Hyponatremic Coma after Bowel Preparation

Abstract

IntroductionColonoscopy is a useful tool in modern medicine and is increasingly employed for both diagnostic and treatment purposes. However, bowel preparations can cause electrolyte imbalance, with the risk apparently related to the type of bowel cleansing solution used, the age of the patient and their comorbidities. Symptomatic hyponatremia, especially coma, is a rare complication of oral bowel preparation for colonoscopy and is thought to result from excessive antidiuretic hormone secretion.Case descriptionThe authors report the case of a 48-year-old man who developed symptomatic hyponatremia (coma) after bowel preparation with sodium picosulfate/magnesium oxide/citric acid prior to a colonoscopy. The patient was admitted to an intensive care unit where other causes of coma were excluded. The symptoms of hyponatremia rapidly resolved after sodium level correction with intravenous administration of hypertonic saline.DiscussionHyponatremic coma is an uncommon but serious complication of colonoscopy bowel preparation. Patients at risk (>65 years old, chronic kidney disease, heart failure, history of electrolyte problems, or taking thiazide diuretics, angiotensin-converting-enzyme inhibitors or antidepressants) should be closely monitored during bowel cleansing and macrogol-based solutions should preferably be used.LEARNING POINTSThe association between coma and hyponatremia should be kept in mind when patients undergo bowel preparation, especially if they have chronic kidney disease, heart failure, a history of electrolyte problems or are taking diuretics or antidepressants.Patients should be closely monitored (and their metabolic profile checked before bowel cleansing) and a low threshold maintained for investigation and treatment initiation in case of symptom development.Medications with the potential to cause fluid and electrolytes disturbances such as diuretics and antidepressants should be stopped or reduced in dose while the patient is undergoing bowel preparation.

Hyponatremia‐induced generalized seizure after taking polyethylene glycol for colon preparation—A case report and brief review of the literature

“…All except two patients were female, and only two patients were younger than 50 years. 5,18 This confirms that old age and female gender predispose to hyponatremia, possibly due to higher sensitivity of their kidneys to arginine vasopressin (AVP) and/or increased renal V2R expression, 19 and higher baseline level or response of AVP to stimuli in elderly patients. 20 One male patient with end stage renal disease (ESRD) died from acute hyponatremia while receiving colon preparation for elective colonoscopy.…”

“…There are few reports related to the development of hyponatremia and seizure in patients receiving colon preparation medications, that are summarized in Table 1. All except two patients were female, and only two patients were younger than 50 years 5,18 . This confirms that old age and female gender predispose to hyponatremia, possibly due to higher sensitivity of their kidneys to arginine vasopressin (AVP) and/or increased renal V2R expression, 19 and higher baseline level or response of AVP to stimuli in elderly patients 20 …”

Seizure from water intoxication following bowel preparation: a case report

“…The associated risk of developing electrolyte imbalances such as hyponatremia has been reported up to 6% [3], however, symptomatic hyponatremia is rare and has mainly been documented by case reports. Patient's age and comorbidities are often believed to directly contribute to the majority of these rare yet severe cases of hyponatremia [4][5][6]. Although the role of antidiuretic hormone (ADH) in hyponatremia has also been emphasized in existing literature, the use of desmopressin has not been reported to contribute to severe hyponatremia in patients undergoing bowel preparation.…”