient ultimately underwent exploratory laparotomy with general anesthesia, considering ingestion; gastric
that delaying the operation would lead to a longer duration of bacterial peritonitis and delay the perforation; case report
standard treatment of postoperative systemic infectious complications. Our literature review revealed
that barotrauma is the unique injury mechanism underlying liquid nitrogen ingestion. Injuries to the
airway and esophagus are rare.

Introduction year-old, 70-kg man presented to the emergency room with a

7-hour history of severe epigastric pain after ingesting a home-
Pneumothorax and subcutaneous emphysema secondary to gas-
made beverage containing liquid nitrogen. Both chest radio-
tric perforation are unusual. Surgical intervention may be delayed
graphy and abdominal computed tomography (CT) showed
because the physicians usually involved in such cases, including
severe pneumoperitoneum and the presence of subphrenic
emergency physicians, surgeons, and anesthesiologists, require
free air, which were highly suspicious for gastric perforation
time to determine the cause of the pneumothorax and subcuta-
(Figure 1(a,b)). The patient was scheduled for emergency sur-
neous emphysema. Early determination of the pathogenesis and
gery and was taken to the operating room without a plan to
diagnosis provides the best opportunity for effective medical
perform the operation that night. The on-call anesthesiologist
treatment and support. We herein present a rare surgical case
noticed that in addition to the signs and symptoms of acute
involving a patient with gastric perforation accompanied by
abdomen, such as intense abdominal pain, tachypnea (respira-
extensive subcutaneous emphysema and bilateral pneumothorax
tory rate of >40 breaths/min), tachycardia (heart rate of >130
due to ingestion of a homemade drink containing liquid nitrogen.
beats/min), and mild hypoxemia (SpO2 of <95%), the patient
We also reviewed the relevant published literature regarding the
also had extensive subcutaneous emphysema (facial region,
pathogenic characteristics of liquid nitrogen ingestion. Five cases
neck, and back) of unknown origin with clear breath sounds
have been reported in the literature. Furthermore, the present
on lung auscultation. A reformatted chest CT image demon-
report does not describe a sporadic case with respiratory syn-
strated extensive subcutaneous emphysema in the lower neck
drome. An understanding of the unique mechanism underlying
and upper back, bilateral pneumothorax, severe pneumome-
the injury is the key to clarifying the diagnosis. Preoperative
diastinum, bilateral pleural effusion, and subdiaphragmatic free
bronchoscopy appears to be useful when tracheal injury is highly
air (Figure 2(a,b)). These findings suggested bronchial injury.
suspected. However, damage to the tracheal mucosa, tracheo-
Thus, the anesthesiologist recommended delaying the surgery
bronchial tree, and esophagus is often difficult to recognize,
for assessment of tracheal rupture or esophageal injury to
even when preoperative bronchoscopy and gastroscopy are prop-
ensure perioperative safety and effective airway management
erly performed. Careful anesthetic management and prompt sur-
during anesthesia.
gical treatment for patients with acute abdomen are required
A multidisciplinary consultation conference of surgeons,
when a diagnosis of gastrointestinal perforation and peritonitis is
anesthesiologists, physicians, and radiologists was performed.
suspected to prevent worsening of the patient’s medical condi-
The first concern expressed by many was possible frostbite or
tion, reduce the occurrence of sepsis, and improve the outcome.
an inflammatory reaction in the esophagus when the liquid
nitrogen was swallowed. Thus, there was concern that gastro-
Case description scopy might aggravate hyperemic swelling of the esophageal
mucosa. In addition, bronchoscopy may have been difficult to
This study was approved by the institutional review board;
perform if the patient did not cooperate. Although establish-
inform consent was obtained from the patient. A healthy 25-
ment of a definitive diagnosis of gastric perforation took

CONTACT Xinli Ni xinlini6@nyfy.com.cn Department of Anesthesiology, General Hospital of Ningxia Medical University, 804 S Shengli Str, Yinchuan
750004, China
© 2018 Informa UK Limited, trading as Taylor & Francis Group
512 Y. ZHENG ET AL.

Figure 1. Axial computed tomography. (a) Abdominal view shows a large amount of free air under the diaphragm (short arrow) with ascites (long arrow) and
bilateral pleural effusion (arrowhead). (b) Chest view shows mediastinal gas (short arrow) and a suspected injury in the bronchial wall (arrowhead).

Figure 2. Reformatted computed tomography image. (a) Coronal view demonstrates subcutaneous gas in the neck (arrowhead), pneumomediastinum (short arrow),
and subdiaphragmatic gas (long arrow). (b) Sagittal view shows gas under the chest wall (long arrow), mediastinum (short arrow), and under the diaphragm
(arrowhead).

almost 12 h, whether the patient had a tracheal or esophageal
rupture remained unclear until the operation was performed.
Eventually, exploratory laparotomy was performed under gen-
eral anesthesia with tracheal intubation and maintenance with
total intravenous anesthesia. The patient’s distended abdo-
men became more severely distended during assisted ventila-
tion. Moreover, his airway pressure was felt to be low by hand-
assisted ventilation. His SpO2 was 91–92% on 100% oxygen.
An esophageal and tracheal rupture was highly suspected.
After the peritoneum was opened, the peak airway pressure
dropped from 38–40 cmH2O to 33–35 cmH2O. About 1500 ml
of purulent abdominal effusion was drained out, and a 6-cm
linear mucosal break and eversion was identified in the ante-
rior wall of the lesser curvature of the stomach. However,
intraoperative bronchoscopy failed to show any lesions in
the trachea or bronchus. Gastroscopy also showed no esopha-
geal cold-induced injury. The patient was sent to the intensive
care unit (ICU) for postoperative treatment. In the ICU, his
airway pressure remained high (32–35 cmH2O) during
mechanical ventilation in the early stage of recovery. The
patient developed a severe and potentially life-threatening
postoperative systemic infection resulting in
hypoalbuminemia, coagulopathy, pulmonary infection, and
abdominal infection in the first week after surgery. He was
extubated on postoperative day 5. The subcutaneous emphy-
sema almost completely disappeared 6 days postoperatively.
He was discharged from the ICU to the surgical ward on
postoperative day 9. The rest of his hospital stay was unevent-
ful, and he was discharged home on postoperative day 22.
Discussion
Liquid nitrogen is not commonly used in food and drink, but if
ingested it can lead to digestive tract injury. When encounter-
ing a patient who has swallowed liquid nitrogen, frostbite is
often considered the main cause of the injury. This is because
liquid nitrogen boils at −196°C and may cause frostbite on
contact. Barotrauma was finally recognized the main injury
mechanism in such cases after a retrospective analysis and
literature review. The unique properties of liquid nitrogen
produce a characteristic injury pattern. That is, liquid nitrogen
gasification will increase the stomach volume by 700 times
followed by a rapid increase in intraluminal pressure, leading

to severe pneumoperitoneum or gastric rupture. Gastric per-
foration always occurs along the lesser curvature, where the
stomach is relatively fixed to adjacent structures. Damage to
the respiratory system is not common.
A PubMed search using the terms ‘liquid nitrogen inges-
tion’ and ‘gastric perforation’ revealed three case reports.
Another two case reports were found in news articles describ-
ing the injury that occurs after liquid nitrogen ingestion. In
one case [1], the authors described a 13-year-old boy who
developed gastric perforation and respiratory insufficiency
after ingesting a mixture of orange crystals with liquid nitro-
gen. During exploratory laparotomy, a large amount of gas
gushed from the abdominal cavity, and two small perforation
sites were found in the posterior aspect of the stomach along
the lesser curvature. The adjacent gastric mucosa appeared
healthy and viable. In another case [2], a 28-year-old man was
admitted to the hospital with severe abdominal distension
and subcutaneous emphysema after ingesting 15 ml of liquid
nitrogen. Preoperative gastroscopy showed no signs of cold-
induced lesions. In the third case [3], an 18-year-old girl devel-
oped a gastric perforation as a result of ingesting an alcoholic
drink containing liquid nitrogen. An emergency laparotomy
was performed. A 4-cm linear perforation was found in the
anterior wall of the stomach overlying the lesser curvature; no
esophageal injury was found except for extensive mucosal
laceration along the lesser curvature identified during esopha-
goscopy. In the fourth case [4], a 15-year-old boy ingested
about 30 ml of liquid nitrogen mixed with a flavoring agent
and was admitted to the hospital because of abdominal pain.
Chest and abdominal CT revealed severe pneumoperitoneum
with minimal mediastinal air at the lowermost portion of the
esophagus, which was interpreted as air tracking from the
abdominal cavity. During laparotomy, a 10-cm linear perfora-
tion was identified in the anterior aspect of the stomach
adjacent to the lesser curvature. Intraoperative bronchoscopy
failed to reveal injury to the tertiary bronchial divisions. The
medical history, symptoms, signs, and surgical findings in the
present case were very consistent with the above-reported
cases. In the fifth case [5], a 19-year-old male college student
presented to the hospital complaining of abdominal pain and
bloating after drinking liquid nitrogen. Abdominal radiographs
revealed massive pneumoperitoneum, but no stomach per-
foration was found during the operation. The sixth case was
reported in Japanese [6] and involved a 17-year-old boy who
had drunk about 30 ml of orange juice mixed with half the
volume of liquid nitrogen. The patient’s clinical course was
similar to the previously reported cases. In all cases, although
some experts stated that frostbite should be considered first,
pressure injury induced by nitrogen gas radicals was finally
considered to be the main cause of the gastric perforation.
All above-described patients as well as the patient in the
present report were healthy and young. In the early stage of
injury, the clinical manifestations in all cases shared some
similar features: (1) acute abdominal pain and severe abdom-
inal distension followed by tachypnea and tachycardia devel-
oped immediately after drinking beverages containing liquid
nitrogen, even small volumes; (2) CT or chest radiography
showed pneumoperitoneum, subcutaneous emphysema, and
POSTGRADUATE MEDICINE 513
pneumomediastinum, and a free air shadow was present
under the diaphragm in some cases, indicating gastric perfora-
tion; and (3) during laparotomy, severe pneumoperitoneum
with or without rupture of the lesser gastric curvature was
observed. In the second case [2], gastric rupture occurred after
the patient ingested 15 ml of the drink. Therefore, the risk of
the above-described clinical manifestations after oral ingestion
of liquid nitrogen is the same regardless of the volume
ingested.
In these clinical cases, the patients rarely had cold-induced
injuries to the mouth, oropharynx, upper airway, or esophagus.
Medical specialists should be aware of these special injury
features of swallowing a beverage containing liquid nitrogen.
The lack of injuries to these sites is attributed to the Leidenfrost
effect [2,3], in which a liquid encountering a temperature sig-
nificantly higher than its boiling point generates an insulating
vapor layer that slows thermal transfer. This mechanism is seen
when water thrown into a very hot frying pan creates dancing
droplets that skitter about instead of boiling. The liquid nitro-
gen in the present case evaporated rapidly, creating a layer of
high-pressure gaseous insulation entrapping the cold inside,
thus protecting the surrounding tissue from cold injury. This
explains why the patient had only a small area of mucosal
injury. Nevertheless, inhalation of liquid nitrogen gas can lead
to mucosal injury in the upper airway, oropharynx, or hypo-
pharynx with a risk of delayed perforation at these sites.
Stenosis and infection of the injured sites are two potential
complications. Furthermore, the gas absorbed from the tissue
may replace oxygen in the bloodstream and cause asphyxia-
induced neurologic symptoms and death [4,5].
Modern medicine has significantly reduced the mortality of
traumatic gastrointestinal perforations. However, morbidity
remains very high, particularly in patients who receive delayed
treatment; such patients often undergo multiple operations and
have a prolonged ICU and hospital stay, resulting in high hospital
costs. The main factor that impacts the mortality and morbidity of
gastrointestinal perforations is the timing of diagnosis. Every effort
should be made to diagnose these injuries early. Once a diagnosis
is made, treatment should be aggressive and expeditious. Our
patient had a treatment delay of 12 h, and the hospital stay was
prolonged to 22 days (the average is 10 days for this condition).
Systemic infection associated with secondary peritonitis and pul-
monary infection due to prolonged mechanical ventilation were
the two crucial complications that required a longer antibiotic
treatment duration, increased the medical costs, prolonged the
duration of hospitalization, and impeded the patient’s recovery.
Conclusion
Liquid nitrogen ingestion is unusual but is potentially lethal. When
encountering a patient with acute abdomen, particularly one with
difficult breathing because of liquid nitrogen ingestion, baro-
trauma must be considered. Gastric perforation together with
pneumothorax and subcutaneous emphysema complicates the
condition. Treatment decisions may be delayed because most
medical staff involved in such cases, such as emergency physi-
cians, surgeons, and anesthesiologists, lack clinical experience and
knowledge about liquid nitrogen ingestion. Actually, barotrauma
514 Y. ZHENG ET AL.
is the main injury mechanism underlying liquid nitrogen ingestion.
Injuries to the airway and esophagus are rare. Early diagnosis and
rapid treatment are very important to decrease the incidence of
infectious complications and to gain better outcomes in surgical
patients with gastric perforation and other conditions.
Acknowledgments
We wish to thank Prof. Weidong Gao from the Johns Hopkins Hospital for
his help in editing this manuscript.
Funding
The study was supported by Ningxia Personnel Training Project
(KJT2015017).
Declaration of interest
The authors have disclosed that they have no significant relationships
with or financial interests in any commercial companies related to this
study or article. Peer reviewers on this manuscript have received an
honorarium from Postgraduate Medicine for their review work, but have
no other relevant financial relationships to disclose.
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