Sorbitol can be the cause of colonic explosion

Endoscopy 2006; 38: 943 - 944

I read the article by Josemanders et al., ”Colonic explosion during endoscopic polypectomy: avoidable complication or bad luck?” with great interest [1]. They concluded that ”the occurrence of intracolonic gas explosion during polypectomy is, practically, an unavoidable complication.” However, the cleansing solution that they used in their patient contained sorbitol, which I believe can yield products that are combustible after bacterial fermentation. Generally, explosion is a rare event during electrocautery treatment in the colon. The cause of the explosion is ignition of gas containing hydrogen (at concentrations greater than 4 %) or methane (at concentrations greater than 5 %), and oxygen [2].

To date, there have been a few reports of colonic explosions occurring during electrocautery treatment as a result of ignition of gas produced by bacterial fermentation of nutrients and cleansing solution, especially mannitol [3] [4]. The ideal solutions for use in colonoscopy should therefore be designed to clear the colon without providing any substrate for fermentation reactions. Sorbitol is one of the sugar alcohols that can be fermented by several organisms. When the reaction takes place in a low-oxygen environment, especially in the colon, sorbitol fermentation can produce large amounts of ethanol, formate, and acetate [5] [6]. Moreover, in special circumstances, hydrogen gas can then be released from formate by formate-hydrogen lyase system activation [7]. It is speculated that hydrogen and ethanol might have been the fuel for the explosion in their case report.

My suggestion for avoiding this complication and reducing the chance of ”bad luck” during electrocautery treatment of the colon is to avoid bowel preparation regimens that contain any kind of sugar compounds, especially mannitol and sorbitol.

Competing interests: None

References

• 1 Josemanders D FGM, Spillenaar Bilgen E J, van Sorge A A. et al . Colonic explosion during endoscopic polypectomy: avoidale complication or bad luck?.  Endocopy. 2006;  38 943-944
• 2 Strocchi A, Bond J H, Ellis C. et al . Colonic concentrations of hydrogen and methane following colonoscopic preparation with an oral lavage solution.  Gastrointest Endosc. 1990;  36 580-582
• 3 Bigard M A, Gaucher P, Lassalle C. Fatal colonic explosion during colonoscopic polypectomy.  Gastroenterology. 1979;  77 1307-1310
• 4 Raillat A, de Saint-Julien J, Abgrall J. Colonic explosion during an endoscopic electrocoagulation after preparation with mannitol [in French].  Gastroenterol Clin Biol. 1982;  6 301-302
• 5 Svensater G, Takahashi-Abbe S, Abbe K. et al . Anaerobic and aerobic metabolism of sorbitol in Streptococcus sanguis and Streptococcus mitior.  J Dent Res. 1985;  64 1286-1289
• 6 Takahashi N, Kalfas S, Yamada T. Effect of acetate on sorbitol fermentation by oral lactobacilli.  Oral Microbiol Immunol. 1995;  10 349-354
• 7 Alam K Y, Clark D P. Anaerobic fermentation balance of Escherichia coli as observed by in vivo nuclear magnetic resonance spectroscopy.  J Bacteriol. 1989;  171 6213-6217