Sodium-phosphate compounds are commonly used bowel cleansing agents, either as enemas or oral preparations. For colon cleansing in particular, a single oral dose of 90 ml (Fleet) phospho-soda has been found to be safe and efI'ective (
1). Small volu- me and . easy administration are advantages of Fleet enema (
1,
2), particularly in relationship to patient tolerance. However, there are many reports about the risks of these compounds, especi- ally in the pediatric age group. These untoward ef fects are hypernatremia, hyperphosphatemia, hypocalcemia, acidosis, cardiac arrest and death (3-12). Such ctimplications are also more readily seen in renal failure, cardiac failure and patients who have massive ascites (
1,
10,
12).
Wilberg et al.ı3 administered a phosphate containing oral laxative at a dose of 7 g elemental phosphorus to normal subjects prior to barium enema. This study resulted in an increase in serum phosphorus from a mean control value of 3.4 mg / dl to a peak of 6.9 mg / dl after three hours and a decline in serum calcium in all subjects. Another study with 90 mls phospho-soda (containing 11.5 g elemental phosphorus) did not yield any significant decrease in serum calcium levels, despite a signifıcant increase in phosphorus (7.2 ± 0.6 mg / dl)1. In Cohan's study,14 two applications of Fleet phospho-soda enema were used and an increased serum phosphorus concentration was detected without any other electrolyte abnormalities. The case presented here was found to have hyperphosphatemia, hypernatremia, hypocalcemia and acidosis. At the time of this acute illness, a dilutional hyponatremia was noted. Later, an increase of sodium to 178 mEq / L despite massive ascites and hypernatremia was striking. It was thought that the patient had prerenal azotemia and that concomitant increased absorption of sodium from the gut lumen added to this increased sodium level. In fact, the hyperphosphatemia was related to the inappropriate use of Fleet enema. Hypocalcemia was probably due to extraosseous deposition of calcium phosphate12,15. Unfortunately, the patient was erroneously given six doses of 133 ml Fleet enema, containing 19 g of monobasic sodium-phosphate and 7 g of dibasic sodium- phosphate. The negative impact of Fleet enema usage in this particular patient may be summarized as follows:
(1) She had prerenal azotemia;
(2) Fleet enema was used in excess of drug safety limits;
(3) The patient had massive ascites and hepatic failure. It is concluded that sodium phosphate compounds should be used in recommended dosages only in selected patient groups. Patients should be evaluated carefully for any underlying disease and particular care should be taken in patients with intestinal obstruction, motility problems, advanced heart failure, renal failure, hepatic failure and asci- tes. As was learned from this particular case, diagnosis of such fatal.complications is difficult and even if no underlying disease exists, patients should be closely monitored for serum electrolytes.
