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Diarrhea precipitated by oral liquid medication
CORRESPONDENCE
especially when the route of ad- liquid medications. However, we ministration bypasses the dilu- need to recognize that osmolality tional effect of the upper gastro- alone will not promote diarrhea. intestinal tract and the agent is The critical feature is not simply instilled directly into the intes- the presence of osmotic particles, but the presence of poorly abtines (i.e., nasogastric tube). Unfortunately, few pharma- sorbed osmotic particles such as ceutical companies provide full sorbitol and magnesium. Soft disclosure of inert ingredients drinks typically have an osmolalused in their products, but the ity of 600 mOsm/kg, malted milk Submitted April 6, 1989, and accepted July 12, 1990 isolation of sorbitol as the precip- 940 mOsm/kg, and grape juice itating factor for the diarrhea 1,170 mOsm/kg [2], yet none of The Reply: may be slightly narrow. After re- these are likely to cause diarrhea We read with interest the letter viewing the labeled contents of 71 if the rate of ingestion does not by Greenspoon and Bernstein. liquid products supplied in our exceed the rate of absorption. Because of space limitations, we hospital pharmacy, we only idenGastrointestinal motility is iniwere unable to include all aspects tified nine that list sorbitol as an tially slowed by either hypotonic of this interesting case in the ingredient. The diarrhea caused or hypertonic solutions placed original publication. Several adby the products not containing into the duodenum [3], while the ditional important pieces of data sorbitol could easily be explained final volume is dependent upon are as follows: (1) The patient by the high osmotic concentra- absorption of solute as well as difhad been amenorrheic for several tion these products provide fusion of water into the lumen. years prior to this episode and (Ernst JA, Williams JM, Glick For this reason, appropriate detherefore was non-ovulatory, (2) MR. Osmolality of substances livery of tube feeding formula after resolution of the acute epiused in the intensive care nurs- should rarely cause diarrhea. Sorsode, results of both a pelvic exery. Pediatrics 1983; 72: 347-52). bitol on the other hand is one of amination and an ultrasound exThis osmotic pressure draws flu- p e r h a p s several c l a n d e s t i n e amination were normal, (3) this id intraintestinally, resulting in causes of diarrhea. We should all patient did have previous bleedliquidation of stool. Thus, it is ir- continue our vigilance for iatroing episodes (although at differrelevant to assess the sorbitol genic problems, and examine the ent sites) both while receiving content in these products be- etiologic possibilities before asand while not receiving oral anticause all liquid medications in- signing the diagnosis. coagulant therapy, and (4) more THOMAS E. EDES, M.D. stilled intraintestinally could than 2 years after the reported Harry S. Truman Memorial precipitate diarrhea. episode, and with appropriate Veterans Hospital GLEN THOMPSON, Pharm.D. Columbia, Missouri control of her anticoagulant dose, WILLIAM D. FIGG, Pharm.D. there have been no further occurUniversity of Alabama Hospital 1. Holtz L, Milton J, Sturek JK. Compatibility of Birmingham, Alabama medications with enteral feedings. J Parenter Enter rences. Nutr 1987; 11: 183-6. Although we do not believe Submitted April 16, 1990, and accepted July 12, 2. American Dietetic Association. Handbook of clini1990 them to be applicable to the case cal dietetics. New Haven: Yale University Press, 1981. we reported, the points made by The Reply: 3. Meeroff JC, Go VLW, Phillips SF. Control of gasGreenspoon and Bernstein are T h o m p s o n and Figg's l e t t e r tric emptying by osmolality of duodenal contents in both cogent and important and raises two important points from man. Gastroenterology 1975; 68: 1144-51. should be kept in mind by all our article: (1) When diarrhea ocphysicians. curs in hospitalized or tube-fed RoY SMITH, M.D. patients, medications rather than JULIO SANTAMARIA, M.D. Medical College of Wisconsin feeding formula should be sus- INCIDENCE OF POSTMilwaukee, Wisconsin pected; and (2) liquid medicaPHLEBITIC SYNDROME AFTER tions often contain substances STREPTOKINASE THERAPY that are not inert. They percep- FOR DEEP VEIN THROMBOSIS DIARRHEA PRECIPITATED BY tively point out that many liquid To the Editor: ORAL LIQUID MEDICATION medications do not contain sorbi- In the comprehensive review by To the Editor: tol, yet may contain other ingre- Rogers and Lutcher (Am J Med Edes's et al (Am J Med 1990; 88: dients that could cause diarrhea. 1990; 88: 389-95) on the use of 91-3) study on diarrhea was most Holtz et al [1] described increases s t r e p t o k i n a s e for deep vein enlightening. Oral liquid medicain the osmolality of tube feeding thrombosis (DVT), they contions have long been overlooked formulations after the addition of clude that this therapy reduces as a potential source of diarrhea, cy. In: Mishell DR Jr, Brenner PF, eds. Management of common problems in obstetrics and gynecology. 1st ed. Oradell, New Jersey: Medical Economics Books, 1983. 6.1turbe-Alessio I, del Carmen-Fonseca M, Mutchinik O, Santos MA, Zajarias A, 8alator E. Risks of anticoagulant in pregnant women with artificial heart valves. N Engl J Med 1986; 315: 1390-3. 7. Liskin L, Blackburn R, Ghani R. Hormonal contraception: new long-acting methods. Popul Rep [K] 1987; 15; K57-87.
November 1990 The American Journal of Medicine
Volume 89
697
especially when the route of ad- liquid medications. However, we ministration bypasses the dilu- need to recognize that osmolality tional effect of the upper gastro- alone will not promote diarrhea. intestinal tract and the agent is The critical feature is not simply instilled directly into the intes- the presence of osmotic particles, but the presence of poorly abtines (i.e., nasogastric tube). Unfortunately, few pharma- sorbed osmotic particles such as ceutical companies provide full sorbitol and magnesium. Soft disclosure of inert ingredients drinks typically have an osmolalused in their products, but the ity of 600 mOsm/kg, malted milk Submitted April 6, 1989, and accepted July 12, 1990 isolation of sorbitol as the precip- 940 mOsm/kg, and grape juice itating factor for the diarrhea 1,170 mOsm/kg [2], yet none of The Reply: may be slightly narrow. After re- these are likely to cause diarrhea We read with interest the letter viewing the labeled contents of 71 if the rate of ingestion does not by Greenspoon and Bernstein. liquid products supplied in our exceed the rate of absorption. Because of space limitations, we hospital pharmacy, we only idenGastrointestinal motility is iniwere unable to include all aspects tified nine that list sorbitol as an tially slowed by either hypotonic of this interesting case in the ingredient. The diarrhea caused or hypertonic solutions placed original publication. Several adby the products not containing into the duodenum [3], while the ditional important pieces of data sorbitol could easily be explained final volume is dependent upon are as follows: (1) The patient by the high osmotic concentra- absorption of solute as well as difhad been amenorrheic for several tion these products provide fusion of water into the lumen. years prior to this episode and (Ernst JA, Williams JM, Glick For this reason, appropriate detherefore was non-ovulatory, (2) MR. Osmolality of substances livery of tube feeding formula after resolution of the acute epiused in the intensive care nurs- should rarely cause diarrhea. Sorsode, results of both a pelvic exery. Pediatrics 1983; 72: 347-52). bitol on the other hand is one of amination and an ultrasound exThis osmotic pressure draws flu- p e r h a p s several c l a n d e s t i n e amination were normal, (3) this id intraintestinally, resulting in causes of diarrhea. We should all patient did have previous bleedliquidation of stool. Thus, it is ir- continue our vigilance for iatroing episodes (although at differrelevant to assess the sorbitol genic problems, and examine the ent sites) both while receiving content in these products be- etiologic possibilities before asand while not receiving oral anticause all liquid medications in- signing the diagnosis. coagulant therapy, and (4) more THOMAS E. EDES, M.D. stilled intraintestinally could than 2 years after the reported Harry S. Truman Memorial precipitate diarrhea. episode, and with appropriate Veterans Hospital GLEN THOMPSON, Pharm.D. Columbia, Missouri control of her anticoagulant dose, WILLIAM D. FIGG, Pharm.D. there have been no further occurUniversity of Alabama Hospital 1. Holtz L, Milton J, Sturek JK. Compatibility of Birmingham, Alabama medications with enteral feedings. J Parenter Enter rences. Nutr 1987; 11: 183-6. Although we do not believe Submitted April 16, 1990, and accepted July 12, 2. American Dietetic Association. Handbook of clini1990 them to be applicable to the case cal dietetics. New Haven: Yale University Press, 1981. we reported, the points made by The Reply: 3. Meeroff JC, Go VLW, Phillips SF. Control of gasGreenspoon and Bernstein are T h o m p s o n and Figg's l e t t e r tric emptying by osmolality of duodenal contents in both cogent and important and raises two important points from man. Gastroenterology 1975; 68: 1144-51. should be kept in mind by all our article: (1) When diarrhea ocphysicians. curs in hospitalized or tube-fed RoY SMITH, M.D. patients, medications rather than JULIO SANTAMARIA, M.D. Medical College of Wisconsin feeding formula should be sus- INCIDENCE OF POSTMilwaukee, Wisconsin pected; and (2) liquid medicaPHLEBITIC SYNDROME AFTER tions often contain substances STREPTOKINASE THERAPY that are not inert. They percep- FOR DEEP VEIN THROMBOSIS DIARRHEA PRECIPITATED BY tively point out that many liquid To the Editor: ORAL LIQUID MEDICATION medications do not contain sorbi- In the comprehensive review by To the Editor: tol, yet may contain other ingre- Rogers and Lutcher (Am J Med Edes's et al (Am J Med 1990; 88: dients that could cause diarrhea. 1990; 88: 389-95) on the use of 91-3) study on diarrhea was most Holtz et al [1] described increases s t r e p t o k i n a s e for deep vein enlightening. Oral liquid medicain the osmolality of tube feeding thrombosis (DVT), they contions have long been overlooked formulations after the addition of clude that this therapy reduces as a potential source of diarrhea, cy. In: Mishell DR Jr, Brenner PF, eds. Management of common problems in obstetrics and gynecology. 1st ed. Oradell, New Jersey: Medical Economics Books, 1983. 6.1turbe-Alessio I, del Carmen-Fonseca M, Mutchinik O, Santos MA, Zajarias A, 8alator E. Risks of anticoagulant in pregnant women with artificial heart valves. N Engl J Med 1986; 315: 1390-3. 7. Liskin L, Blackburn R, Ghani R. Hormonal contraception: new long-acting methods. Popul Rep [K] 1987; 15; K57-87.
November 1990 The American Journal of Medicine
Volume 89
697