Intra-esophageal whitish mass - a challenging diagnosis

Clinical and Forensic Aspects of Pharmacobezoars

BACKGROUND

Pharmacobezoars are specific types of bezoars formed when medicines, such as tablets, suspensions, and/or drug delivery systems, aggregate and may cause death by occluding airways with tenacious material or by eluting drugs resulting in toxic or lethal blood concentrations.

OBJECTIVE

This work aims to fully review the state-of-the-art regarding pathophysiology, diagnosis, treatment, and other relevant clinical and forensic features of pharmacobezoars.

RESULTS

Patients of a wide range of ages and of both sexes present with signs and symptoms of intoxications or more commonly gastrointestinal obstructions. The exact mechanisms of pharmacobezoar formation are unknown but are likely multifactorial. The diagnosis and treatment depend on the gastrointestinal segment affected and should be personalized to the medication and the underlying factor. A good and complete history, physical examination, image tests, upper endoscopy, and surgery through laparotomy of the lower tract are useful for diagnosis and treatment.

CONCLUSION

Pharmacobezoars are rarely seen in clinical and forensic practice. They are related to controlled or immediate-release formulations, liquid, or non-digestible substances, in normal or altered digestive motility/anatomy tract, and in overdoses or therapeutic doses, and should be suspected in the presence of risk factors or patients taking drugs which may form pharmacobezoars.

Activated Charcoal Haemoperfusion in the Treatment of Experimental Amitriptyline Poisoning in Pigs - The Effect on Amitriptyline Plasma Concentration and Haemodynamic Parameters

Coated activated charcoal haemoperfusion (CAC-HP) is a well-known treatment modality. Case reports have revealed conflicting results about the efficacy of CAC-HP in the treatment of amitriptyline (AT) poisoning, and no randomized clinical trials have been identified in the literature. This study aimed at quantifying the efficacy of modern CAC-HP as an adjunctive treatment of AT intoxication compared with standard care alone. Fourteen female Danish landrace pigs were randomized to either standard care or standard care plus 4 hr of CAC-HP. The pigs were anaesthetized, and vital parameters were continuously recorded. Amitriptyline infusion (7.5 mg/kg) was completed in 20 min. Thirty minutes after AT infusion, activated charcoal was instilled orally in both groups. In the intervention group, CAC-HP was initiated 60 min. after AT infusion. Blood and urine samples were collected as were vital parameters at specific time intervals. The protocol was approved by the Danish Experimental Animal Expectorate and complied with the NIH guide for care and use of laboratory animals. Data were managed according to the ARRIVE guidelines. No statistical significant differences between intervention and control groups were found when analysing for differences in AT levels in plasma at any time-point. Furthermore, significant differences between the control and intervention groups in regard to vital parameters could not be found either. In our animal model, the addition of CAC-HP did not improve the clearance of AT compared with standard treatment alone. We suggest that the effect of modern CAC-HP as a treatment modality in AT-poisoned human patients may be inadequate.

[Paediatric pharmacobezoar in vitamin overdose]

BACKGROUND

Pharmacobezoars are aggregates of undigested medications that accumulate in the gastrointestinal tract and can cause obstructive or toxic complications. In this paper, the first case is reported of a paediatric pharmacobezoar formation after a vitamin overdose. The objective of this report is to prevent the occurrence of this complication and the action to be taken.

CLINIC CASE

A 6-year-old child, 6h after ingesting 40 chewable tablets of a hydrophobic vitamin E with high capacity to form a pharmacobezoar, underwent urgent oesophagogastroscopy. A viscoelastic mass of 10×4cm was observed stretching from the cardia to the greater curvature. Seventy-five percent of the mass was removed and the remainder was fragmented, hydrated and aspirated. The patient remains asymptomatic to date.

CONCLUSIONS

An overdose of hydrophobic drugs can produce a bezoar formation therefore prompt evacuation is recommended with an upper gastrointestinal endoscopy, which is a safe and effective technique in gastric bezoars.