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Paper text:
hydrogen peroxide is a chemical compound that has a single peroxide chain which is unstable and splits into reactive radicals . in the past
it was used for therapeutic enemas to relieve meconium ileus in infants and fecal impaction in adults for nearly 100 years , but this practice has largely been abandoned after it was proven that it can cause colonic damage similar to that of ulcerative colitis or pseudomembranous colitis .
there are some case reports of chemical colitis resulting from self - administered hydrogen peroxide enema in naturopathic therapy in adults , but no case has been reported of caustic injury after ingesting hydrogen peroxide in children .
we report a rare case of severe , acute colitis after administration of a hydrogen peroxide enema in a child .
a 2-year old girl was referred to our emergency department complaining of bloody stools and cramping abdominal pain for a 12-hour period .
the hydrogen peroxide solution was stored in a home refrigerator for cleansing properties , but it was mistaken for a glycerin suppository . a small amount of hematochezia was noted . on arrival at the emergency department , she was hemodynamically stable and in no respiratory distress .
the abdominal physical examination revealed a soft abdomen with mild , diffuse tenderness and hyperactive bowel sounds .
all results of blood tests were normal except for mild leukocytosis ; white blood cell count was 10 900/l and the hemoglobin ( hb ) level was 11.4 g / dl . her growth and development were normal and there was no evidence of physical or sexual child abuse .
a flexible sigmoidoscopy was performed to assess the severity of the mucosal injury ; it showed diffuse mucosal hemorrhage and marked edema with friability in the rectal mucosa ( figure 2 ) .
pathologic findings revealed erosion of the surface and sloughing with lymphocyte aggregation ( figure 3 ) . on subsequently obtaining a history
, the caregivers indicated that the 35% hydrogen peroxide was used for natural health purposes .
it was kept in a home refrigerator for cleansing properties , but it was mistaken for a glycerin suppository by them .
the patient was managed conservatively with nothing per mouth and antibiotics ( metronidazole , 30 mg / kg / d ) .
hematochezia resolved within six hospital days and abdominal pain was improved on the third hospital day .
it has concentrations ranging from 3% to 90% , and is widely available in a variety of medical and household products .
it is most often used as an irrigation and disinfecting solution , and 3% solutions are used as common household disinfectants .
therefore , it can be a common source of accidental poisonings , especially in children .
because of its instability and decomposability into water and oxygen in the presence of alkali or enzyme catalase , it can affect mucous membranes such as those in the liver , kidney , red blood cells and bone marrow .
so , the quantity of oxygen produced exceeds maximum blood solubility ; venous gas formation within the mesenteric and portal venous system can occur , resulting in systemic embolization and lipid peroxidation .
chemical colitis is a type of colitis , an inflammation of the large intestine , caused by the introduction of chemicals to the colon by an enema or other procedures . like other injury ,
the pathogenesis of hydrogen peroxide colitis is thought to be secondary to the chemical reaction resulting in penetration of highly reactive oxygen species , resulting in damage to the colonic mucosa .
the volume of oxygen liberated from the decomposition of hydrogen peroxide can be considerable , with 30 ml of 35% hydrogen peroxide yielding 3.5 l of oxygen , and it is thought to be secondary to absorption of hydrogen peroxide into the epithelial interstices and capillaries .
hydrogen peroxide enteritis with 3% solution can cause instant bubbling on the mucosal surface followed by a whitening of the mucosa termed the  snow white sign .
after exposure , the colon becomes distended within moments . despite the potential for severe injury from hydrogen peroxide ,
many cases have occurred after accidental contamination of endoscopes with hydrogen peroxide in adults . clinical sequelae range from mild , self - limited colitis to strictures , perforations requiring surgery or even fatality .
for example , there is a report about a patient who developed chemical colitis with rectal bleeding after self - administration of a hydrogen peroxide enema in korea , and the clinical course was good with conservative management .
but in another case report , the clinical presentation was consistent with acute ulcerative colitis symptoms  sudden onset of abdominal pain with bloody diarrhea  and the patient developed shock and died on the fourth hospital day .
endoscopy should be performed in all hemodynamically stable patients to assess for injury because signs and symptoms do not consistently correlate with the extent of injury .
the recommended treatments include bowel rest , broad spectrum antibiotics and fluid resuscitation . in this case , the patient presented with symptoms that included abdominal pain and hematochezia .
clinical manifestations were similar to other cases of hydrogen peroxide enema in adults , and the radiologic and endoscopic findings were similar to other chemical colitis including mucosal friability and hemorrhage , but the  snow white sign was not seen .
pathologic findings were also similar to other cases of chemical colitis by hydrogen peroxide enema in adults . because this is the first report of chemical colitis caused by 35% hydrogen peroxide in children
, we chose the recommended treatments for adults , and the clinical course was good in this child .
however , she should be monitored for late - onset complications because there is no exact data about long - term complications of chemical colitis in children .
hydrogen peroxide is readily available from pharmacies in korea , and several websites are available to the public that describe its use as an enema .
therefore , we believe clinicians and caregivers should be aware of this potentially lethal chemical culprit and pay attention to handling hydrogen peroxide because the storage and use of 35% hydrogen peroxide for natural health benefits can result in an emerging source for more a serious accident in children .
a 2-year - old girl , previously healthy , was brought to the emergency department because of significant cramping abdominal pain with recurrent hematochezia after an accidental hydrogen peroxide enema ( 35% , 5 ml ) by her caregiver . 
 she was hospitalized to the pediatric department and treated with nothing per mouth , intravenous fluid and parenteral antibiotic therapy . 
 laboratory , radiologic and endoscopic evaluation was performed during the admission period . 
 she was discharged in a fully recovered state on the tenth hospital day , and this is the first case report of acute chemical colitis by accidental hydrogen peroxide enema in children .