대한응급의학회지 제 27 권 제 5 호 � 증례� Volume 27, Number 5, October, 2016

Toxicology A Case of Upper Airway and Esophageal Injury after Ingestion of Sodium Picosulfate and Magnesium Citrate for Colonoscopy

Song Yi Park, M.D.

Department of Emergency Medicine, Inje University Haeundae Paik Hospital, Busan, Korea

Sodium picosulfate and magnesium citrate are widely used low volume bowel cleansing agents considered to be effec- tive and relatively safe. We describe a case of a woman who presented with an upper airway and esophageal injury after ingestion of a sodium picofulfate and magnesium citrate. A 63-year-old woman presented to emergency department complaining of throat pain and hoarseness after ingestion of sodium picosulfate and magnesium citrate as preparation for colonoscopy. This powder is dissolved in a low volume of water. She had ingested the substance that was not completely dissolved. After ingestion, she experienced a burning sensation in the throat. Promptly, neck radiography and computed tomography (CT) were performed. Radiography revealed epiglottis swelling and narrowing airway. Computed tomogra- phy demonstrated diffuse soft tissue edema and thickening with increased enhancement in the upper airway and entire esophagus. She was admitted and treated with parenteral nutrition, intravenous proton pump inhibitor, empirical antibi- otics, and steroids. Nine days after the admission, she underwent an esophagogastroduodenoscopy (EGD). Esophageal multiple ulcerative lesions with exudate were observed. Twelve days after admission, she was discharged from the hospi- tal with improvement of pain in her throat and toleration to a solid diet.

Key Words: Caustics, Esophagitis, Picosulfate sodium

volume and the unpleasant taste are the major disadvan- Introduction tages of this solution. Sodium phosphate is a saline laxa- tive administered in two doses of 45 mL diluted in 250 Colonoscopy is the method of choice to evaluate mL water each. It is non-absorbable osmotic substances colonic mucosa and the distal ileum, and play an impor- that attract and retain water in the intestinal lumen, tant role in diagnosis and treatment. Its successful imple- increasing intraluminal pressure that mechanically stim- mentation depends on many factors, but colon cleansing ulates evacuation of the bowel. Examples are magnesium is a key factor. There are several types of bowel cleans- citrate, magnesium hydroxide and magnesium sulfate. ing agents but the most commonly used agents are high Both laxative can lead to significant adverse effects like volume polyethylene glycol (PEG) electrolyte solution dehydration, hypotension, acid-base and electrolyte and sodium phosphate1). PEG electrolyte solution con- imbalance. Other significant adverse effects include sists of an isotonic oral, non-digestible and non- rhabdomyolysis, renal failure2). Usually this adverse absorbable solution. It is a hyperosmotic agent that caus- effects result in loss of water and electrolytes. Here, we es the intestines to hold more water within and create an report the case of corrosive and thermal upper airway osmotic effect that stimulates a bowel movement. and esophageal injury due to the ingestion of Sodium Examples are glycerin, sorbitol, lactulose. Typically, 4 L picosulfate and magnesium citrate (Picolight Powder, of PEG electrolyte solution is administered. The high Pharmbio Korea Co., Seoul, Korea).

책임저자: 박 송 이 부산광역시 해운대구 해운대로 875 인제대학교 해운대백병원 응급의학과 Tel: 051-797-0172, Fax: 051-797-0034, E-mail: [email protected] 접수일: 2016년 5월 3일, 1차 교정일: 2016년 5월 4일, 게재승인일: 2016년 8월 12일

492 Picolight Ingestion Injury / 493

found to have mild edema and whitish color change in Case Report oropharyngeal mucosa without stridor. Laboratory test- ing showed leukocytosis (white blood cell 19,240/mm3) A 63-year-old woman presented to the emergency and other results, including coagulation and electrolytes, department with throat pain, after ingestion of sodium were within normal limits. A neck radiography revealed picosulfate and magnesium citrate prescribed by her epiglottis swelling and narrowing of the airways (Fig. 1). physician for colonoscopy. At initial presentation, she Computed tomographic scans of the neck and chest complained only of throat pain and foreign body sensa- demonstrated diffuse soft tissue edema and thickening, tion. On visual examination of the throat, there were no with increased enhancement in the oropharynx, abnormal signs on her oropharynx and she was stable. hypopharynx and supraglottis of the larynx, including Accordingly she was discharged without patient depart- epiglottis and severe swelling with deep ulceration in the ment arrangement; however, one hour later, she reported entire esophagus (Fig. 2). She was hospitalized and on to the emergency department complaining of aggravated the following day, a diffuse esophageal wall edema with- throat pain and hoarseness without respiratory discom- out contrast leakage or passage disturbance was identi- fort. She failed to mix sodium picosulfate/magnesium fied by esophagography using gastrografin (Fig. 3). citrate power with 200 ml of water as instructed on the During her hospital stay, she was treated with conserva- product directions. She mixed it with only one spoon of water. She had ingested powder that was not completely dissolved in water. During ingestion, she experienced an immediate burning sensation in her oropharynx. Initial vital signs were as follows: blood pressure 155/78 mmHg, heart rate 109 beats/min, respiratory rate 20 breaths/min, temperature, 36.5�C, and pulse oximetry 98% in room air. Upon physical examination, she was

Fig. 2. Computed tomography scan showing diffuse soft tis- sue edema and thickening with increased enhance- ment in the oropharynx, hypopharynx and supraglot- Fig. 1. Neck radiography showing epiglottis swelling and tis of larynx including epiglottis and severe swelling narrowing airway (white arrow). with deep ulceration in the entire esophagus. 494 / Song Yi Park

tive methods, including parenteral nutrition, an intra- venous proton pump inhibitor, empirical antibiotics and steroids. Four days after admission, she started to take sips of water. She was stable, except for tolerable throat pain. Nine days after admission, she underwent an esophagogastroduodenoscopy (Fig. 4). It demonstrated that the whole esophagus was covered with exudate and multiple ulcerative lesions as well as the mucosal edema and inflammation, without definite esophageal structure. It was impossible to proceed to the stomach due to esophageal vulnerability. Twelve days after admission, she tolerated a solid diet and was discharged with no acute complications.

Discussion

PICOLIGHT is dispensed in powder form (Sodium picosulfate 0.01 g, magnesium oxide 3.5 g, citric acid 12.0 g per sachet), with the magnesium oxide and citric acid components forming magnesium citrate when the Fig. 3. Gastrografin esophagography showing diffuse powder is dissolved in water. Sodium picosulfate is a esophageal wall edema without contrast leakage or prodrug. It is metabolized by gut bacteria into the active passage disturbance. compound 4,4’-dihydroxydiphenyl-(2-pyridiyl)-methane

Fig. 4. Esophagogastroduodenoscopy showing whole esophagus was covered with exudate and multiple ulcerative lesion along by mucosal edema and inflammation without definite esophageal stricture. Picolight Ingestion Injury / 495

(DPM, BPHM). This compound is a stimulant laxative volume of water is inappropriately ingested8). Although that improves bowel peristalsis and increases bowel corrosive ingestion injury is well described in the litera- mucosal secretions3). It is known to be highly efficient ture, emergency physicians should be aware of this and a relatively safe medication for colon cleansing prior potential thermal injury. Furthermore, if there is no sig- to colonoscopy4). However, this laxative is known to nificant abnormal sign at initial presentation, the patient induce some adverse effects. The most common side must stay in the emergency department for observation effects are abdominal cramps and diarrhea. It also has and serial examinations. Moreover, emphasis should be been associated with rhabdomyolysis and electrolyte made to dissolve the sodium picosulfate and magnesium imbalance, such as hyponatremia5). Once sodium pico- citrate powder in an adequate volume of water (at least sulfate is dissolved in water, it is acidic and releases 200 mL of water) before ingestion by the prescribing hydrogen ions by hydrolysis. To prevent the possibility physician. of esophageal injury, ingestion of this powder with at least 200 ml volume of water is strongly recommended. Dissolving it in a low volume of water results in a more References acidic liquid, possibly leading to corrosive esophageal injury6). Magnesium citrate is used as an osmotic laxa- 01. Parra-Blanco A, Ruiz A, Alvarez-Lobos M, Amoros A, tive. It works by attracting water through the bowel tis- Gana JC, Ibanez P, et al. Achieving the best bowel prepa- sues by osmosis and induces defecation. Magnesium cit- ration for colonoscopy. World J Gastroenterol. 2014;20:17709-26. rate should always be followed with a full glass of water 02. Nyberg C, Hendel J, Nielsen OH. The safety of osmotical- to help it absorb properly and prevent complications4). ly acting cathartics in colonic cleansing. Nat Rev Caustic ingestion can cause severe injury to the esoph- Gastroenterol Hepatol. 2010;7:557-64. agus and the stomach. Both alkaline and acidic sub- 03. Hoy SM, Scott LJ, Wagstaff AJ. Sodium picosulfate/mag- stances can induce corrosive esophagitis. However, the nesium citrate: a review of its use as a colorectal cleanser. effect of these two types of agents is explained by differ- Drugs. 2009;69:123-36. ent pathophysiology. Ingestion of alkali results in a pen- 04. Janisch HD, Koppold B, Deissler H, Riemann JF. etrating injury, called liquefactive necrosis. It extends Observational multicentric study to evaluate efficacy, rapidly through the mucosa and wall of the esophagus, adverse effects and acceptance of bowel cleansing prior to characterized by erythema and ulceration with 24 hours. colonoscopy with sodium picosulfate / magnesium citrate formulation CitraFleet. Z Gastroenterol. 2016;54:19-25. The process lasts three to four days and is associated 05. Mas A, Chillaron JJ, Esteve E, Navalpotro I, Supervia A. with vascular thrombosis and mucosal inflammation Severe rhabdomyolysis and hyponatremia induced by resulting in ulceration. In the stomach, partial neutraliza- picosulfate and bisacodyl during the preparation of tion of the ingested alkali by gastric acid may limit colonoscopy. Rev Esp Enferm Dig. 2013;105:180-1. 7) injury . Acid ingestion produces a superficial coagula- 06. Ramasamy K, Gumaste VV. Corrosive ingestion in adults. tion necrosis with eschar formation, which may limit tis- J Clin Gastroenterol. 2003;37:119-24. sue penetration7). 07. Zargar SA, Kochhar R, Nagi B, Mehta S, Mehta SK. Sodium picosulfate and magnesium citrate is a low Ingestion of strong corrosive alkalis: spectrum of injury to volume bowel cleansing agent that has been used, wide- upper gastrointestinal tract and natural history. Am J ly. It is generally well tolerated and considered pleasant Gastroenterol. 1992;87:337-41. 08. Suh JP, Choi YS, Lee SH. Education and Imaging. to taste. However, inadvertent consumption of sodium Gastroenterology: acute mucosal injury of esophagus and picosulfate and magnesium citrate is considered as a stomach induced by sodium picosulfate/magnesium citrate cause of, not only corrosive injury, but also thermal for bowel preparation. J Gastroenterol Hepatol. 2014;29: injury. Heat can be generated when a mixture of sodium 1571. picosulfate and magnesium citrate powder with a small