0016-5107/92/3805-0575$03.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1992 by the American Society for Gastrointestinal Endoscopy

Serum electrolyte, mineral, and blood pH changes after phosphate enema, water enema, and electrolyte lavage solution enema for flexible sigmoidoscopy Charles F. Cohan, DO Shailesh C. Kadakia, MD Ami S. Kadakia, MD San Antonio, Texas

Hypertonic sodium phosphate (Fleet®) enema is a commonly used preparation for fiberoptic flexible sigmoidoscopy. Unfortunately, Fleet® has been associated with complications in children and adults. The purpose of this study was to compare the serum electrolytes, mineral, and blood pH changes before and after the administration of Fleet® with water and polyethylene glycol electrolyte lavage solution (Golytely®) as enemas in an adult population undergoing flexible sigmoidoscopy. Sixty-six patients were randomized in a double-blind fashion to receive two enemas of either Fleet(8) (N = 22), water (N = 20), or Golytely® (N = 24). The cleansing ability was graded from 1 to 4 (1 poor, 4 excellent). The Fleet(8) had significantly better optimal cleansing efficacy compared with water (p < 0.05) but not to Golytely(8) (p > 0.05). There was a significant increase in the serum phosphorus in the Fleet(8) group compared with water (p < 0.001) or Golytely® (p < 0.001). However, absolute serum phosphorus values after Fleet® enema always remained within normal range in all but one patient. The changes in other electrolytes, minerals, and venous pH were insignificant. (Gastrointest Endosc 1992;38:575-578)

=

Fleet® (C. B. Fleet Co., Lynchburg, Va.) enema containing hypertonic sodium phosphate solution is commonly recommended as a cleansing preparation for fiberoptic flexible sigmoidoscopy (FFS).l It is also used, although very cautiously recommended, for treatment of constipation and fecal impaction. 2 In general, it is a safe and effective bowel cleansing enema in patients undergoing FFS. Unfortunately, Fleet® enema or its oral ingestion as a laxative can cause fluid and serum electrolyte and mineral complications manifested by tetany,3-11 coma/ 2-15 shock/ 6 cardiac arrest,17 and death. 18,19 Most complications occur in infants and children,3-7, 11-18,20-22 but have also Received January 9, 1992. For revision February 10, 1992. Accepted April 2, 1992. From the Department of Medicine, Gastroenterology Service, Brooke Army Medical Center, San Antonio, Texas. Reprint requests: Ltc Shailesh C. Kadakia, Department of Medicine, Gastroenterology Service, Brooke Army Medical Center, Ft. Houston, Texas 782346200. The opinions and assertions herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Army or the Department of Defense. VOLUME 38, NO.5, 1992

=

been reported in adults after Fleet® enema,8, 9, 23 and after oral ingestion of Fleet® solution. 10, 19 Schuchmann and Barcia24 evaluated phosphorus absorption from Fleet® enemas in adults undergoing proctoscopy in an outpatient setting. They noted a significant increase in serum phosphate after Fleet® enemas with a decrease in venous pH. We were prompted to initiate this study in light of this relevant information, as well as reported complications in the literature, and our own familiarity with a pediatric death from Fleet® enema administration at our institution. The aim of our randomized double-blind trial was to compare the changes in serum electrolytes, blood urea nitrogen, creatinine, calcium, phosphorus, and blood pH after Fleet® enema, water enema, and polyethylene glycol electrolyte lavage solution (Golytely®) enema in patients undergoing FFS. PATIENTS AND METHODS

Patients were evaluated in the Gastroenterology Service of Brooke Army Medical Center. FFSs were performed using a 60-cm length Olympus P-20S (Olympus Corporation of 575

America, Lake Success, N. Y) sigmoidoscope. Patients were excluded if (1) they had FFS without prior enemas (unprepped examinations), (2) they routinely used enemas for constipation, (3) they preferred to use enemas at home prior to FFS, and (4) they took stool softeners for constipation. The study was approved by the Clinical Investigation Service and the Institutional Review Board of Brooke Army Medical Center. Informed consents were obtained. Patients were randomized using a computer-generated randomization schedule to receive either Fleet® enema, water enema, or Golytely(ii) enema. Patients and investigators were blinded to the type of the enema used. The adult-sized Fleet") enema bottles containing 133 ml of hypertonic sodium phosphate solution were obtained from C. B. Fleet Company, Lynchburg, Virginia, who also provided the identical empty plastic bottles. The empty bottles were then filled with 133 ml of tap water or Golytely@ (Braintree Laboratories Inc., Braintree, Mass.) solutions and stored at room temperature. The patients arrived in the clinic approximately 45 to 60 min prior to the FFS. Soon after their arrival, blood was drawn and carried immediately to the laboratory for measurement of serum sodium, potassium, chloride, bicarbonate, calcium, phosphorus, blood urea nitrogen, and creatinine. Venous blood was obtained in a heparinized syringe and transported immediately, in ice, for determination of pH. Two enemas were administered by the patients as instructed. The first enema was administered within 5 min of pre-enema blood collection. It was retained for 10 min and then evacuated. The second enema was administered immediately after the evacuation of the first enema. It also was retained for 10 min and then evacuated. Blood was collected for the above-mentioned laboratory studies within 5 min after the evacuation of the second enema. The laboratory values for each of these measurements obtained after the enema (post-enema) was administered were subtracted from the values obtained before the enema (pre-enema) was determined to determine the change which is referred to as "delta." Fiberoptic flexible sigmoidoscopy was then performed by two ofthe three authors (S. C. K. and C. 0.). The endoscope was advanced as far as possible depending on patient tolerance while the distance of insertion and the time to complete the examination was noted. The adequacy of preparation was visually graded as described by DiPalma et al.: 25 1 (poor)-large amount of fecal residue; 2 (fair)-enough feces to prevent a completely reliable examination; 3 (good)small accumulation of feces not interfering with a thorough examination; and 4 (excellent)-absent to no more then small bits of adherent feces. Grade 1 was unacceptable requiring repeat examination. Grades 2 to 4 were acceptable, grades 3 and 4, optimal. Physician assessment of acceptable and optimal FFS grades was analyzed by the Fischer's exact test. One-way analysis of variance was used to compare changes in laboratory parameters. Newman-Keuls post hoc analysis was used to determine specific significant differences between means. The results are expressed as mean ± SE, and p values of

Serum electrolyte, mineral, and blood pH changes after phosphate enema, water enema, and electrolyte lavage solution enema for flexible sigmoidoscopy.

Hypertonic sodium phosphate (Fleet) enema is a commonly used preparation for fiberoptic flexible sigmoidoscopy. Unfortunately, Fleet has been associat...
451KB Sizes 0 Downloads 0 Views