Bismuth toxicity: Difference between revisions

(Text replacement - "Poison Control Center" to "poison control")
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*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

Revision as of 00:27, 21 October 2018


  • 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


  • 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



  • 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

Heavy metal toxicity



  • 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


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


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


  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