J. Coloproctol. (Rio J.) vol.36 número2

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jcoloproctol(rioj).2016;36(2):119–121

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Case

Report

Absence

seizure

associated

with

coloprep

consumption

in

colonoscopy

Abin

Chandrakumar

∗

_,

_Pretty

_Geevarghese

_Tharakan,

_Bittu

_Thomas,

Anu

Albert,

Teena

Jacob

DepartmentofClinicalPharmacy,KIMSHospital,Thiruvananthapuram,India

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Articlehistory:

Received20October2015 Accepted6December2015 Availableonline19March2016

Keywords: Adversereaction Seizure

Purgative Hyponatremia Sodiumphosphate

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Coloprepisabowelpreparatorysolutiongivenbeforeendoscopicprocedurestogeta unob-scuredinternalvision.Ithasamongitsconstituents’sodiumsulphate,potassiumsulphate andmagnesiumsulphatewhichproduceanosmoticeffectinthebowel.However,theuse ofsuchagentsinhyponatremicandpatientspredisposedtoseizurescanhaveadverse ramifications.Thecurrentcaseoutlinesmanifestationofabsenceseizureina52-year-old malepatientwhowasadministeredColoprepforcolonoscopy.Therewasabsenceofother predisposingfactorsandthesymptomswereamelioratedusingtimelyidentificationand rectificationoftheunderlyingderangements.

Convulsão

de

ausência

com

o

uso

de

Coloprep

em

colonoscopia

Palavras-chave: Reac¸ãoadversa Convulsão Purgante Hiponatremia Fosfatodesódio

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Coloprep é uma solução preparatória intestinal administrada antes de procedimentos endoscópicos,comoobjetivodeseterumavisãointernanãoobscurecida.Entreos consti-tuintesdeColoprep,observa-sesulfatodesódio,sulfatodepotássioesulfatodemagnésio, queprovocamefeitoosmóticonointestino.Masousodetaisagentesempacientes hipona-trêmicosecompredisposiçãoparaconvulsõespodeterramificaçõesadversas.Ocasoem teladelineiaumamanifestaçãodeconvulsãodeausênciaempacientedogêneromasculino com52anosequerecebeuColoprepparacolonoscopia.Nãohaviaoutrosfatores predispo-nenteseossintomasmelhoraramgraçasàoportunaidentificaçãoecorreçãodostranstornos subjacentes.

∗ _{Corresponding}_author.

E-mail:abinchandrakumar@gmail.com(A.Chandrakumar).

http://dx.doi.org/10.1016/j.jcol.2015.12.007

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120 Introduction

Absence seizure also known as petit mal seizure belongs to the group of non-convulsive status epilepticus and is characterizedin EEG bybilateral synchronized spikes with wavecomplexbursts.Itshallmarkfeaturesinclude sudden-onsetimpairmentofconsciousness,blankstare,upwardgaze, frozenmovementsandabruptspeechdraught.1_Unlike_other

seizures, it does not have post-dromal disorientation and lethargy.Althoughhyponatremiaisararecausativefactorof absenceseizure,itisnotunheardofandcanbeprecipitated duetoexcesssodiumlossorasaresultofpolydipsia.The ther-apymainlyinvolvesadministrationofnormalsalinesolution tocorrecttheimbalanceandsinceinitiallythecausationis unknown,abenzodiazepineagentcanbeusedtosubduethe episodesbeforemovingtowardsfurtherwork-upontheissue. ColoprepTM _is_a_bowel_preparatory_solution_used_prior_to endoscopicandsurgicalprocedureswhichnecessitateaclean bowel.Itiscomposedofsodiumsulphate17.5g,potassium sulphate 1.6g and magnesium sulphate 3.13g/177mL and produceswaterybowelstoolsthroughitsosmoticeffect.The modality,althoughextremelycommonisnotwithout risks andhasseriouspotentialtoinduceelectrolyteabnormalities whichmayfurtherpropagateintoseizures.

Case

history

A52-year-oldmalepatientpresentedtotheinternalmedicine departmentofasuper-specialityhospitalinKeralawith com-plaintsofanorexia,tirednessandconstipationsince3weeks. The patient was conscious and alert with the vitals nor-malexceptformildelevationsinbloodpressure(140/85mm Hg)and temperature(99◦_F)._The_patient_had _been _on

anti-hypertensivetherapywithLisinopril5mgsince3yearsand priorhistoryofinterstitiallungdiseaseaswellasgallstones. Thepatientexpressedconcernsoverlossof5kginthepast 2weeksand afterexamination,the physicianordered liver function test (LFT), blood routine examination, differential leukocytecountandserumelectrolyteconcentrations.Blood and electrolyte investigations divulged elevations in total leukocyte (15000cells/mm3_), _differential _lymphocyte _(39%) andserumpotassium(5.4mmol/L)TheLFTresultsrevealed elevationsinALP(223IU/L)andgamma-glutamyltransferase (149U/L)whichsuggestedapossibilityofcholestasisandthe patient was admitted for further evaluation. Therapy was started with paracetamol, multivitamin & mineral supple-mentandcalciumgluconate.Thephysicianaftermeticulous contemplation,decidedtoperformanoesophago-gastro duo-denoscopy(OGD)coupledwithmagneticresonance cholan-giopancreatography(MRCP)andcolonoscopyuptoileumto ruleoutpossibilitiesofmalignanciesandexploreforpossible gallstoneobstructions.Thepatientclearedthecardiac, pul-monology andneurologydepartments riskevaluationsand gotagreenflagforendoscopicexamination.Aspreparation fortheprocedure,patientwasadvisedtointake2bottlesof ColoprepTM _composed_of_sodium_sulphate_17.5_g,_potassium sulphate 1.6gand magnesium sulphate 3.13g/177mL. The advicewastointake1stbottlealongwith1Lofwateronthe

nightbeforeandthenextbottle,onthemorningofthe pro-cedureday.However,duringtheperiodofintakeofthefirst bottles,thepatientcontractedbriefepisodesoflossof con-sciousness and orientation characterized by unresponsive-nessdespitehiseyesstaringwideopen.Therewerealso symp-tomsofbradykinesiauponregainingconsciousness,decrease inspeechandconfusion.Thepatientwasimmediatelyshifted tothe intensivecareunitand wasorderedforserum elec-trolyte levels and electroencephalogram. The EEG showed revealed bilateralspikeandslowwavecomplexeswhereas, theserumsodiumlevelwasfoundtobeonthelowersidewith valueof128mmol/L.Thepatientwasstableaftershiftingto ICUwherehewasadministered1500mLnormalsaline infu-sionand5mgdiazepam.Thecausalityassessmentwasdone usingNaranjoalgorithmwitharesultingscoreof5indicating towardsaprobableassociationbetweenthedrugandreaction. Afterstabilizationofthepatient,colonoscopywasperformed withoutfurthercolorectalevacuationandMRCPrevealedgall stonesforwhichfurthertherapywasinitiated.

Discussion

Thesignsofreactionindicatedtowardssymptomsofabsence seizure andwasfurthercementedbytheEEG reading.The patientwasevaluatedtohavenootherriskfactorsor recur-rence ofseizure episodesindicating a strong linkbetween thedrugandreaction.Althoughveryfewcasereportshave emerged regarding bowel cleansing medications induced seizureepisodes,theyallconcuronthemechanismthrough which seizures are induced and the current case is not dissimilar.2,3 _The_serum_electrolyte_disturbance_with

potas-sium was evident on the initial day which was rectified usingcalcium gluconate;however,thesodiumlevelswhich were normal on the first day was found to have declined to a hyponatremic level in the post-seizure phase. How-ever, there wasno electrolytemonitoring done onthe day of administration of ColoprepTM _which _obscures _the _fact whetherhyponatremiawasalreadypresentandpotentiated orwhethertherewasanexclusiveinduction.Electrolyte dis-turbances hasbeen clearlystated asacontraindicationfor the useofcombination ofsodiumsulphate,potassium sul-phateandmagnesiumsulphateinlightsofitspotentialfor precipitatingseizureepisodes.4,5

Althoughinternationalleagueagainstepilepsy(ILAE) com-missiononepidemiologyrecognizedlackcomprehensivedata onthecausaleffectrelationshipsbetweenmetabolic derange-ments and seizure, it has laid down arbitrary limits for disturbances such as hyponatremia and risk of seizure.6

Serum sodium level below 125mmol/L is regarded as a potentialriskfactorfordevelopmentofseizureinpatients, especially those with underlying seizure risk. When there ishyponatremia,acerebralprotectivemechanismsets into motionthroughactiveextrusionofelectrolytesand organic osmolytes.However,whenthisprotectivemechanismis over-whelmedduetootherpredisposingfactorssuchashypoxia, itcanculminateincerebraledemawhichmanifestsas refrac-toryseizures.7

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121

individualizedmonitoringcanbeprovidedround theclock. Initially,adifferentialdiagnosisshouldbeconsideredandthe treatmentcanbeprovidedwithanaimtoestablishpatient sta-bility.Differentreasonsshouldbeconsideredsuchaschance ofhypotensivesyncopeandotherreasonsforsodium deple-tioninthepatient.Causalityassessmentcanbeutilizedasan integralpartoftherootcauseanalysistoprovideamore com-prehensiveinterpretation.Normalsalineinfusion,either1000 to1500mLwillusuallybesufficienttoreplenishtheelectrolyte abnormalitiesinthesepatientsandpreventfurther deterio-rationofthepatientstatus.Thepatientcanbeimmediately givenabenzodiazepineagentsuchasdiazepamatlowdose tosubduetheseizureepisodeandpreventfurtheradversities. Eachpatientwhoisbeinggivensuchbowelcleansing solu-tionsmustbecarefullyanalyzedforcontraindicationssuch aselectrolyteabnormalitiesandotherpotentialpredisposing factorsforseizurebeforeinitiationoftheregimen.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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2.MackeyAC,ShafferD,PrizantR.Seizureassociatedwiththe useofvisicolforcolonoscopy.NEnglJMed.2002;346: 2095.

3.AzumaH,AkechiT,FurukawaTA.Absencestatusassociated withfocalactivityandpolydipsia-inducedhyponatremia. NeuropsychiatrDisTreat.2008;4(2):495–8.

4.LexicompOnline®_,_Lexi-Drugs®_._Hudson,_OH:_Lexi-Comp,_Inc.;

2015.January29.

5.HalawaI,AnderssonT,TomsonT.Hyponatremiaandriskof seizures:aretrospectivecross-sectionalstudy.Epilepsia. 2011;52(2):410–3.

6.BeghiE,CarpioA,ForsgrenL,HesdorfferDC,MalmgrenK, SanderJW,etal.Recommendationforadefinitionofacute symptomaticseizure.Epilepsia.2010;51:671–9.