Bismuth toxicity: Difference between revisions

(Created page with "==Background== *Heavy Metal *Available in two forms **Elemental ***Nontoxic **Bismuth Salts ***Uses ****Oral preparations for traveler's diarrhea, nausea, and vomiting ***...")
 
 
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****Gastric ulcers
****Gastric ulcers
***Cause toxicity
***Cause toxicity
==Toxicokinetics==
 
===Toxicokinetics===
*Poorly understood due to lack of data
*Poorly understood due to lack of data
*Low absorption in the GI tract, approximately 0.2% is systemically absorbed <ref>Hundal O, Bergseth M, Gharehnia B, et al. Absorption of bismuth from two bismuth compounds before and after healing of peptic ulcers. Hepatogastroenterology. 1999;46:2882-2886.</ref>
*Low absorption in the GI tract, approximately 0.2% is systemically absorbed <ref>Hundal O, Bergseth M, Gharehnia B, et al. Absorption of bismuth from two bismuth compounds before and after healing of peptic ulcers. Hepatogastroenterology. 1999;46:2882-2886.</ref>
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*Levels may be increased in those taking PPI
*Levels may be increased in those taking PPI
**Ranitidine does not alter the absorption of bismuth
**Ranitidine does not alter the absorption of bismuth
==Clinical Features==
==Clinical Features==
*'''Acute'''
===Acute===
**Abdominal pain
*[[Abdominal pain]]
**Oliguria
*Oliguria
**Acute tubular necrosis and renal failure
*Acute tubular necrosis and renal failure
*'''Chronic'''
 
**Diffuse progressive encephalopathy
===Chronic===
**Neurobehavioral changes
*Diffuse progressive encephalopathy
***Apathy
*Neurobehavioral changes
***Irritability
**Apathy
***Poor concentration
**Irritability
***Worsened short term memory
**Poor concentration
***Visual hallucinations
**Worsened short term memory
**Movement disorders
**Visual hallucinations
***Myoclonus  
*Movement disorders
***Ataxia
**Myoclonus  
***Tremors
**[[Ataxia]]
**Pigmentation of skin and oral mucosa
**Tremors
**Seizure
*Pigmentation of skin and oral mucosa
**Coma and death
*[[Seizure]]
*[[Coma]] and [[death]]


==Differential Diagnosis==
==Differential Diagnosis==
===[[Heavy metal]] toxicity===
{{Heavy metals list}}
*[[Aluminum toxicity]]
 
*[[Antimony toxicity]]
*[[Arsenic toxicity]]
*[[Barium toxicity]]
*[[Bismuth toxicity]]
*[[Cadmium toxicity]]
*[[Chromium toxicity]]
*[[Cobalt toxicity]]
*[[Copper toxicity]]
*[[Gold toxicity]]
*[[Iron toxicity]]
*[[Lead toxicity]]
*[[Lithium toxicity]]
*[[Manganese toxicity]]
*[[Mercury toxicity]]
*[[Nickel toxicity]]
*[[Phosphorous toxicity]]
*[[Platinum toxicity]]
*[[Selenium toxicity]]
*[[Silver toxicity]]
*[[Thallium toxicity]]
*[[Tin toxicity]]
*[[Zinc toxicity]]
===[[Encephalopathy]]===
===[[Encephalopathy]]===
*[[Viral encephalopathy]]
*[[Viral encephalopathy]]
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*[[Postanoxic encephalopathies]]
*[[Postanoxic encephalopathies]]
*[[Progressive multifocal ataxia]]
*[[Progressive multifocal ataxia]]
==Evaluation==
==Evaluation==
*Need to have high index of suspicion  
*Need to have high index of suspicion  
*BMP
*BMP
*CBC
*CBC
*UA
*[[Urinalysis]]
*CT head for cases of encephalopathy
*CT head for cases of encephalopathy
**May show diffuse cortical hyperdensity of the grey matter
**May show diffuse cortical hyperdensity of the grey matter
*Salicylate level
*[[Salicylate]] level
**In the United States bismuth subsalicylate is the most common oral compound, and up to 90% of salicylate is absorbed <ref>Pickering LK, Feldman S, Ericsson CD, Cleary TG. Absorption of salicylate and bismuth from a bismuth subsalicylate containing compound (Pepto- Bismol). J Pediatr. 1981;99:654-656.</ref>
**In the United States [[bismuth subsalicylate]] is the most common oral compound, and up to 90% of salicylate is absorbed <ref>Pickering LK, Feldman S, Ericsson CD, Cleary TG. Absorption of salicylate and bismuth from a bismuth subsalicylate containing compound (Pepto- Bismol). J Pediatr. 1981;99:654-656.</ref>
*EEG
*EEG
==Management==
==Management==
*Supportive care
*Supportive care
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**Limited data to support its use
**Limited data to support its use
**Exact timing and dosages are unknown
**Exact timing and dosages are unknown
**British anti-Lewisite (BAL)
**[[Dimercaprol]] (BAL)
***Undergoes biliary elimination which is useful in those with renal insufficiency
***Undergoes biliary elimination which is useful in those with renal insufficiency
***Benefits shown in experimental models
***Benefits shown in experimental models
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==Disposition==
==Disposition==
*Admission if evidence of renal failure or encephalopathy manifestations
*Admission if evidence of renal failure or encephalopathy manifestations
*Consult Toxicology or Poison Control Center
*Consult Toxicology or [[poison control]]
 
==See Also==
*[[Toxicology (main)]]


==References==
==References==
<references/>
<references/>
Rao, R. Bismuth. In: Goldfrank's Toxicologic Emergencies. 9th Ed. New York: McGraw-Hill; 2011: 1233-1236
Rao, R. Bismuth. In: Goldfrank's Toxicologic Emergencies. 9th Ed. New York: McGraw-Hill; 2011: 1233-1236
[[Category:Toxicology]]

Latest revision as of 21:51, 8 March 2021

Background

  • Heavy Metal
  • Available in two forms
    • Elemental
      • Nontoxic
    • Bismuth Salts
      • Uses
        • Oral preparations for traveler's diarrhea, nausea, and vomiting
        • Bismuth-impregnated surgical packing pastes for ileostomies and colostomies
        • Gastric ulcers
      • Cause toxicity

Toxicokinetics

  • Poorly understood due to lack of data
  • Low absorption in the GI tract, approximately 0.2% is systemically absorbed [1]
  • 90% excreted from kidneys
  • Levels may be increased in those taking PPI
    • Ranitidine does not alter the absorption of bismuth

Clinical Features

Acute

Chronic

  • Diffuse progressive encephalopathy
  • Neurobehavioral changes
    • Apathy
    • Irritability
    • Poor concentration
    • Worsened short term memory
    • Visual hallucinations
  • Movement disorders
  • Pigmentation of skin and oral mucosa
  • Seizure
  • Coma and death

Differential Diagnosis

Encephalopathy

Evaluation

  • Need to have high index of suspicion
  • BMP
  • CBC
  • Urinalysis
  • CT head for cases of encephalopathy
    • May show diffuse cortical hyperdensity of the grey matter
  • Salicylate level
    • In the United States bismuth subsalicylate is the most common oral compound, and up to 90% of salicylate is absorbed [2]
  • EEG

Management

  • Supportive care
  • Consider whole bowel irrigation
  • Chelation
    • Limited data to support its use
    • Exact timing and dosages are unknown
    • Dimercaprol (BAL)
      • Undergoes biliary elimination which is useful in those with renal insufficiency
      • Benefits shown in experimental models

Disposition

  • Admission if evidence of renal failure or encephalopathy manifestations
  • Consult Toxicology or poison control

See Also

References

  1. ↑ Hundal O, Bergseth M, Gharehnia B, et al. Absorption of bismuth from two bismuth compounds before and after healing of peptic ulcers. Hepatogastroenterology. 1999;46:2882-2886.
  2. ↑ Pickering LK, Feldman S, Ericsson CD, Cleary TG. Absorption of salicylate and bismuth from a bismuth subsalicylate containing compound (Pepto- Bismol). J Pediatr. 1981;99:654-656.

Rao, R. Bismuth. In: Goldfrank's Toxicologic Emergencies. 9th Ed. New York: McGraw-Hill; 2011: 1233-1236

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