Bismuth toxicity
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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
- Uses
- Elemental
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
- Abdominal pain
- Oliguria
- Acute tubular necrosis and renal failure
- Chronic
- Diffuse progressive encephalopathy
- Neurobehavioral changes
- Apathy
- Irritability
- Poor concentration
- Worsened short term memory
- Visual hallucinations
- Movement disorders
- Myoclonus
- Ataxia
- Tremors
- Pigmentation of skin and oral mucosa
- Seizure
- Coma and death
Differential Diagnosis
Heavy metal toxicity
- 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
- Phosphorus toxicity
- Platinum toxicity
- Selenium toxicity
- Silver toxicity
- Thallium toxicity
- Tin toxicity
- Zinc toxicity
Encephalopathy
- Viral encephalopathy
- Ethanol withdrawal
- Creutzfeld-Jacob disease
- Lithium toxicity
- Neurodegenerative leukoencephalopathies
- Nonketotic hyperosmolar coma
- Postanoxic encephalopathies
- Progressive multifocal ataxia
Evaluation
- Need to have high index of suspicion
- BMP
- CBC
- UA
- 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
- British anti-Lewisite (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 Center
References
- ↑ 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.
- ↑ 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