Extended Release

Abstract

To describe a challenging clinical entity that should be considered in patients presenting with drug overdose and recurrent symptoms, and to provide a discussion of the approach to endoscopic therapy. Medline search using various combinations of the following term(s): “bezoar,”“medication,”“pharmacobezoar,”“endoscopy,”“nifedipine.” Additionally, a review of the references in the citations provided by this search was performed. A 61 year-old female presented to the emergency department with a drug overdose of extended-release nifedipine and venlafaxine. In the emergency department she was treated with activated charcoal, calcium chloride and sodium bicarbonate. She exhibited bradycardia, hypotension, respiratory failure and was subsequently intubated. Within the initial 24 hours, the patient became hemodynamically stable, was extubated, and was transferred to the floor. Approximately 12 hours later, the patient became hypotensive and unresponsive, requiring transfer back to the intensive care unit. A cystic lesion was seen in the abdomen on a radiograph of the abdomen. Because of concern for a medication bezoar, an upper endoscopy was performed. On endoscopy a mass containing extended-release nifedipine tablets, venlafaxine granules and charcoal was seen in the fundus. An overtube was placed, and the bezoar was fragmented using a large snare. The pills were then removed using a Roth® retrieval net (US Endoscopy, Mentor, OH.) In total 167 extended-release nifedipine tablets were removed. Unfortunately, the patient expired 72 hours later due to multisystem organ failure related to hypotension. There have been nine previous reports of medication bezoars composed of extended-release nifedipine preparations (Procardia XL®, Adalat XL®, nifedipine gastrointestinal system). None of the prior cases described ongoing or recurrent symptoms related to the active medication. This is the first known report of the endoscopic removal of a bezoar containing an antihypertensive medication in a symptomatic patient. A medication bezoar should be considered in any patient with recurrent symptoms following a drug overdose. Endoscopic removal is the treatment of choice for symptomatic bezoars.