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The authors describe a case of fatal hypermagnesemia caused by an Epsom salt enema. A 7-year-old male presented with cardiac arrest and was found to have a serum magnesium level of 41.2 mg/dL (33.9 mEq/L) after having received an Epsom salt enema earlier that day. Side Effects & Safety. Phosphate salts containing sodium, potassium, aluminum, or calcium are LIKELY SAFE for most people when taken by mouth, inserted into the rectum, or given intravenously (by IV) appropriately and short-term. Phosphate salts should only be used intravenously (by IV) under the supervision of a physician. Epsom salts can also cause serious side effects or interact negatively with other medications, like antibiotics. In general, talking with a health professional before using magnesium sulfate and other laxatives is a good idea.

1. Dangers Of Epsom Salt Baths
2. Epsom Salt Enema Youtube Video
3. Epsom Salt Enema For Constipation

Jul 11, 2017  Epsom Salt and soapsuds together in the same enema. Warm, but NOT HOT! Like anything else, you CAN overdo it! But in answer to your question, I know someone who is 50 and has used the occasional Epsom salt enema since he was 14. When it’s used as directed, Epsom salt is an effective alternative to stimulant laxatives for relieving constipation. As long as you use Epsom salt in recommended doses, the side effects are.

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Abstract

Epsom salts contains the active compound magnesium sulfate and is used most commonly as a laxative. There are potential serious toxic effects, including cardiac arrest, when the serum concentration rises above therapeutic values. We present a case of deliberate self poisoning with a large quantity of Epsom salts, resulting in a toxic serum magnesium concentration of 9.7 mmol/l (0.70–1.0 mmol/l). Clinical features included limb weakness, vomiting and confusion, with a subsequent rapid deterioration in level of consciousness and bradydysrhythmia. There was no significant response to calcium gluconate, so haemodialysis was urgently arranged. The patient made a full recovery. Hypermagnesaemia is unusual in patients with normal renal function. Although clinical severity does not always correlate with serum magnesium values, risk of cardiac arrest occurs with concentrations >6 mmol/l. Initial treatment is supportive. Dialysis should be considered when life threatening features or renal impairment are present.

BACKGROUND

Epsom salts contains the active compound magnesium sulfate, which is medically used for the treatment of eclampsia, asthma and cardiac arrhythmias. When the serum concentration rises above therapeutic values serious toxicity may occur, including cardiac arrest. The National Poisons Information Service provides expert toxicology advice, invaluable when patients are critically ill and unresponsive to initial treatment.

CASE PRESENTATION

A 46-year-old woman deliberately ingested approximately 2 kg of Epsom salts in a suicide attempt. Approximately 2 h after ingestion she presented to the emergency department complaining of difficulty standing and shortness of breath, having collapsed and vomited in the bathroom at home.

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Initial Glasgow Coma Scale (GCS) was 13/15 (eye 3 motor 6 verbal 4), non-invasive blood pressure 125/65 mm Hg, pulse 56 beats/min, and respiratory rate 15/min. Physical examination demonstrated generalised limb weakness, hypotonia, and reduced deep tendon reflexes.

INVESTIGATIONS

An electrocardiogram revealed sinus bradycardia that progressed to first degree atrioventricular block within 30 min of presentation. Blood results were normal other than serum magnesium concentration of 9.7 mmol/l, potassium 2.9 mmol/l, and glucose 8.9 mmol/l. Chest x ray revealed radiological evidence of aspiration.

TREATMENT

In addition to supportive treatment, intravenous fluids and oxygen, 10 ml of 10% calcium gluconate was given to counteract the myocardial depressant effects of the magnesium. There was no improvement. A bradydysrhythmia developed with a heart rate of 20–30 beats/min. Blood pressure was stable throughout. The heart rate responded to 0.5 mg of atropine. During this time the patient’s GCS had fallen to 3/15. A rapid sequence induction was performed and mechanical ventilation commenced.

Toxicology advice from the National Poisons Information Service was to expedite haemodialysis.

The patient was transferred to the intensive therapy unit and dialysed. Serum magnesium concentration was 1.3 mmol/l after 72 h.

OUTCOME AND FOLLOW-UP

There were no further episodes of cardiac dysrhythmias. The patient developed sepsis secondary to aspiration pneumonia that responded to antibiotics and inotropes. Due to recurrent right pleural effusions she remained in hospital for a further 3 weeks, but subsequently made a full recovery.

Psychiatric review concluded this was an impulsive act with no ongoing suicidal ideation and she was discharged home with community mental health follow-up.

DISCUSSION

A number of cases reporting accidental toxicity and death from Epsom salts either orally or rectally have been documented in the literature as far back as the early 1900s.^–8 We are not aware of any reports of deliberate self poisoning with suicidal intent using Epsom salts.

Magnesium is an essential cofactor for over 300 enzymatic reactions, especially those involving adenosine triphosphate (ATP). Only 1% of magnesium occurs extracellulary, with the majority in the skeleton and the rest in muscle and soft tissues. Therapeutic administration has become established in the treatment of eclampsia, torsades de pointes, atrial fibrillation, and asthma. It also has less well defined roles in the treatment of myocardial infarction, alcoholism, stroke and hypertension.

Magnesium is mostly absorbed from the small intestine. Hypermagnesaemia is rare without concomitant renal failure since the kidney can normally excrete excess magnesium efficiently by reducing tubular reabsorption to negligible amounts.

Initial signs of toxicity are non-specific. Nausea, vomiting and flushing progress to reduced conscious level, hypotonia, hyporeflexia, hypothermia, hypotension and bradydysrhythmias. Risk of cardiac arrest is documented to occur at concentrations >6 mmol/l. Clinical severity is not always correlated with the degree of hypermagnesaemia. Cardiovascular effects are due to direct vasodilatation of vascular smooth muscle and inhibition of noradrenaline (norepinephrine) release from post-ganglionic sympathetic nerves. This produces hypotension, QT prolongation and delayed intraventricular conduction, potentially leading to heart block and asystole. Neurotoxicity is due to inhibition of acetylcholine release from the neuromuscular endplate.

Treatment in most cases is supportive. If necessary, the airway should be protected and adequate ventilation provided. Intravenous fluids maintain blood pressure and urine output, and promote diuresis with elimination of magnesium. Specific treatment with intravenous calcium (either gluconate or chloride) directly antagonises the effects of magnesium. It can reverse effects such as respiratory depression, hypotension and arrhythmias and may be life saving. Our patient continued to deteriorate after administration of calcium gluconate, but it is unclear whether this was entirely attributable to the toxic effects of magnesium. Inotropic support may be necessary.

In patients who fail to respond to these measures, have life threatening features or have renal failure, dialysis is the treatment of choice.^,,,8 Most of the ingested dose of magnesium would have remained in the extracellular compartment, since intracellular free magnesium is rigidly and homeostatically regulated, even in the face of very large changes in extracellular magnesium concentrations. Dialysis rapidly and efficiently removes small molecules from plasma within a short period of time and is far more effective than haemofiltration for this purpose.

LEARNING POINTS

• Urgent dialysis should be considered for all patients with features of life threatening magnesium toxicity or those not responding to intravenous calcium and other supportive measures.

• The authors acknowledge the expert advice from the National Poisons Information Service, which is invaluable in unusual or complicated cases of poisoning.

Footnotes

Competing interests: none.

Patient consent: Patient/guardian consent was obtained for publication

REFERENCES

Abstract

Various colonic side-effects of herbal enema have been reported in literature ranging from mild abdominal discomfort to self-limiting haemorrhagic colitis. It rarely requires blood transfusion or subtotal colectomy. We report a 57-year-old male patient developing severe ileo-colitis with persistent massive rectal bleeding immediately after herbal enema administration for the treatment of chronic constipation and was resistant to conservative management. Patient was managed successfully with emergency total laparoscopic colectomy. Post-operative recovery of the patient was excellent.

INTRODUCTION

Enema administration has been a common practice worldwide for several centuries for the treatment of chronic constipation and for preparation of patient for a diagnostic test or a surgery.

The injurious effect of herbal enema is usually self-limiting. It seldom causes so prolonged lower gastrointestinal bleed that requires massive blood transfusion and rarely requires colectomy. There are few reports about the harmful effects of herbal enema in literature. Here we report an unusual complication of herbal enema in the form of severe ileo-colitis with persistent massive lower gastrointestinal bleed immediately after administration of enema for the treatment of chronic constipation. The bleeding was refractory to conservative treatment and was managed with emergency total laparoscopic colectomy.

CASE REPORT

A 57-year-old male patient presented with persistent massive bleeding per rectum for one month that developed immediately after administration of herbal enema by a religious quack for the treatment of chronic constipation. He was admitted at some other hospital for the same complaint and was managed conservatively with oral glucocorticoid, 5-aminosalicylate preparation, metronidazole, entofoam (hydrocortisone acetate) and sucralfate enema. He had history of 48 units of blood transfusions during the course of conservative management to raise the haemoglobin above 8 mg/dl, but the condition did not improve and the patient was referred to our centre for further management.

On clinical examination, the patient was pale, had tachycardia (pulse, 136/min.) and hypotension (systolic blood pressure, 70 mmHg). Abdominal examination revealed normal findings. Rectal examination showed altered blood. His haemoglobin was 5.9 g/dl with haematocrit 20%. All other blood investigations were normal. Colonoscopy revealed extensive ulcerations and friability of entire colon, more on left colon and ileal intubation also showed multiple ulcerations [Figure 1]. CECT of abdomen showed distended small and large bowel with no air-fluid level.

Endoscopic view: ulcerations and friability of colonic mucosa

We gave the patient a trial of conservative management because the condition was not permissible to withstand a major abdominal surgery. Conservative management did not work and once again patient developed massive lower gastrointestinal bleed bringing haemoglobin down to 4.9 g%. Patient was planned for emergency laparoscopic total colectomy. On laparoscopy, there was evidence of mild ascites, thick oedematous inflamed and friable large bowel and distal 30 cm of ileum. Large bowel was very friable and developed 3 small inadvertent perforations by bowel holding grasper during dissection and manipulation of colon [Figure 2]. The perforations were managed by intracorporeal sutures to avoid peritoneal contamination. Total colon with distal inflamed ileum was resected laparoscopically. Hartmann procedure was done with end ileostomy at right spino-umbilical line. Specimen was retrieved by a small Pfannenstiel incision. The patient developed hyponatremia and paralytic ileus in early postoperative period that were managed conservatively. Oral liquids were started on postoperative day (POD) 3 and after that stoma started functioning. There was no wound infection. Drains were removed on POD5 and patient was discharged on POD 7 with advice of restoration of bowel continuity after 8-10 weeks.

Intraoperative view showing an inadvertent perforation in edematous friable colon

DISCUSSION

Majority of the population of India is seemingly unaware of the potential hazards associated with herbal medications and of the limited knowledge and diagnostic skill of those who are prescribing such type of treatments.

Contrary to the widespread belief that because it is natural it is safe, herbal therapy probably carries major risks and produces more serious side-effects than any other form of alternative medicine.[]

The common natural ingredients used in enemas are aloe, coffee, garlic and milk thistle. Other types of enemas include the ones made with mineral water, Epsom salt, glycerin, vinegar, bark of the marula tree, fruit of the Cucumis africanus, various wild herbs, industrial thinner, turpentine, undiluted dettol, ginger, pepper or soap.[]

The injurious side-effects of herbal enema vary from mild abdominal discomfort and self-resolving haemorrhagic proctocolitis to severe colitis. Most of the time, colitis responds conservatively and rarely require blood transfusion and colectomy.

Herbal enema induced massive lower gastrointestinal bleed is a life threatening clinical condition usually refractory to conservative management as in our case. Nowadays, the indication for surgery is mainly limited to acute, uncontrollable, and recurrent forms of lower gastrointestinal bleed.[] There are few studies in literature that address the feasibility of laparoscopic colectomy in emergency conditions. Marcello et al[] reported in their case-control study comparing laparoscopic total colectomy for acute colitis with a matched open colectomy group that laparoscopic total colectomy is feasible and leads to a faster recovery. The mortality rate from a subtotal colectomy in emergency setting is approximately 20% in most collected series,[5] because of the reluctance of surgeons to perform a subtotal colectomy early and defer it till desperate circumstances arise.[] Early surgical intervention in such patients can improve the survival rate.

CONCLUSION

On the basis of surgical outcomes of this patient and literature support, we need for spreading awareness regarding the potentially disastrous adverse effects of herbal medications prescribed by quacks and advocate early intervention in such type of severe ileocolitis with massive rectal bleed.

Footnotes

Dangers Of Epsom Salt Baths

Source of Support: Nil

Conflict of Interest: None declared.

REFERENCES

Epsom Salt Enema Youtube Video

Epsom Salt Enema For Constipation