Hypertonic Phosphate Enemas Research Articles

Flow-through peritoneal dialysis in neonatal enema-induced hyperphosphatemia

Fleet enemas are hypertonic solutions with an osmotic action and a high concentration of phosphate. When retained in the human body they have a great toxic potential, causing severe hydro-electrolyte disorders in children, especially in newborns. We report the case of a previously healthy 8-day-old newborn who needed neonatal intensive care treatment after the inadvertent administration of an osmotically active hypertonic phosphate enema. Taking into account that phosphate removal by peritoneal dialysis (PD) strongly depends on total dialysate turnover, we chose continuous flow PD (CFPD) as the treatment option, with a successful outcome. Clinical experience with this dialytic modality is limited to a few case reports in pediatric and adult patients. To the best of our knowledge, we report here the first description of CFPD in the setting of acute phosphate nephropathy in the neonatal period. The modality of PD described here has potential as an alternative management option as it is a highly efficient, methodologically simple, and low-cost method without any need for sophisticated equipment. Physicians and parents should be aware of the adverse effects of a hypertonic phosphate enema and should never use these medications in infants and newborns.

Enema-induced severe hyperphosphatemia in children

We report the case of a 13-year-old boy with Costello syndrome and chronic constipation who received phosphate-containing Fleet-pediatric enemas at regular intervals. The day before admission he was given four enemas for severe constipation. Within 24 h the boy had developed severe hyperphosphatemia (phosphate 17.75 mmol/L), hypertonic dehydration (sodium 171 mmol/L) and severe hypocalcemia (calcium 0.56 mmol/L). With early intervention and treatment, the child survived without sequelae. Osmotically acting hypertonic phosphate enemas may result in severe toxicity. Children with developmental delay often display bowel dysfunction and chronic constipation and are therefore high-risk patients. The accepted opinion-that these enemas are not absorbed and therefore systemically inactive-is not true. Physicians should be aware of the potentially lethal complications of this treatment, which is part of everyday clinical practice.

TAP WATER AND THE MALONE ANTEGRADE CONTINENCE ENEMA: A SAFE COMBINATION?

The Malone antegrade continence enema provides independence and improved quality of life in patients with fecal incontinence or intractable constipation. However, isolated reports of fatal hypernatremia after irrigation with normal saline have raised safety concerns about frequent colonic irrigation in children. Significant electrolyte abnormalities have also been reported with hypertonic phosphate and high colonic tap water enemas. Because our patients routinely use tap water for Malone antegrade continence enema irrigations, we examined the safety profile of this practice In the last 3.5 years 71 patients at our institution have used antegrade tap water enemas for managing fecal incontinence or intractable constipation. Standard serum electrolytes were measured We obtained 101 sets of serum electrolyte measurements in 71 patients at a mean of 8.4 months postoperatively (range 1 to 33). A girl who presented with severe hyponatremia and hypochloremia had not used the Malone antegrade continence enema for several days. The most interesting finding was significantly elevated sodium and chloride in 1 case 6 weeks after surgery that was associated with tap water treated with a home softening system. Electrolytes reverted to normal 1 week after using untreated tap water We did not detect significant hyponatremia or hypochloremia in any patient using tap water for Malone antegrade continence enema irrigation. Although dangerous electrolyte abnormalities are rare, potential morbidity in those cases warrants periodic evaluation. Due to the elevated sodium content in softened tap water families should be alerted to use untreated tap water for preparing enemas.

A comparison of bowel preparations for flexible sigmoidoscopy: oral magnesium citrate combined with oral bisacodyl, one hypertonic phosphate enema, or two hypertonic phosphate enemas

OBJECTIVE: Magnesium citrate with hypertonic enemas or oral bisacodyl provides superior preparation quality for sigmoidoscopy over enemas alone. We compared three magnesium citrate sigmoidoscopy preparations in a randomized, single-blind, controlled trial. METHODS: Two hundred and ninety-one adults scheduled for routine sigmoidoscopy were randomly assigned to receive one of three preparations containing oral magnesium citrate (296 cc) taken the night before the procedure in combination with the following: 1) oral bisacodyl (10 mg), given with the magnesium citrate the night before the procedure; 2) one hypertonic phosphate enema 1 h before the procedure; or 3) two hypertonic phosphate enemas, given singly at 2 and 1 h before the procedure. Endoscopists rated preparation quality, procedure duration, and depth of endoscopic insertion. Patients assessed preparation comfort and overall satisfaction. RESULTS: Preparation quality was rated as excellent or good for 80.6% in the bisacodyl group, 88.7% in the one-enema group, and 85.1% in the two-enema group ( p = 0.30). Patients reported the oral bisacodyl regimen was better tolerated ( p = 0.032). Although the three regimens were comparable in most side effects, the bisacodyl preparation was associated with more diarrhea ( p = 0.0003). Mean procedure duration, mean insertion depth, and prevalence of diverticula and polyps were similar in all groups. Fewer than 4% of patients required repeat procedures due to poor preparation quality. CONCLUSIONS: There was no statistical difference between the quality of the three bowel preparations. Patients considered an oral bisacodyl and magnesium citrate regimen more easily tolerated, though it was associated with more diarrhea.

Life-threatening electrolyte abnormalities induced by hypertonic phosphate enema intoxication

We describe an elderly woman with a hyperphosphatemic hypocalcemic coma, hypernatremia, hypokalemia, metabolic acidosis, convulsions and respiratory and renal failure, following the administration of hypertonic sodium phosphate enemas. Physicians and pharmacists should be aware of the possible adverse effects that can be caused by these enemas.

Life-threatening electrolyte abnormalities induced by hypertonic phosphate enema intoxication

Life-threatening electrolyte abnormalities induced by hypertonic phosphate enema intoxication

Constipation and Encopresis in Childhood

Constipation and Encopresis in Childhood

Hypocalcemia and hyperphosphatemia after phosphate enema use in a child

The authors present a 3-year-old girl in whom severe hyperphosphatemia and hypocalcemia developed after the administration of three adult-sized hypertonic phosphate enemas. The commonly held notion that these enemas are not absorbed and therefore are systemically inactive is incorrect. With early intervention and treatment, the child survived without sequelae despite a serum phosphate level (74.7 mg/dL) that is greater than those previously reported. The treatment of hyperphosphatemia is reviewed as well as underlying pathology such as altered gastrointestinal motility and renal insufficiency, which may predispose the patient to this problem. Physicians should be aware of the possible adverse effects that can be caused by hypertonic phosphate enemas.

Optimal bowel preparation for flexible sigmoidoscopy—Are two enemas better than one?

Recommendations regarding optimal bowel preparation for fiberoptic flexible sigmoidoscopy remain anecdotal and inconclusive. We prospectively evaluated three commonly recommended regimens for administering hypertonic phosphate enemas to subjects undergoing 60-cm fiberoptic flexible sigmoidoscopy for routine indications. Patients were randomly assigned to one of three hypertonic phosphate enema regimens. Group A received one enema 1 hour before fiberoptic flexible sigmoidoscopy, group B received two enemas 1 hour before, and group C received one enema 3 hours before and a second enema 1 hour before fiberoptic flexible sigmoidoscopy. Adequacy of bowel preparation was graded as excellent, adequate, or poor. Results revealed no statistically significant difference in the adequacy of bowel preparation between the three regimens, all resulting in adequate or excellent preparation in approximately 80% of patients. We recommend the use of one hypertonic phosphate enema 1 hour before routine fiberoptic flexible sigmoidoscopy. Implementation of this recommendation is efficacious, convenient for patients, and cost-effective. (Gastrointest Endosc 1994;40:474-6.)

Connatal rickets following repeated administration of phosphate enemas in pregnancy: A case report

We present a case of antenatal failure of bone growth and mineralisation in a newborn whose anorectic mother repeatedly administered hypertonic phosphate enemas during pregnancy. Phosphate overload in pregnant women appears to impede calcification of the fetal skeleton.

Hyperphosphataemia and Hypocalcaemia Induced by Hypertonic Phosphate Enema - An Experimental Study and Review of the Literature

1. The study objective was to determine the hyperphosphataemic and hypocalcaemic effect of hypertonic phosphate enema. The study was conducted in a department of Internal Medicine at a University Medical Center. 2. Fourteen patients were studied. Patients' mean age (+/- s.d.) was 78.5 +/- 9 years. The creatinine clearance was 48.2 +/- 17.4 ml min-1 (mean +/- s.d.). 3. 500 ml (approx. 7 ml kg-1) of Fleet enema (FE - Na2HPO4.7H2O 224 mmol l-1 and NaH2PO4.H2O 1160 mmol l-1) were administered to each patient. Blood was drawn before FE administration and 1/2, 1, 3, 5, 12 and 24 h thereafter. Serum was analysed for levels of inorganic phosphorus and for calcium. 4. The serum inorganic phosphorus level rose from 1.01 +/- 0.3 mmol l-1 to 1.4 +/- 0.5 mmol l-1 (P = 0.001) 1 h after FE was administered. Serum calcium decreased from 2.32 +/- 0.12 mmol l-1 to 2.12 +/- 0.1 mmol l-1 (P less than 0.001) 12 h after FE was administered. 5. We conclude that FE carries a potential risk for acutely ill elderly patients. To avoid untoward effects due to hyperphosphataemia and hypocalcaemia, the phosphate load must be adjusted to the patient's renal function, i.e. enema volume is to be lowered when phosphate concentration is high, so that if renal function is compromised the amount of phosphate absorbed does not exceed renal excretion capacity.

Sodium Phosphate Enemas: How to Kill Cats, Cause Cardiac Arrest, and Cure Eye Rolling at Stanford

To the Editor.— The continuing reports of intoxication following administration of commercial hypertonic sodium phosphate enema solution in both the human1,2and veterinary3literature and the recent comment on the lack of animal studies of sodium phosphate enema intoxication prompt me to write. In a recent study,4we systematically evaluated alterations in acid-base, fluid, and electrolyte balance after administration of hypertonic sodium phosphate enemas to normal adult cats. Study.— Ten awake cats, in whom arterial catheters had been previously implanted, were divided into two groups. Group A received 60 mL (mean dose, 18 mL/kg) of hypertonic sodium phosphate enema solution and group B received 120 mL (mean dose, 32 mL/kg) of hypertonic sodium phosphate enema solution, both with five minutes' forced retention. Abnormalities, noted as early as 15 minutes following administration of enema solution, included severe hyperphosphatemia, mild hypernatremia, hyperglycemia, hypocalcemia, lactic acidosis with an increased anion

Transfer of cefazolin into human milk

phate load will be rapidly excreted by the kidney in the presence of normal glomerular and tubular function, but only in conjunction with a cation to preserve electroneutrality. This is a possible explanation for the large concentration of cations (sodium and potassium) noted in the random urine specimen obtained at the time of the initial admission. In the presence of extracellular volume contraction and increased aldosterone production, a significant proportion of this cation loss could be potassium. The use of enemas, especially hypertonic phosphate enemas, has become routine in pediatrics in preparation for roentgen studies and in the treatment of chronic constipation. Although enemas given to normal individuals usually do not cause electrolyte imbalance, children with abnormal colons or impaired renal function are especially prone to fluid and electrolyte disturbances following the administration of enemas. If the chronic use of enemas cannot be avoided, such patients should be monitored with periodic determinations of serum electrolyte, phosphorus, and calcium concentrations.

Hypocalcemia, hyperphosphatemia, and dehydration following a single hypertonic phosphate enema

Previous reports of hypocalcemia and hyperphosphatemia following use of phosphate enemas have either been in patients with renal disease or followed prolonged abuse of these products. The two patients described here had marked elevation of serum phosphate and concomitant lowering of serum calcium secondary to absorption of phosphate from a single administered enema. Associated moderate dehydration resulted in poor renal excretion of the absorbed phosphate and prolongation of hypocalcemia. Hydration was effective in permitting clearance of phosphate and restoration of normocalcemia.

Tetany following phosphate enemas in chronic renal disease.

A girl with chronic pyelonephritis and dehydration developed tetany on two occasions after receiving a hypertonic phosphate enema. Biochemical evaluation disclosed hypocalcemia, hypomagnesemia, and, on one occasion, hyperphosphatemia. The tetany responded to calcium and magnesium therapy. We discuss the relationship of hyperphosphatemia, presumably secondary to colonic phosphate absorption, to hypocalcemia and hypomagnesemia. Phosphatecontaining enemas probably should be used with caution in patients with chronic renal insufficiency.

Severe Tetany in an Azotemic Child Related to a Sodium Phosphate Enema

The potential toxicity of neutral sodium phosphate medications to infants and azotemic children is rarely taken into consideration. Since the sole route of excretion of absorbed phosphate is renal, diminished renal function secondary to chronic renal disease or renal immaturity will limit the ability to excrete a sudden phosphate load. Previous reports document toxicity of phosphate laxatives to normal infants and hypertonic phosphate enemas to patients with Hirschprung's disease. This report presents a 4½-year-old azotemic boy who was admitted with carpopedal spasm and acidosis in the presence of profound hyperphosphatemia, following administration of a sodium phosphate enema for chronic constipation.

Fluid and serum electrolyte disturbances as a complication of enemas in Hirschsprung's disease.

HIRSCHSPRUNG'S disease, or intestinal aganglionosis, is generally characterized by abdominal distention with constipation secondary to a functional colonic obstruction; an aganglionic segment of bowel usually in the rectosigmoid area lacks coordinated propulsive contractions. Anatomically, the aganglionic portion is narrowed and the proximal colon is dilated and hypertrophied. Several complications are known to result from the compromised ability to evacuate colonic contents: intestinal obstruction, enterocolitis, spontaneous rupture of the colon, anemia, hypoproteinemia and edema, and retarded growth. 1 Enemas to facilitate colonic evacuation are recommended treatment for this disease. However, because the enema may be retained and because a large surface area is available for absorption, tap-water enemas are known to produce water intoxication, and their use is not recommended. Recently the use of other types of enemas has been suggested, among them hypertonic phosphate enemas. 1 Our experience with four children in whom two additional complications of enemas, hypernatremic dehydration