A glass of caustic cleaner poured from a beer tap does not always look like a hazard. Line cleaners are usually brightly colored, but a Brewers Association expert has said that when the chemical pulls residue from a line that carried dark beer, it can take on the beer's color. That may help explain how drinkers swallow it before realizing something is wrong.
The problem is back in focus after a case series published in February in Case Reports in Gastroenterology described three people who drank beer line cleaner at separate taverns in the same U.S. county. The cleaner, a strongly alkaline solution that typically has a pH of 13 to 14, left all three with lasting esophageal injuries, according to authors from the University of Nevada, Reno, and the University of Nevada, Las Vegas.
The authors blame gaps in regulatory oversight and enforcement. They call for standardized flushing, tracer dyes, and point-of-use testing to confirm that what leaves the tap is actually beer.
When Cleaner Passes for a Dark Pour
After three people fell ill at Burke Street Pub in Winston-Salem, North Carolina, in November 2023, Chuck Skypeck of the Brewers Association explained to WFDD how such a mistake can slip past staff and customers.
He said a sodium hydroxide-based cleaner had likely never been rinsed from the line. Usually, the cleaner is so brightly colored that the error would be obvious. But residue from a dark beer can make the chemical "mimic the color of the beer," he said. If patrons ordered a darker beer and drank it quickly, he added, the problem might not have become apparent until it was too late.
Skypeck told the station he had heard of about 20 such incidents in his 40-year career, none of them fatal. He advised drinkers to smell beer before drinking it and said beer with a high concentration of chemicals likely would not have a foamy head.
News reports at the time said one of the three Winston-Salem patrons had died. A medical examiner later ruled that his death, which came weeks after he was hospitalized with a caustic esophageal injury, was natural and tied to chronic alcoholism rather than the cleaner, FOX8 reported. The Nevada case series still lists Winston-Salem as a possible fatality.
Who Checks the Tap Lines
The Winston-Salem case exposed how little oversight may apply. According to WFDD, local health departments there inspect only bars that serve food, and North Carolina's health department and the state's Alcohol Law Enforcement division both said the matter fell outside their purview.
"The culprit is not the beer, but the culprit is the chemicals," Skypeck said, adding that draft beer lines in the U.S. face little strong regulation. In most states, he said, no rules require training for line cleaners, limit who may clean lines, or set how often lines must be cleaned.
Some states do set schedules. Ohio's rule requires beer lines to be cleaned at least every two weeks, or as recommended by the beer, equipment, or cleaner manufacturer, and requires signed cleaning records. Illinois requires weekly cleaning for most systems, along with a signed record of each cleaning. Neither rule's text spells out a test to confirm that the cleaner has been rinsed away.
Even recommended schedules are unevenly followed. The case series cites an industry survey in which only 43% of accounts cleaned their lines every two weeks, the recommended minimum, while 36% cleaned them monthly.
The Cheap Rinse Check Bars Can Do
The Brewers Association's safety guidance says the best way to confirm that all chemical residue is gone is to check that the rinse water's pH is neutral, which can be done very affordably with test strips. Skypeck gave similar advice and also recommended tagging lines filled with chemicals and removing the tags only after rinsing.
The guidance also calls for training anyone who cleans lines, posting signs on tap handles during cleaning, never leaving a cleaning job unattended, and keeping safety data sheets for every chemical. It describes a brewery sales representative who was unknowingly served caustic solution from a line being cleaned and spent a night in the hospital with throat and esophageal burns.
In the U.K., the Nevada authors note, the British Institute of Innkeeping recommends testing beer with litmus paper before serving it. They add that without a national reporting system, the true number of these injuries is hard to measure.
Injuries That Outlast the Drink
The three patients in the case series, a 37-year-old woman, a 37-year-old man, and a 40-year-old man, all needed extended acid-suppressing treatment and dietary changes. The alkaline cleaner destroys tissue by breaking down fats and proteins, a process that disrupts cell membranes, the authors wrote.
Endoscopy findings ranged from redness and small nodules to narrowing of the esophagus and very severe Grade D esophagitis. The patients reported trouble swallowing, reflux, taste changes, and weight loss. In their own cases, the authors could not determine the specific product or how much of it was involved.
Caustic ingestions account for 9.28% of poisoning cases in the U.S., the authors note, and endoscopy is recommended within 24 to 48 hours of an accidental caustic ingestion. Anyone whose drink burns, smells like chemicals, or looks oddly flat should stop drinking, alert staff, and call Poison Control at 1-800-222-1222 or seek emergency care.
Key Questions Answered
How can line cleaner end up in a glass?
If a draft line is not fully rinsed after cleaning, the caustic solution can be dispensed as though it were beer.
Why might a drinker not notice?
A Brewers Association expert said cleaner that picks up residue from a dark beer line can mimic the beer's color, and a fast drinker may not catch it.
What simple check can prevent it?
The Brewers Association says inexpensive pH test strips can confirm that rinse water is neutral before a line goes back into service.
Did someone die in the Winston-Salem incident?
One patron died weeks later, but a medical examiner ruled the death natural and related to chronic alcoholism, not the cleaner.
What should someone do after drinking suspected cleaner?
Stop drinking, tell staff, and call Poison Control at 1-800-222-1222 or seek emergency care.
