Introduction: Hydrogel capsules are FDA-approved superabsorbent agents used for weight loss. Typically, 3 capsules are swallowed with water before eating. When in contact with water, the particles inside the capsules expand a hundredfold into an elastic gel-like structure that creates a satiated feeling in the user and promotes fullness. The capsular contents are not absorbed into the bloodstream. The most common side effects are bloating, flatulence, and abdominal pain (1-2). In this case, we discuss a patient who experienced dysphagia from pill impaction in the esophagus. Case Description/Methods: A 39-year-old female with eosinophilic esophagitis (EoE) presented following impaction of 3 cellulose/citric acid hydrogel capsules taken all at once before eating as the instructions stated. She reported feeling the capsules stuck in her esophagus and she was unable to tolerate swallowing. She has had issues with dysphagia in the past, but these episodes typically improved with drinking water. At the time of presentation, she was not taking any medications for EoE. Esophagogastroduodenoscopy (EGD) was performed and demonstrated gelatinized capsules within the esophagus (Figure ) at 20 cm and extending 5 cm distally. The impaction was broken down with graspers and retrieval devices, and the remaining material was pushed into the stomach. Due to the gelatinous content, it was extremely challenging to capture the loose material to be removed. Biopsies were taken of the esophagus which demonstrated mild to moderate eosinophilic infiltration. Discussion: For some individuals, hydrogel capsules can be useful adjuncts for weight loss. However, esophageal impaction and dysphagia can occur if not swallowed properly. To reduce this risk, users should consider swallowing each of the 3 capsules individually, followed each time by a glass of water. This method of administration will likely prevent the chance of the expansion of the capsular contents into the larger gelatinous material in the esophagus and encourage it to occur in the stomach. People with dysphagia, diverticula, and other motility disorders should be extremely careful and take these gelatinous capsules individually.
Introduction: Polyethylene glycol 3350 and electrolytes (PEG) is a perceived safe and commonly prescribed solution prior to colonoscopy, yet case reports suggest the potential for volume overload. We describe a patient with cardiopulmonary comorbidities who developed pulmonary edema and acute hypoxic respiratory failure (AHRF) due to PEG administration. Case Description/Methods: A 55-year-old man with interstitial lung disease (ILD), mild pulmonary hypertension (pHTN), and coronary artery disease (CAD) with multiple coronary stents was admitted to our tertiary academic hospital with cough and constitutional symptoms. He had a brain natriuretic peptide (BNP) of 50 pg/mL, was found to be in AHRF and intubated due to labored breathing. He received broadspectrum antibiotics and corticosteroids with clinical improvement and within 4 days was extubated. Given his severe ILD, he was evaluated for lung transplant. As part of this evaluation, mandatory colon cancer screening was needed in the form of computed tomography (CT) colonography. He had difficulty consuming Golytely at an appropriate rate. Despite 16 liters (L) of PEG over 3 days, the stools were not clear. He then re-developed hypoxia and tachypnea and BNP rise to 475 pg/mL. Chest X-ray (CXR) showed new bilateral opacities concerning for pulmonary edema. Echocardiography demonstrated an IVC greater than 2.0 cm without respiratory variation consistent with volume overload. His bowel prep was held, and he was given diuretics with improvement in his respiratory status, BNP, and CXR. The patient was re-trialed on 6L PEG by nasogastric tube successfully without cardiopulmonary complications and his CT colonography showed no colonic polyps or malignancy. He eventually underwent successful bilateral orthotopic lung transplant. Discussion: Prior research has shown that consumption of 6-8 L of PEG increases mean plasma volume by 5.88% on average, but up to 29.8% in some patients. In this case, our patient consumed double that amount of PEG, with subsequent increase in plasma volume, resulting in pulmonary edema and AHRF due to limited respiratory reserve from his severe ILD, pHTN, and CAD. Literature review shows less than 10 cases worldwide with similar findings. In high-risk patients such as the one described, providers must consider judicious use of PEG for colonoscopy preparation and be quick to identify PEG-associated pulmonary edema as an etiology for respiratory decompensation.
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