LAUSR

Introduction: Esophagogastroduodenoscopy (EGD) has been described as a necessary route of intestinal decontamination in the presence of a pharmacobezoar but may also have further utility in other overdose patients. We describe a life-threatening ingestion complicated by prolonged serotonergic symptoms and ileus alleviated by EGD pill removal. Description: A 14-year-old male presented from an outside facility with confusion and seizures at school. On admission, he was noted to have significant agitation, clonus, mydriasis, and tachycardia. He was also afebrile and had a lack of sweat production. The patient had a prior history of major depressive disorder and anxiety managed with Fluoxetine 40mg daily. Serotonin Syndrome was presumed diagnosis. Seizures and agitation were controlled with intermittent benzodiazepines and he eventually required a midazolam infusion. He received a short course of cyproheptadine, which was stopped when we had concern for anticholinergic co-ingestion. He continued to have escalating agitation and developed respiratory failure requiring intubation on hospital day 3. Given his worsening exam, the decision was made to obtain an EGD on hospital day 4 which identified and removed twenty foreign bodies. These had a white shell with an inner gelatinous material that were adhered to the gastric fundus. The patient improved clinically within hours and was extubated the following day. We later found that he had also ingested synthroid tablets and had a free T4 of 17.7mcg/dl (range 4.7 8.6) and a TSH of 0.01 mIU/L (range 0.79 3.98). Hyperthyroidism can cause autonomic nervous system dysfunction with decreased vagal influence resulting in delayed gastric emptying. Whole bowel irrigation or gastric lavage could be considered a parallel treatment modality, but both have been shown to be unsuccessful if medications are significantly adhered to gastric mucosa or in the obvious case of a pharmacobezoar. Discussion: This report will review the current indications for EGD in overdose patients and suggest that it should be strongly considered as an adjunctive therapy, especially in the case of a patient with an unknown overdose or concern for multidrug ingestion with prolonged or worsening symptoms.