At that moment the patient’s condition was stable but considered at high risk for developing toxic complications. We therefore tried to remove the tablets endoscopically. The endoscopy was performed through an overtube (outer diameter 19.5 mm) to protect the throat and oesophagus from damage in case the endoscope would have to be introduced several times to remove the tablets. Due to the presence of activated charcoal the visibility was impaired. Several gastric lavages were performed after which 30-40 whole and fragmented tablets were removed using the Roth Net Retriever (figures 2A and B). No complications occurred during the procedure. Afterwards, she showed a good recovery regaining a normal level of consciousness. She was extubated 12 hours later and was discharged home 48 hours after endoscopic treatment. Further follow-up was organised by the consulted psychiatrist.

Discussion

Our patient presented with severe autointoxication with slowrelease clomipramine and slow-release quetiapine. The calculated ingested dose for slow-release clomipramine was 75 mg/kg (severe toxicity: >10 mg/kg), and for slow-release quetiapine 50 mg/kg (severe toxicity: >30 mg/kg), implying that clomipramine was the most important intoxication.[6] As the serum level of clomipramine is an unreliable predictor for the clinical severity of intoxication, the combined serum level of clomipramine and desmethylclomipramine was assessed, showing a level of 0.82 mg/l (severe toxicity: >0.6 mg/l.)[6] Moreover, this was a mixed-drug overdose implying a complex and unpredictable intoxication. The patient was treated according to our national guidelines for intoxication with tricyclic antidepressants and antipsychotic drugs.[6] However, despite this management a large number of tablets were still clearly visible in the stomach 20 hours after ingestion. Slow-release clomipramine as well as slowrelease quetiapine have previously been described to cause an accumulation of undigested tablets in the gastrointestinal tract, also called a pharmacobezoar.[4,7,8] The massive intake of tablets, cellulose coating and anticholinergic properties reducing gastrointestinal motility probably contribute to pharmacobezoar formation.[3,4] Both clomipramine and quetiapine intoxication can lead to severe clinical complications such as central nervous system depression, seizures and cardiovascular instability with dysrhythmias.[6,7,9] Moreover, clomipramine can induce serotonergic syndrome. Our patient only showed a disturbance of consciousness (GCS 9) and a transient supraventricular tachycardia, but was considered at high risk for developing more toxic complications. As hyperthermia, diaphoresis, hyperreflexia, hypertonia and tremor were lacking, she did not yet have any clear signs of serotonergic syndrome. Maximum serum levels of slow-release quetiapine and slowrelease clomipramine will usually be reached after six hours and 12-18 hours, respectively.[6] However, in case of pharmacobezoar formation, active substances may be released from the bezoar causing persistent or recurrent intoxication and could therefore lead to a further increase of the serum level.[10] Therefore, it was decided to remove the pharmacobezoar endoscopically, after which our patient made a full recovery. It is plausible that the endoscopic procedure contributed to the shortened ICU stay without further toxic complications, as also previously described by Höjer et al.[7] Although endoscopic removal of pharmacobezoars seems logical, published recommendations on this subject are inconclusive and it is not advised in international guidelines.[4,7,8] Severe complications such as gastric haemorrhage have been reported relatively frequently and multiple introductions of the endoscope could increase the risk of airway injury and aspiration of gastric content.[7,8,11] It must be stated that the procedure should be performed by an experienced gastroenterologist. In conclusion, pharmacobezoars can pose an important threat in case of slow-release clomipramine and/or slowrelease quetiapine intoxication. Endoscopic removal has to be considered, but should only be performed in selected cases and by a skilled gastroenterologist.

Disclosures

All authors declare no conflict of interest. No funding or financial support was received.