Gastrointestinal Decontamination Procedure Research Articles

The role of whole bowel irrigation in the treatment of toxic ingestions.

There is no high-quality evidence regarding the benefit of any gastrointestinal decontamination procedure in the overdose patient. The original and twice reaffirmed position of the AACT and EAPCCT is based upon the best evidence and practical considerations. WBI was recommended as a treatment for the ingestion of modified release pharmaceuticals, iron salts and other substances not adsorbed by activated charcoal. This is a best evidence recommendation.

Demographic and Clinical Characteristics of Theophylline Exposures between 1993 and 2011

Acute and chronic exposure to theophylline can cause serious signs and symptoms of poisoning. Additionally, with a narrow therapeutic range, toxicity could be observed even with therapeutic doses of theophylline. Epidemiological data on theophylline exposures in our country are extremely limited. The results of our study may improve the clinical management of theophylline poisoning in our country and elsewhere. To present aetiological and demographic features, clinical findings and treatment attempts with regard to theophylline exposures reported to Dokuz Eylül University Drug and Poison Information Center (DPIC), between 1993 and 2011. Descriptive study. The data regarding demographics, date, time, type of exposure, route of and reason for exposure, signs and symptoms upon admission, clinical management and outcome were retrospectively evaluated. The DPIC recorded 88,562 poisoning calls between 1993 and 2011; 354 (0.4%) of them were due to theophylline exposure. The mean age of all cases was 24.1±15.4 (range between 1 month and 90 years). Females dominated all age groups (72.6%, 257 females). Intentional exposure was significantly higher in women than in men (88.2% vs. 68.2% for all age groups; p<0.001 for children; p<0.001 for adults; p<0.001 for all age groups). While 60.5% of the cases had no symptoms, severe signs of toxicity were present in 1.9% of theophylline exposure cases during the telephone inquiry. Signs and symptoms were found to be significantly more prevalent in adults than in children (p<0.01). The serum theophylline level was regarded as toxic in 74% (65 toxic levels) of theophylline measured cases. Clinical signs and symptoms were found to be significantly prevalent in cases with toxic theophylline levels (p<0.001). The rate of gastrointestinal decontamination procedures was higher than that of recommended gastrointestinal decontamination procedures by DPIC (83% and 66%, respectively). There were two fatalities (4.6%) associated with chronic theophylline toxicity and theophylline overdose in an acute setting for suicide (a 90 year-old and 25 year-old, respectively). Although most of the theophylline exposure cases had no symptoms, some reported serious signs and symptoms of poisoning such as hypokalaemia, tachycardia and hyperglycaemia. DPICs have an important role in the management of theophylline exposure without unnecessary gastrointestinal decontamination procedures.

IS-067 Accidental Poisoning In Children

Although all the preventive efforts made to avoid paediatric poisonings, these remain a major health problem. Non intentional poisonings in young children are the most commonly registered in the Paediatric Emergency Departments (PED). Although there is a great variability all over the world, most common way of poisoning is the ingestion of therapeutic drugs (frequently psychotropic medications), followed by household products, and not always kept out of the child’s reach and in their original container. CO inhalation and ingestion of pesticides are quite frequent in some regions. Children are usually carried by their parents to the PED in the family vehicle just after the event. Poison Control Centres and Medical Pre-hospital Services are not often contacted by the families before going to the hospital. A large amount of children do not receive any treatment although 5–10% of the ingested substances are considered to be toxic in small doses. The administration of activated charcoal is the most common gastrointestinal decontamination procedure performed and ipecac is no longer used. However, there is a great variability in the management of these children. Prognosis is usually good, being the death exceptional, and sequelae are very rare and usually related with the ingestion of caustic household products. An exhaustive analysis is needed to design different improvement actions required to prevent these poisonings, to manage correctly these children adapted to best international practices and to use health resources in a better way.

Impact of a working group on gastrointestinal decontamination in Spanish emergency departments

The aim of this study is to analyze the impact of the actions carried out by the Intoxications Working Group (IWG) of Spanish Society of Pediatric Emergencies in the management of acute pediatric intoxications in Spain, specifically the publishing of a Handbook in 2004 or the creation of the Toxicologic Surveillance System in 2009. Gastrointestinal decontamination procedures were analyzed in three periods of time in Pediatric Emergency Departments (PEDs) included in the IWG: group A (2001-2002, 17 PED, 2157 episodes), group B (2008-2009, 22 PED, 612 episodes), and group C (2009-2011, 42 PED, 400 episodes). These periods were chosen because the main actions of the IWG were developed in the time in-between them. Of the 3169 episodes included, a gastrointestinal decontamination procedure was performed in 1031. The use of ipecac syrup decreased from 22.8% in group A to 0 in group C and the performance of a gastric lavage decreased from 29.1% in group A to 26% in group C (NS), although on splitting yearly patients of group C, it decreased to 14.7% in 2011. Recommendations developed and spread by a Working Group have approached the management of acute pediatric intoxications in Spain to international guidelines on the basis of scientific evidence.

Outcome following gastrointestinal tract decontamination and intravenous fluid diuresis in cats with known lily ingestion: 25 cases (2001–2010)

To describe the outcome of cats treated with gastrointestinal tract decontamination, IV fluid diuresis, or both after ingestion of plant material from lilies of the Lilium and Hemerocallis genera. Design-Retrospective case series. 25 cats evaluated after ingestion of lily plants. Medical records of cats examined at the Matthew J. Ryan Veterinary Hospital of the University of Pennsylvania with known lily ingestion between July 2001 and April 2010 were reviewed. Inclusion in the study required evidence of lily plant ingestion within the preceding 48 hours. Type of lily ingested, time of ingestion, gastrointestinal tract decontamination procedures performed, and IV fluid diuresis were recorded. The presence or absence of acute kidney injury was determined by evaluating BUN concentration, creatinine concentration, and urine specific gravity. Outcome was defined as survival to discharge, death, or euthanasia. The time from ingestion until evaluation at the Matthew J. Ryan Veterinary Hospital of the University of Pennsylvania ranged from < 30 minutes to 48 hours. Nineteen cats received gastrointestinal tract decontamination (18 cats at our hospital and 1 cat by the referring veterinarian). Twenty-three cats were admitted to the hospital for IV fluid diuresis, supportive care, and monitoring. Seventeen of these 23 (74%) cats had normal BUN and creatinine concentrations throughout hospitalization. At the time of discharge from the hospital, 2 of the 23 (9%) hospitalized cats had an increased BUN concentration, creatinine concentration, or both. All 25 (100%) cats survived to discharge from the hospital. In this series of cats treated with gastrointestinal tract decontamination, IV fluid diuresis, or both within 48 hours after lily ingestion, the outcome was good, with a low incidence of acute kidney injury. Future studies are needed to determine the most effective gastrointestinal tract decontamination procedures and optimal duration of IV fluid therapy.

374 Impact of a Working Group on Gastrointestinal Decontamination of Pediatric Emergency in Spain

IntroductionIn a study conducted in 2001–02 including 17 pediatric emergency departments (PED) in Spain high variability was detected in management of acute pediatric intoxications and, more specifically in the gastrointestinal...

The effect of curcumin on lung injuries in a rat model induced by aspirating gastrointestinal decontamination agents

BackgroundAspiration is one of the most feared complications of gastrointestinal decontamination procedures with nonabsorbed polyethylene glycol (PEG) solution and activated charcoal (AC). We aimed to investigate the protective effects of curcumin (CUR) on lung injury in rats induced by aspiration of these agents. MethodsExperimental rats were divided randomly into 6 groups (n = 7): a saline-aspirated control (group I), sterile saline aspirated with CUR treatment (group II), PEG aspirated (group III), PEG aspirated with CUR treatment (group IV), AC aspirated (group V), and AC aspirated with CUR treatment (group VI). After aspiration, treatment groups II, IV, and VI were given 150 mg/kg CUR intraperitoneally once a day for 7 days. After 7 days, the rats were humanely killed, and both the lungs and serum specimens from all groups were evaluated histopathologically, immunohistochemically, and biochemically. ResultsAspiration of gastrointestinal decontamination agents produced histopathologic changes, elevated levels of malondialdehyde and surfactant protein D, reduced levels of antioxidant enzymes, and increased expression of inflammatory cytokines interleukin-1β and tumor necrosis factor α. Curcumin treatments effectively attenuated the rats' pulmonary inflammation responses (as shown by reduced alveolar damage), decreased serum malondialdehyde and surfactant protein D levels, and inhibited the expressions of tumor necrosis factor α and interleukin-1β. ConclusionsBecause of its anti-inflammatory effects, CUR treatment may have preventive effects on lung injuries induced by aspirating gastrointestinal decontamination agents.

Infliximab attenuates activated charcoal and polyethylene glycol aspiration-induced lung injury in rats

ABSTRACTAspiration is a serious complication of gastrointestinal (GI) decontamination procedure. Studies have shown that tumor necrosis factor-α (TNF-α) blockers have beneficial effects on lung injury. Therefore, the authors investigated the attenuation by infliximab (INF) on activated charcoal (AC)- and polyethylene glycol (PEG)-induced lung injury in rat model. Forty-two male Sprague-Dawley rats were allotted into 1 of 6 groups: saline (NS), activated charcoal (AC), polyethylene glycol (PEG), NS+INF treated, AC+INF treated, and PEG+INF treated. All materials were aspirated into the lungs at a volume of 1 mL/kg. Before aspiration, the rats were injected subcutaneously with INF. Seven days later, both lungs and serum specimens in all groups were evaluated histopathologically, immunohistochemically, and biochemically. Following aspiration of AC and PEG, evident histopathological changes were assigned in the lung tissue that were associated with increased expression of inducible nitric oxide synthase (iNOS), increased serum levels of oxidative stress markers (malondialdehyde [MDA], surfactant protein-D [SP-D], TNF-α), and decreased antioxidant enzyme (glutathione peroxidase [GSH-Px]) activities. INF treatment significantly decreased the elevated serum MDA and TNF-α levels and increased serum GSH-Px levels. Furthermore, the current results show that there is a significant reduction in the activity of iNOS in lung tissue and increased serum SP-D levels of AC and PEG aspiration-induced lung injury with INF treatment. These findings suggest that INF attenuates lung inflammation and prevents GI decontamination agent–induced lung injury in rats.

A retrospective evaluation of analgesic exposures from Izmir, Turkey

The objective of this study is to analyze exposures concerning analgesics that were reported to Dokuz Eylul University Drug and Poison Information Center (DPIC) and admitted to the Department of Emergency Medicine in Dokuz Eylul University Hospital (EMDEU) between 1993 and 2004. Demographics of the patients, characteristics of analgesic exposures, performed treatment attempts and outcome of the poisoned patients were recorded on standard data forms and were then entered into a computerized database program. Statistical analysis was performed by using the chi-square test. The DPIC recorded 55 962 poisoning calls, 48 654 (86.9%) of them related to medicines. Analgesics accounted for 16.3% (7 939 cases) of all medicine-related exposures; among them 446 exposures were admitted to EMDEU. More than half of the analgesic exposure calls and admitted cases involved adults (55.9%, 4 440). Females dominated in all age groups (70.3%, 5 578). Mean age was 20.2 +/- 11.8. The most involved analgesics were paracetamol (47.9%), propionic acid derivatives (16.1%) and salicylates (13.7%). Most of the poisonings were intentional (75.1%), especially in 19-29 years age group of adults and 13-18 years age group of children. Most of the patients reported to DPIC and admitted to EMDEU were asymptomatic (84.4% and 54.7%, respectively). Gastrointestinal decontamination methods were performed more frequently for admitted poisoning cases before hospital admission than reported poisoning cases (61% vs. 23%). Paracetamol ingestion was the most common cause of analgesic exposures reported to our DPIC. Most of the analgesic exposures reported to DPIC were asymptomatic or mild. DPICs have an important role for the referral of analgesic exposures without unnecessary gastrointestinal decontamination procedures.

The treatment of overdose--time for a change?

To determine emergency management of overdose relating to gastrointestinal decontamination procedures in Scottish Accident & Emergency (A & E) Departments. A postal questionnaire was sent to the 28 main A & E Departments in Scotland. There was a 75% response rate. Nineteen departments(90%) continue to perform gastric lavage, with the majority carrying out this procedure more than one hour post-ingestion of commonly presenting overdoses. Sixteen departments (76%) regularly administer activated charcoal and four (19%) use syrup of ipecacuanha. Twenty departments (95%) had access to Toxbase. The majority of respondents (86%) feel there is a need for standardisation of treatment in acute overdose. Despite the availability of guidelines provided by the UK National Poisons Information Service and the Position Statements, there is no consensus in the actual management of acute overdose among Scottish A&E departments.

GASTROINTESTINAL DECONTAMINATION AFTER POISONING: Where Is the Science?

The approach to the use of gastrointestinal decontamination procedures in the treatment of ingested toxins has changed in recent years. Many toxicologists and physicians have taken strong positions either for or against the use of emesis, gastric lavage, activated charcoal, or other procedures. What is the scientific basis for these positions? This article reviews and comments on the published studies comparing the effectiveness of these widely used procedures.

Efficiency of whole bowel irrigation with and without metoclopramide pretreatment

Whole bowel irrigation (WBI) with a polyethylene glycol electrolyte lavage solution (PEG-ELS) is a gastrointestinal (GI) decontamination procedure used after selected ingestions of toxic substances. The purpose of this study was to evaluate the ability of WBI, with and without metoclopramide pretreatment, to clear the GI tract of foreign bodies using previously established WBI end points, ie, the presence of a clear effluent or the administration of 2 L/h PEG-ELS for 5 hours. Eleven healthy, adult, male volunteers participated in this controlled, two-phase, blinded, crossover study. Ten fluorescent coffee beans were ingested after an overnight fast followed 1 hour later by 10 mg of metoclopramide syrup or an equivalent volume of placebo; 30 minutes later, WBI with PEG-ELS was begun at 2 L/h. All volunteers received 10 L of PEG-ELS during a 5-hour period. No statistically significant difference ( P > .05) was found between the two pretreatments. For the metoclopramide group, the mean number of beans passed was equal to 3.8 (±2.5 standard deviation [SD]; 1 to 8 R); the mean number at clear effluent was equal to 2.3. For the placebo group, the mean number of beans passed was equal to 3.5 (±1.9 SD; 2 to 7 R), and the mean number at clear effluent was equal to 2.3. In conclusion, the presence of a clear effluent or the administration of 10 L of PEG-ELS are not valid markers for the termination of WBI if complete elimination of a foreign body is required. Pretreatment with 10 mg of oral metoclopramide does not enhance the efficiency of WBI.

Gastrointestinal decontamination and the prevention of absorption

The benefit of performing gastrointestinal decontamination in many patients who have had overdoses has not been clearly documented and may have significant complications. An analysis of the literature on gastrointestinal decontamination allows qualitative conclusions about broad treatment measures but does not produce answers to complex clinical problems. Syrup of ipecac remains the method of choice for gastrointestinal decontamination in the home because of its availability, safety, reliability, and compliance. However, its effectiveness is limited by a slow onset of action and the postingestion initiation time. The prolonged emetic action of syrup of ipecac may interfere with the administration of activated charcoal and oral antidotes. In the emergency department the use of syrup of ipecac is limited to substances not adsorbed by activated charcoal and those too large to be removed by the orogastric tube. Gastric lavage is useful when time is of the essence and in evacuating liquids and smaller particles. Its effectiveness is limited by the postingestion initiation time. Neither syrup of ipecac emesis nor gastric lavage completely evacuates the stomach, and both leave substantial gastric residual of the ingested substance. Neither method obviates careful follow-up and observation in significant poisonings. Activated charcoal absorbs many substances, even beyond the pylorus. Although activated charcoal shortens the nonrenal half-life and the area under the concentration curve of many substances, there is controversy regarding its effect on the clinical course of the poisoned patient. Activated charcoal often requires a small nasogastric tube to ensure compliance and may interfere with oral antidotes. There is no scientific proof that cathartics are effective in gastrointestinal decontamination. Whole bowel irrigation is still investigational but it may be useful in certain situations such as removal of long-acting preparations, bezoars, and containers of contraband. Gastrointestinal decontamination procedures should not be routine but should be carefully individualized based on the substance ingested, clinical presentation, and the time of ingestion. Gastrointestinal decontamination should be preserved for patients who are most likely to benefit because the procedures carry some risk. None of the present methods of gastrointestinal decontamination has proven universally effective.

Iron poisoning: Report of three cases and a review of therapeutic intervention

Although the acute ingestion of iron-containing preparations can produce very serious consequences, the majority of reported exposures are not associated with significant morbidity or mortality. We present 3 cases of acute iron ingestion and review the aspects of general management, with an emphasis on the appropriate choice of a gastrointestinal decontamination procedure.

Superiority of activated charcoal alone compared with ipecac and activated charcoal in the treatment of acute toxic ingestions

A prospective, randomized clinical trial compared the clinical effectiveness of syrup of ipecac and activated charcoal to that of activated charcoal alone in the treatment of acute toxic ingestions. Two hundred adult patients with mild to moderate oral overdoses were entered into the trial. Patients receiving only activated charcoal were discharged from the emergency department in significantly (P less than or equal to .05) less time than those receiving both syrup of ipecac and activated charcoal (6.0 +/- 0.3 vs 6.8 +/- 0.2 hours, respectively). The percentage of patients requiring nonpsychiatric hospitalizations was not significantly different between the two groups (11.2% vs 14.0%, respectively). For the hospitalized patients, the length of time spent in the ICU and in the hospital was not statistically different between the two groups. A complication rate of 5.4% was found with the ipecac and activated charcoal treatment compared with a 0.9% complication rate in the activated charcoal group (P less than or equal to .05). Three episodes of aspiration pneumonitis occurred after administration of ipecac and activated charcoal, while no episodes of aspiration were noted after treatment with only activated charcoal. Together, these data are consistent with the recommendation that ED treatment with activated charcoal alone be the gastrointestinal decontamination procedure of choice for the routine mildly-to-moderately orally poisoned adult patient.

Whole bowel irrigation as a gastrointestinal decontamination procedure after acute poisoning.

Assuming a stable or stabilised patient, preventing the absorption of ingested toxins becomes a primary objective in the treatment of acute overdose. Traditional interventions aimed at achieving this end include ipecac-induced emesis, large bore orogastric lavage and activated charcoal administration (Cupit & Temple 1984; Easom & Lovejoy 1979). Whether any of these procedures benefits the patient remains unknown. Induced emesis and gastric lavage have especially been questioned (Comstock et al. 1981; Corby et al. 1968; Fane et al. 1971; Neuvonen et al. 1983; Tenenbein 1985a; Vale et al. 1986) and the literature seems to favour activated charcoal administration without a gastric emptying procedure (Chin 1972; Curtis et al. 1984; Fane et al. 1971; Kulig et al. 1985; Tenenbein et al. 1987a). However, the most common practice is to use one of the gastric emptying procedures, followed by activated charcoal. Apart from the concerns about their effectiveness, situations arise where all 3 of these interventions can be expected to be of limited benefit to the poisoned patient. These include the ingestion of a very large amount of a toxic substance (e.g. many times the lethal dose) , late presentation after the overdose, ingestion of delayed release pharmaceuticals and ingestion of substances not adsorbed by activated charcoal (particularly iron). In these situations whole bowel irrigation with polyethylene glycol electrolyte lavage solution offers promise as a method of treatment. The purpose of this article is to review relevant data and experience regarding this technique.

Efficacy of ipecac-induced emesis, orogastric lavage, and activated charcoal for acute drug overdose

The efficacy of ipecac-induced emesis, large-bore orogastric lavage, and activated charcoal as gastrointestinal decontamination procedures after acute drug overdose is unknown. Using an ampicillin overdose model, these three procedures were compared with one another and to a control ingestion in ten human volunteers. Serial serum ampicillin levels were used to compute the areas under the concentration vs time curves (AUC) for each study. The reductions of ampicillin absorption compared to control were as follows: orogastric lavage 32% (NS), ipecac-induced emesis 38% (P less than .01), and activated charcoal 57% (P less than .01). This model examines each intervention in a mutually exclusive fashion. It supports activated charcoal administration as the primary gastrointestinal decontamination procedure after acute drug overdose.

Whole Bowel Irrigation as a Decontamination Procedure After Acute Drug Overdose

Whole bowel irrigation, routinely used before colonoscopy, is evaluated as a potential gastrointestinal decontamination procedure for acute drug overdose. Nine adult volunteers, who served as their own controls, each ingested 5.0 g of ampicillin trihydrate on two occasions, one week apart. Whole bowel irrigation with polyethylene glycol electrolyte lavage solution was performed one hour after one ingestion. Serial serum ampicillin levels, electrolytes, osmolalities, body weights, and hematocrits were obtained. The areas under the concentration vs time curves for ampicillin were computed for both groups, and their means were compared. Mean duration of the procedure was 234 minutes and mean volume of infused polyethylene glycol electrolyte lavage solution was 7.7 L. Whole bowel irrigation produced a 67% decrease in ampicillin absorption and there were no significant changes in body weight, hematocrit, serum electrolytes, or osmolality. We conclude that whole bowel irrigation is an effective and safe gastrointestinal decontamination procedure for acute drug ingestion.

Benign course after massive levothyroxine ingestion.

Management of thyroid hormone ingestion is controversial. We present nine children with massive levothyroxine ingestion who experienced a benign course. Their serum thyroxine levels ranged from 19.9 to 84.7 micrograms/dl. Seven were clinically euthyroid, and the other two had mild symptoms. No specific therapy was given. We recommend gastrointestinal decontamination procedures and serum thyroxine levels for an ingestion of greater than 2.0 mg of levothyroxine (or its equivalent). If levothyroxine has been ingested, neither immediate hospitalization nor prophylactic antihyperthyroidism therapy is recommended. If the initial serum thyroxine level is significantly elevated, close outpatient follow-up, especially during days three to 10, is warranted. However, massive ingestion of thyroid extract or triiodothyronine may require immediate hospitalization for observation. Therapeutic interventions aimed at extracorporeal removal of excess thyroid hormones are not recommended. Specific antithyroid therapy should be reserved for those rare patients with significant symptoms of thyrotoxicosis.