Three Part Question
In [paracetamol poisoning] is [gastric lavage better than activated charcoal or nothing] at [reducing hepatotoxicity]?
A 26 year old woman attends the Emergency Department 40 minutes after having taken 80 500mg paracetamol tablets. As the dose taken is high and within the last hour you wonder whether she would benefit from gastric lavage.
Medline 1966-10/03 using the OVID interface.
[exp acetaminophen OR paracetamol.mp OR acetaminophen.mp] AND [exp poisoning OR poison$.mp OR exp overdose OR overdos$.mp] AND [exp gastric lavage OR gastric lavage.mp OR gastric decontamination.mp OR exp gastric emptying OR gastric emptying.mp OR exp irrigation OR washout.mp] LIMIT to human AND English.
Altogether 63 papers found of which 59 were irrelevant or of insufficient quality. Four of the remaining papers are shown below the fifth is a position statement mentioned in the comments section.
|Author, date and country
||Study type (level of evidence)
|Underhill TJ et al,|
|60 Patients taken 5g or more within 4 hours of attendance. Gastric lavage (14) vs ipecacuanha (21) vs activated charcoal(20) or nothing(5)||RCT||Plasma concentrations at 0,1.0,1.5 and 2.5 hours post treatment.||39.3% reduction in concentration compared to 52.2% charcoal||Small study|
|Buckley NA et al,|
|981 consecutive paracetemol overdose
Gastric lavage and charcoal vs charcoal alone vs nothing||Observational study||Patients developing high risk concentrations||No statistically significant improvement with lavage + charcoal than charcoal alone.|
|Grierson R et al,|
|10 volunteers given 4.0g paracetemol
Gastric lavage at 1 hour compared to no treatment as crossover||Crossover study||8 plasma concentrations over 8 hours||Reduction of 20% (95% CI 3-37%)||Small study
Liquid paracetemol only|
|Christophersen AB et al,|
|12 volunteers given 50mg/kg paracetamol
Lavage + charcoal vs charcoal||Crossover study||12 plasma concentrations over 7 hours||Charcoal 66% reduction in concentration, lavage + charcoal 48.2%||Small numbers
The 1997 Joint Position Statement by the American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists (5) stated gastric lavage should not be routinely used for poisoned patients. A similar statement from the British Poisons Centres indicates that gastric lavage is only to be used within 60 minutes of overdose and only with drugs not absorbed by charcoal.
For UK position statement on gastric lavage see http://www.spib.axl.co.uk/toxbaseindex.htm
Clinical Bottom Line
Gastric lavage is less effective than charcoal alone after paracetamol poisoning.
- Underhill TJ, Greene MK, Dove AF. A comparison of the efficacy of gastric lavage, ipecacuanha and activated charcoal in the emergency management of paracetemol overdose. Arch Emerg Med. 1990;7(3):148-154.
- Buckley NA, Whyte IM, O'Connell DL et al. Activated charcoal reduces the need for N-acetylcysteine after acetaminophen (paracetemol) overdose. J Toxicol-Clin Toxicol. 1999;37(6):753-7.
- Grierson R, Grren R, Sitar DS, Tenenbien M. Gastric lavage for liquid poisons. Ann Emerg Med 2000;35(5):435-439.
- Christophersen AB, Levin D, Hoegberg LCG et al. Activated charcoal alone or after gastric lavage: a simulated large paracetamol intoxication. Br J Clin Pharmacol 2002;53:312-317.