Whole Bowel Irrigation Research Articles

Effect of Whole Bowel Irrigation for Ingested Lead-Containing Foreign Bodies: A Pediatric Case Series

Background Foreign body (FB) ingestions cause lead toxicity in pediatric patients. These ingestions result in continued lead absorption until passage or removal from the gastrointestinal (GI) tract. Whole-bowel irrigation (WBI) is frequently recommended to aid in the removal of FBs, however effectiveness of this practice is not clear. Methods We performed a retrospective chart review of pediatric patients (<18 years old) admitted for treatment of lead toxicity at an academic pediatric medical center from 1 January 2017 through 31 October 2023. We abstracted patient age, identity of ingested FB, lead concentrations, duration of WBI, maximum flow rate of WBI, success or failure of FB passage, performance and results of endoscopy, and duration of hospital stay. Results Nine cases with radiopaque FB suspected to be lead were treated with WBI. Three cases resulted in the complete expulsion of the ingested FB. Four patients underwent endoscopic removal after WBI median duration of 47.5 h (range 27–80.5 h). One patient failed to clear despite 168.5 h of WBI. Conclusion WBI did not lead to the clearance of all FBs in this series. Practitioners should consider early endoscopic removal if WBI does not result in passage of the FB within the first 48 h.

Whole Bowel Irrigation should not be used routinely in poisoned patients.

Whole bowel irrigation is a method of gastric decontamination in the poisoned patient involving administration of large volumes of osmotically balanced polyethylene glycol-electrolyte solution to empty the gastrointestinal tract of ingested toxins before absorption, limiting systemic toxicity. While this approach may seem intuitive, and observational studies confirm it can lead to expulsion of tablets or packets in the rectal effluent, there is a lack of evidence correlating this with improved patient outcomes. Administration of whole bowel irrigation is also challenging to the inexperience physician and associated with adverse effects, which may be serious. Recommendations for the consideration of whole bowel irrigation are therefore limited to patients who have ingested modified release preparations, those of have ingested pharmaceuticals not adsorbed by activated charcoal, and for the removal of packages in body packers. Until more robust evidence is available from high-quality prospective studies demonstrating efficacy, the use of whole bowel irrigation should not be used routinely in poisoned patients.

Iron; Benefits or threatens (with emphasis on mechanism and treatment of its poisoning).

Iron is a necessary biological element and one of the richest in the human body, but it can cause changes in cell function and activity control. Iron is involved in a wide range of oxidation - reduction activities. Whenever iron exceeds the cellular metabolic needs, its excess causes changes in the products of cellular respiration, such as superoxide, hydrogen peroxide and hydroxyl. The formation of these compounds causes cellular toxicity. Lack of control over reactive oxygen species causes damages to DNA, proteins, and lipids. Conversely, superoxide, hydrogen peroxide and hydroxyl are reactive oxygen species, using antioxidants, restoring DNA function, and controlling iron stores lead to natural conditions. Iron poisoning causes clinical manifestations in the gastrointestinal tract, liver, heart, kidneys, and hematopoietic system. When serum iron is elevated, serum iron concentrations, total iron-binding capacity (TIBC) and ferritin will also increase. Supportive care is provided by whole bowel irrigation (WBI), esophagogastroduodenoscopy is required to evaluate mucosal injury and remove undissolved iron tablets. The use of chelator agents such as deferoxamine mesylate, deferasirox, deferiprone, deferitrin are very effective in removing excess iron. Of course, the combined treatment of these chelators plays an important role in increasing iron excretion, and reducing side effects.

Compliance to whole bowel irrigation recommendations: a single poison center study

Introduction: Whole Bowel Irrigation (WBI) is used as a method of gastrointestinal decontamination for poisoned patients and may have low compliance when recommended by poison centers (PC). We set out to determine WBI compliance and analyze trends and possible associations between WBI compliance and clinical outcomes. Methods: We conducted a single-center retrospective chart review of PC data from 1/1/2011 to 12/31/2019 and included cases in which WBI was recommended. We collected demographic data, exposure history, therapies recommended and performed, and clinical outcomes. Compliance rate was calculated. Chi-squared and Mann-Whitney U tests were performed to look for differences in compliance based on case characteristics such as compliance rate by year, compliance based medication ingested and presence of intubation. We also looked for a possible association between WBI compliance and clinical outcome. Results: Four hundred and eighty-three cases met inclusion criteria. Fifty-five percent of patients were male and the median age was 32.5 years. Compliance to WBI recommendations was 58.2%. There was no significant difference in compliance when comparing by age, gender, medication ingested, or year. There was no association between compliance to WBI and clinical outcomes. Conclusions: We calculated a compliance rate of 58% when WBI was recommended. Compliance to WBI does not appear to be associated with changes in clinical outcome.

Whole-bowel irrigation in cases of poisoning: A retrospective multicentre study of feasibility, tolerability, and effectiveness

BackgroundWhole-bowel irrigation (WBI) is a strategy of gastrointestinal decontamination, recommended by several European and American learned societies, which may be used in the management of the poisoned patients. ObjectivesThe objectives of this study were to describe the feasibility and tolerability of this technique and to compare the clinical outcome of a group of poisoned patients treated with WBI versus that of an untreated group. MethodsThis was a retrospective and observational study of data recorded by the Angers Poison Control Centre (PCC) between 2012 and 2018. All cases for which the PCC advised WBI were included. The association between outcomes (clinical deterioration after WBI advised by a PCC, length of hospitalisation), WBI treatment, and relevant associated risk factors was determined using univariate and multivariate logistic regression. ResultsA total of 257 patients were included. One hundred forty-one patients were treated with WBI with clearly successful induction of diarrhoea in 47 cases (31%). WBI was not initiated in 89 patients. WBI was initiated but unsuccessful (no diarrhoea) in nine cases. The median age is 46 years (interquartile range: 32-55 years), with a sex ratio (M/F) of 1.3. A total of 27 of 150 patients (18%) who underwent WBI had adverse effects possibly linked to WBI, mainly vomiting (n=23). The patients with clinical deterioration (n=49) were irrigated significantly less often (95% confidence interval: 0.13-0.52; p<0.001). After adjustment for sex, age, time to implementation of WBI, type of substance ingested, and admission to intensive care, patients who were treated with WBI were less likely to deteriorate clinically than patients who were not treated with WBI (p<0.001). ConclusionDespite a low rate of completion of this procedure, WBI appeared to provide clinical benefits in patients treated in comparison of an untreated group and is associated with an acceptably low risk of direct complications.

Demography and Mortality of Body Packers; an Extended Experience from a Referral Center.

The incidence of smuggling and illegal transport of substances by internal concealment, also known as body packing, is increasing. The clinical approach to body packers has changed significantly over the past two decades. In addition, the mortality of body packers is an important issue in patient management. The purpose of the current study is to determine the statistics and mortality related to body packing. In this cross-sectional study, all body packer patients who referred to Loghman Hakim hospital were evaluated from 2010 to 2017. Demographic characteristics, findings of clinical imaging, treatment, and outcome of the patients were recorded. The data were analyzed using SPSS version 21. A total of 303 patients were enrolled in the study after the diagnosis of body packing by abdominal CT scanning without contrast. Conservative treatment including whole bowel irrigation (WBI) accompanied by close monitoring was done for 78% (n = 236) of patients; moreover, 26 patients (8.5%) underwent surgery after WBI, and 41 patients (13.5%) underwent surgery without bowel irrigation. Mortality was observed in eight patients (2.7%) five of whom (62.5%) died before surgery and had the clinical manifestation of crystal (methamphetamine) and cannabis toxicity. Furthermore, three patients (37.5%) died due to the complications of surgery such as gastrointestinal leakage of an abdominal abscess. Conservative treatment seems to be better for the management of body packers. In addition, it is necessary to monitor patients for possible signs and symptoms of intoxication and gastrointestinal obstruction.

Iron Tablets or Gallstones? Iron Overdose in Situs Inversus

A 38 year-old male with a history of psychiatric illness and methamphetamine abuse presented to the emergency department (ED) reporting intentionally taking cyclobenzaprine, alprazolam, and iron tablets. He could not provide history regarding exact dosages or time of ingestion. An abdominal x-ray showed multiple radio-opacities in the right upper quadrant. (Panel A) The location and exact nature of these opacities was initially unclear. A chest x-ray suggested situs inversus. (Panel B) The foreign bodies were then found to be iron tablets located in the stomach. Whole bowel irrigation (WBI) with polyethylene glycol was instituted to decontaminate the gastrointestinal tract. Following WBI, the gastrointestinal tract was clear of all radiopaque tablets. (Panel C) The patient had no complications following the procedure and remained stable after the remaining iron tablets were removed.

The Influence of Polyethylene Glycol Solution on the Dissolution Rate of Sustained Release Morphine.

Whole bowel irrigation (WBI) is a management option for overdose of medications poorly adsorbed to activated charcoal, with modified release properties, or for body packers. Polyethylene glycol (PEG) is a mixture of ethylene oxide polymers of varying molecular weight. PEG with an average molecular weight of 3350g/mol is used for WBI. PEG electrolyte lavage solution has been shown in vitro to hasten the dissolution of acetaminophen. The impact of PEG on the pharmacokinetics of extended release pharmaceuticals is unknown. Lower average molecular weight PEG mixtures are used as solvents and excipients. We sought to investigate the impact of PEG on the release of morphine from several extended release morphine formulations. An in vitro gastric model was developed. To test the validity of our model, we first investigated the previously described interaction of ethanol and Avinza®. Once demonstrated, we then investigated the effect of PEG with several extended release morphine formulations. In the validation portion of our study, we confirmed an ethanol Avinza® interaction. Subsequently, we did not observe accelerated release of morphine from Avinza® or generic extended release morphine in the presence of PEG. The use of PEG for gastric decontamination following ingestion of these extended release morphine formulations is unlikely to accelerate morphine release and aggravate intoxication.

Calcium channel antagonist and beta-blocker overdose: antidotes and adjunct therapies.

Management of cardiovascular instability resulting from calcium channel antagonist (CCB) or beta-adrenergic receptor antagonist (BB) poisoning follows similar principles. Significant myocardial depression, bradycardia and hypotension result in both cases. CCBs can also produce vasodilatory shock. Additionally, CCBs, such as verapamil and diltiazem, are commonly ingested in sustained-release formulations. This can also be the case for some BBs. Peak toxicity can be delayed by several hours. Provision of early gastrointestinal decontamination with activated charcoal and whole-bowel irrigation might mitigate this. Treatment of shock requires a multimodal approach to inotropic therapy that can be guided by echocardiographic or invasive haemodynamic assessment of myocardial function. High-dose insulin euglycaemia is commonly recommended as a first-line treatment in these poisonings, to improve myocardial contractility, and should be instituted early when myocardial dysfunction is suspected. Catecholamine infusions are complementary to this therapy for both inotropic and chronotropic support. Catecholamine vasopressors and vasopressin are used in the treatment of vasodilatory shock. Optimizing serum calcium concentration can confer some benefit to improving myocardial function and vascular tone after CCB poisoning. High-dose glucagon infusions have provided moderate chronotropic and inotropic benefits in BB poisoning. Phosphodiesterase inhibitors and levosimendan have positive inotropic effects but also produce peripheral vasodilation, which can limit blood pressure improvement. In cases of severe cardiogenic shock and/or cardiac arrest post-poisoning, extracorporeal cardiac assist devices have resulted in successful recovery. Other treatments used in refractory hypotension include intravenous lipid emulsion for lipophilic CCB and BB poisoning and methylene blue for refractory vasodilatory shock.

Whole-Bowel Irrigation As Adjunctive Treatment For Sustained-release Theophylline Poisoning: A Case Report

Whole-Bowel Irrigation As Adjunctive Treatment For Sustained-release Theophylline Poisoning: A Case Report

Endoscopic Removal of Pharmacobezoar in Case of Intentional Potassium Overdose

BackgroundHyperkalemia is a potentially life-threatening electrolyte abnormality commonly seen in the emergency department (ED). Intentional overdose of potassium supplements is an uncommon occurrence. ObjectiveThis case illustrates a novel approach to treatment of pharmacobezoar with esophagogastroduodenoscopy (EGD) and demonstrates its effectiveness in the setting of extended-release potassium chloride overdose. Case ReportA 44-year-old female presented to the ED with intentional ingestion of an unknown amount of extended-release potassium chloride (K-Dur®) tablets and alprazolam (Xanax®). The patient's serum potassium was initially 7.3 mmol/L and she was treated with standard treatments, including albuterol, calcium gluconate, insulin, dextrose, and sodium bicarbonate. Radiographic investigation showed a pharmacobezoar in the gastric fundus. Treatment was then augmented with whole bowel irrigation (WBI) using polyethylene glycol solution via nasogastric tube. Patient did not tolerate the nasogastric tube, became combative with increasing alteration in her level of consciousness, and WBI therapy was stopped. After discussion with the gastroenterologist, the patient was treated with EGD to remove the pharmacobezoar. The EGD was successful in the removal of the pharmacobezoar and the patient's potassium normalized without complications. ConclusionsWe recommend that in cases of suspected or confirmed potassium drug bezoar in the stomach, physicians consider EGD for removal. This allows for normalization of potassium level while preventing adverse sequelae.

Treatment of foodborne botulism in current clinical toxicology: authors' reply.

Dr. Zamani pointed out the role of the wholebowel irrigation (WBI) with polyethylene gly-col as an appropriate adjunctive option of gas-trointestinal decontamination in severe botu-lism poisoning. Secondly, the author underlinethe early administration of trivalent antitoxinas soon as clinical suspicion of botulism poi-soning is made.[...]

A retrospective review of whole bowel irrigation in pediatric patients

Background. Traditionally whole bowel irrigation (WBI) has been advocated for ingestions involving substances not bound with activated charcoal as well as extended release and enteric coated medications. Other than isolated case reports, little exists in the literature regarding the use of WBI in poisoned pediatric patients. The purpose of this study is to better understand the use of WBI in pediatric patients. Method. A retrospective chart review of California Poison Control System electronic database for human poisoning cases between the years 2000 and 2010 was performed. Results. A total of 176 cases were identified. The most common age of poisoned patients that received WBI was 2 years. There were more pediatric patients who received WBI between 2000 and 2005 then between 2006 and 2010. The top three substances in which WBI was used were calcium channel blockers, iron, and antidepressants. There were 72 cases involving sustained release and delayed release substances. The top five sustained release/delayed release substances were nifedipine, bupropion, verapamil, diltiazem, and felodipine. Adverse drug reactions were noted in 17 patients, vomiting in 16 patients and abdominal pain in one patient. In 36 cases, abdominal radiographs were performed. Sixteen were positive, and in four cases, repeat abdominal radiographs demonstrated a decrease in opacities. Twelve patients had documented pills in their effluent. Conclusion. Transient adverse drug reactions, vomiting and abdominal pain, were associated with WBI. Polyethylene glycol plus electrolyte lavage solution (PEG–ELS) was more frequently administered through the nasogastric tube. Patients who underwent WBI through nasogastric tube received higher doses of PEG–ELS.

The effect of decontamination procedures on the pharmacodynamics of venlafaxine in overdose.

To investigate the relationship between decontamination procedures and seizure events caused by venlafaxine overdose and to estimate the time at which 90% of patients would have had their first seizure in the presence and absence of decontamination. Data were collected from 319 patients who took an overdose of venlafaxine on 436 occasions. Seizures occurred on 24 of 436 occasions (5%). Patients received one of single dose activated charcoal (SDAC), whole bowel irrigation (WBI), a combination of either (SDAC/WBI) or no decontamination. Logistic regression and time to event analysis were used to investigate the influence of dose and decontamination on the probability of seizures and time to 90% (t(90) ) of seizure, respectively. A linear logistic regression model described the data. Simulation from the model showed that the probability of seizure was 0.05 (0.03-0.08), 0.19 (0.09-0.35) and 0.75 (0.30-0.96) at 1000, 5000 and 10 000 mg, respectively (median and 95% credible interval). At the mean dose of 2100 mg the odds ratios (OR) in the presence of SDAC, WBI and SDAC/WBI were 0.48 (0.25-0.89), 0.71 (0.35-1.22) and 0.25 (0.08-0.62), respectively. A modified Gompertz model described the time to seizure events. Simulations from the Gompertz model showed that the t(90) values for first seizure was 26 h and was not affected by dose or decontamination procedure. SDAC/WBI provided greater benefits than the sum of the independent effects of SDAC and WBI. Patients should be observed for at least 24 h for seizures based on the dose and risk of seizure occurring.

Management of Poisonings: Core Curriculum 2010

Management of Poisonings: Core Curriculum 2010

Body Packing: A Case of Intestinal Heroin Transport

A 50-year-old woman ingested 50 pellets of packed heroin for transport. Detained by customs agents in an international airport because of a history of drug trafficking, the patient was brought to the emergency department by law enforcement. Her medical history included a general anxiety disorder treated with diazepam. On physical examination, the patient was alert, coherent, and normotensive, with a normal respiratory rate. Findings on pupillary and abdominal examination were normal. A complete blood cell count and metabolic panel were within normal limits. A urinary toxicology examination was positive for benzodiazepines. Upright abdominal radiography revealed rectangular intracolonic masses. Abdominal computed tomography without contrast revealed numerous pellets in the ascending and transverse colon, with no obstruction or inflammation. The patient was given an electrolyte lavage solution. She showed no signs of sedation, dyspnea, peritonitis, or obstruction. Customs agents collected 49 intact pellets that each contained 12 g of heroin. Repeated imaging confirmed decontamination. On discharge, the patient was taken into federal custody. Body packing is the ingestion or insertion of packed illicit substance for transport. Imaging is essential in diagnosing body packing. Although abdominal radiography and ultrasonography are useful screening tools in airports,1 computed tomography is more effective in the assessment and management of patients.2 Body packers should undergo whole-bowel irrigation to hasten transit time. Heroin packers should receive naloxone hydrochloride if they are sedated or are experiencing respiratory depression. In cases of severe opiate toxicity, patients are at increased risk of acute lung injury, and surgical decontamination should be considered.3

The Effect of Decontamination Procedures on the Pharmacokinetics of Venlafaxine in Overdose

The aim of this work was to investigate the pharmacokinetics (PK) of venlafaxine in overdose and the effects of single-dose activated charcoal (SDAC) and whole-bowel irrigation (WBI), alone or in combination, as methods of decontamination. The data included 339 concentration-time points from 76 venlafaxine overdose events (median dose 2,625 (150-13,500 mg)); 69 were slow-release doses. SDAC, WBI, a combination of both, or no decontamination were administered to patients as decided by the treating clinician. The data were modeled using WinBUGS (Windows Bayesian Inference Using Gibbs Sampling). A one-compartment model with first-order input and elimination provided an adequate description of the data. SDAC increased clearance (CL) of venlafaxine by 35%, and SDAC and WBI combined reduced the fraction absorbed by 29%. However, the latter produced a greater reduction in maximum plasma concentration (C(max)) for a similar drop in area under the plasma concentration-time curve (AUC). Both SDAC alone, and a combination of SDAC and WBI, decreased the AUC after venlafaxine overdose, but the combination may be more beneficial because it reduces peak concentrations to a greater extent.

Mercury ingestion retrieved by colonoscopy

A 48-year-old woman ingested an unknown amount of elemental mercury in a suicide attempt. On presentation, she was noted to have silver-colored droplets encased below her lower teeth, and an abdominal plain film showed speckled radiopaque material throughout the stomach and small intestine (A). Her initial serum mercury level was 239 μg/L (normal 0-60 μg/L). The patient was initially given succimer, a chelating agent, and subsequently received 4 L of polyethylene glycol to facilitate whole-bowel irrigation.

Lithium overdose with electrocardiogram changes suggesting ischemia

Lithium toxicity is associated with electrocardiogram (ECG) changes, but changes suggestive of an ST segment elevation myocardial infarction have not been reported. A 46-year-old incarcerated man suffering from diabetes, hypertension, and schizoaffective/bipolar disorder was treated with lithium 1,200 mg twice daily. Two days prior to presentation the patient became confused, ataxic, and anorexic in jail. Lithium level was 4.69 mmol/L. He was transferred to the emergency department. On arrival, vital signs were normal. The ECG showed a normal sinus rhythm. ST segments were elevated in the anterior leads with downward concavity. T waves were biphasic. Since these changes suggested cardiac ischemia and the patient was unable to respond to questions about chest pain, cardiac enzymes and an emergent echocardiogram were done. Troponin I was less than 0.1 microg/L. Echocardiogram was normal, without wall motion abnormalities. Treatment was with hemodialysis and whole-bowel irrigation. Postdialysis lithium level was 1.30 mmol/L. Over the next several days, electrocardiogram normalized. His speech gradually became coherent. After a 1-week hospitalization, he returned to jail. Lithium intoxication can cause transient ST segment elevations suggesting an acute myocardial infarction. In the absence of a clear history, echocardiogram and cardiac enzymes can be used to rule out a myocardial infarction.

Whole Bowel Irrigation and the Hemodynamically Unstable Calcium Channel Blocker Overdose: Primum Non Nocere

Sustained-release calcium channel blocker (CCB SR) overdoses are potentially life-threatening ingestions. These patients may not become hemodynamically unstable until many hours after ingestion. On theoretical grounds, some have suggested that whole bowel irrigation (WBI) with polyethylene glycol electrolyte lavage solution may be of value in the management of these cases. We report two cases with poor outcome (including one fatality) that were complicated by the use of WBI. Both cases were treated with WBI beginning before and continuing after developing hypotension. WBI should be avoided in the setting of the hemodynamically unstable CCB SR overdose.