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Image challenge: Bowel preparation agent-associated complication

A 66-year-old man was referred for gastrointestinal bleeding after a negative upper endoscopy. He underwent a colonoscopy with bowel preparation using sodium picosulfate/magnesium citrate (SPMC).

Clinical Gastroenterology and Hepatology (CGH) Image of the Month: The patient reported having chest discomfort after taking the first dose of SPMC. The colonoscopy suggested small-bowel bleeding and an enteroscopy was performed. Mucosal necrosis of the middle to lower esophagus (figure A) and linear erythema in the proximal stomach (figure B) was found during enteroscopy.

Based on the history, the patient had ingested the SPMC powder without dissolving it in water as per the manufacturer’s recommendations and acute mucosal injury caused by SPMC occurred. The patient received supportive care and a subsequent endoscopy showed healing of the mucosal injury without luminal stenosis.

SPMC is a low-volume bowel cleansing agent that is pleasant to taste and improves patient compliance. When SPMC is dissolved in water, an exothermic reaction occurs with a temperature increase to 68° C. Esophageal or gastric injury is a rare serious complication after inadvertently taking this agent. Treatment of esophageal thermal injury is conservative with hydration and fasting, and the prognosis usually is good. No esophageal stricture or perforation was reported.

This case was featured in this month’s CGH.

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