Portal de Periódicos da CAPES

Colorectal ulcers associated with sodium phosphate catharsis

1995; Elsevier BV; Volume: 42; Issue: 1 Linguagem: Inglês

10.1016/s0016-5107(95)70260-1

1097-6779

Lee J. Hixson,

Mycobacterium research and diagnosis

Sodium phosphate solution has gained popularity as an effective oral colonic cleansing preparation because of recent studies demonstrating better patient acceptance, superior or comparable bowel cleansing result, and reduced cost compared with polyethylene glycol lavage.1Vanner SJ MacDonald PH Paterson WG Prentice RSA Da Costa LR Beck IT A randomized prospective trial comparing oral sodium phosphate with standard polyethylene glycol-based lavage solution (Golytely) in the preparation of patients for colonoscopy.Am J Gastroenterol. 1990; 85: 422-427PubMed Google Scholar, 2Kolts BE Lyles WE Achem SR Burton L Geller AJ MacMath T A comparison of the effectiveness and patient tolerance of oral sodium phosphate, castor oil, and standard electrolyte lavage for colonoscopy or sigmoidoscopy preparation.Am J Gastroenterol. 1993; 88: 1218-1223PubMed Google Scholar, 3Marshall JB Pineda JJ Barthel JS King PD Prospective, randomized trial comparing sodium phosphate solution with polyethylene glycol-electrolyte lavage for colonoscopy preparation.Gastrointest Endosc. 1993; 39: 631-634Abstract Full Text PDF PubMed Scopus (194) Google Scholar After recently switching from polyethylene glycol lavage to a sodium phosphate preparation (Fleet Phospho-Soda) for most colonic examinations, I began noticing small (1 to 3 mm) aphthous ulcers with an erythematous halo in occasional patients (Fig. 1 ) and was perplexed as to their pathogenesis. In patients complaining of chronic diarrhea, I initially assumed that the lesions were perhaps secondary to early Crohn's disease, an unsuspected infectious process, nonsteroidal anti-inflammatory drugs (NSAIDS), or resolving mucosal ischemia. However, mucosal biopsies typically demonstrated only edema within the lamina propria with extravasation of red blood cells, and focal superficial mucosal disruption, often centered over lymphoid aggregates; inflammatory cell infiltration was minimal and gland architecture intact. I also noted the lesions in patients without any history suggestive of an inflammatory process (e.g., patients with a past history of colon polyps or rectal bleeding without diarrhea) and recently suspected the ulcers might be secondary to the sodium phosphate prep. Supportive evidence was particularly apparent in two patients: one patient underwent flexible sigmoidoscopy after magnesium citrate preparation and the mucosa was normal except for a benign polyp. She was subsequently prepped with sodium phosphate 2 weeks later for colonoscopy and at that time demonstrated punctate ulcers in the sigmoid colon; another patient demonstrated the ulcers from the transverse colon to the sigmoid colon at colonoscopy but had normal mucosa 4 months later at flexible sigmoidoscopy after magnesium citrate preparation. I have retrospectively identified 17 cases with aphthous ulcers that I believe are secondary to sodium phosphate catharsis. The lesions are predominantly located in the distal sigmoid and rectum with a few individuals demonstrating subtle cecal ulcers. The age range of these patients is 26 to 84 years and 7 were taking various doses of aspirin or other NSAIDs. Eight of the 17 individuals complained of intermittent or chronic diarrhea. However, none of these patients had clinical features which otherwise suggested inflammatory bowel disease. No mention of colorectal ulceration is made in three recent prospective randomized trials comparing sodium phosphate with polyethylene glycol lavage.1Vanner SJ MacDonald PH Paterson WG Prentice RSA Da Costa LR Beck IT A randomized prospective trial comparing oral sodium phosphate with standard polyethylene glycol-based lavage solution (Golytely) in the preparation of patients for colonoscopy.Am J Gastroenterol. 1990; 85: 422-427PubMed Google Scholar, 2Kolts BE Lyles WE Achem SR Burton L Geller AJ MacMath T A comparison of the effectiveness and patient tolerance of oral sodium phosphate, castor oil, and standard electrolyte lavage for colonoscopy or sigmoidoscopy preparation.Am J Gastroenterol. 1993; 88: 1218-1223PubMed Google Scholar, 3Marshall JB Pineda JJ Barthel JS King PD Prospective, randomized trial comparing sodium phosphate solution with polyethylene glycol-electrolyte lavage for colonoscopy preparation.Gastrointest Endosc. 1993; 39: 631-634Abstract Full Text PDF PubMed Scopus (194) Google Scholar In the study conducted by Vanner et al.,1Vanner SJ MacDonald PH Paterson WG Prentice RSA Da Costa LR Beck IT A randomized prospective trial comparing oral sodium phosphate with standard polyethylene glycol-based lavage solution (Golytely) in the preparation of patients for colonoscopy.Am J Gastroenterol. 1990; 85: 422-427PubMed Google Scholar mucosal biopsies were taken adjacent to resected polyp specimens in a small sample of patients prepped with sodium phosphate; the only apparent alteration was minimal depletion of goblet cells in a few patients. However, Meisel et al.4Meisel JL Bergman D Graney D Saunders DR Rubin CE Human rectal mucosa: proctoscopic and morphological changes caused by laxatives.Gastroenterology. 1977; 72: 1274-1279Abstract Full Text PDF PubMed Scopus (118) Google Scholar reported that administration of sodium phosphate enemas uniformly induced proctoscopic changes of rectal mucosal hyperemia and obliteration of the vascular pattern, with histologic disruption of the surface epithelium in most biopsy specimens. The proctoscopic changes resolved within 7 days after enema administration. In contrast, polyethylene glycol lavage (Golytely) was reported in another study to preserve normal colonic mucosal histology.5Pockros PJ Foroozan P Golytely lavage versus a standard colonoscopy preparation.Gastroenterology. 1985; 88: 545-548PubMed Google Scholar Bowel preparation-induced macroscopic ulceration would undoubtedly increase the chance of misdiagnosis and inappropriate therapy in clinical practice. A prospective, randomized, investigator blinded study with follow-up endoscopy in affected patients would confirm whether sodium phosphate catharsis induces colorectal ulceration compared with polyethylene glycol lavage.