대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

ARDS caused by aspiration of golytely (polyethylene glycol solution)

Radiologic Findings

A 70-year-old-man with no history of cardiopulmonary disease was suffering from abdominal pain. He was admitted and scheduled for colonoscopy. Initial chest X-ray obtained at admission showed no abnormal finding except emphysema. In the early morning before colonoscopy, approximately 2L of Golytely was administered by mouth. Severe vomiting developed during administration of Golytely. After colonoscopy, he complained about breathing difficulties and tachypnea. Oxygen saturation went down to 70% on room air. Follow up CXR after symptom onset revealed bilateral diffuse pulmonary infiltrates. HRCT scan of the lung showed diffuse ground-glass opacities in both lungs with underlying bullous changes. We suspected simple aspiration pneumonia of gastric contents with ARDS patterns. But, as his condition did not improve during the following week, we suspected permeability edema caused by Golytely aspiration. And then, we performed bronchoalveolar lavage (BAL) and started intravenous methylprednisolone administration. After BAL, his condition rapidly improved. Repeated chest X-ray obtained 10 days after BAL showed near complete resolution of pulmonary infiltration.

Brief Review

Golytely, a compound solution of polyethylene glycol, sodium chloride, sodium bicarbonate, potassium chloride, and sodium sulfate is a purgative laxative widely used for bowel cleaning and surgery preparation. It also has been recommended for preparation before colonoscopy, for treatment of constipation, and for gastrointestinal decontamination. Polyethylene glycol causes a substantial flow of fecal water by osmosis, and because volumes required for bowel cleansing are larger than many patients can comfortably drink. Common adverse symptoms from polyethylene glycol include nausea, abdominal fullness, and bloating. Although less common, allergic reactions, angioedema, colonic perforation, esophageal perforation, Mallory-Weiss tear, ventricular arrhythmia, pancreatitis and several cases of life-threatening aspiration after polyethylene glycol lavage have been reported. The intense osmotic action of the polyethylene glycol allowed a small aspiration to facilitate pulmonary edema, and its large molecular size prevented pulmonary absorption with a continuing osmotic action and the ongoing requirement for ventilation. So, pulmonary edema induced by aspiration of polyethylene glycol can be successfully treated by bronchoscopy with bronchoalveolar lavage, concomitant with administration of systemic corticosteroid and positive pressure ventilation. Early bronchoscopy and BAL may prevent pulmonary edema and parenchymal lung damage and lead to shortening of both the need for ventilatory support and overall hospitalization time.

References

1. Paap CM, Ehrlich R. Acute pulmonary edema after polyethylene glycol intestinal lavage in a child. Ann Pharmacother 1993; 27:1044-1047

2. Wong A, Briars GL. Acute pulmonary oedema complicating polyethylene glycol intestinal lavage. Arch Dis Child 2002; 87:537

3. Liangthanasarn P, Nemet D, Sufi R, et al. Therapy for pulmonary aspiration of a polyethylene glycol solution. J Pediatr Gastroenterol Nutr 2003; 37:192-194

4. Marschall HU, Bartels F. Life-threatening complications of nasogastric administration of polyethylene glycol-electrolyte solutions (Golytely) for bowel cleansing. Gastrointest Endosc 1998; 47:408-410

Keywords

Lung, Interstitial lung disease, Aspiration,