Radiopacity of clomipramine conglomerations and unsuccessful endoscopy: Report of 4 cases

Background: The radiopacity of ingested substances may serve as a clue to t he presence of particular compounds, as this characteristic varies consider ably among medications and household products. Tablet conglomerations are a lso variably radiopaque. We report 4 cases of clomipramine poisoning associ ated with formation of radiopaque masses, believed to be clomipramine, in t he area of the stomach. Case Reports: Four patients were admitted to the To xicological Intensive Care Unit after ingestions of, respectively, 8.5 g (1 80 tablets of mixed strength), 7.5 g (100 tablets), 10.5 g (140 tablets), a nd 4.5 g (60 tablets) of clomipramine, along with other sedatives and antip sychotics. In each case, a rounded density was observed in the gastric area on plain chest radiograph. The hospital courses of each patient were marke d by tachycardia, hypotension, QRS and QT prolongation, seizures, and decre ased mental status. Three of 4 patients underwent unsuccessful endoscopy to remove tablet fragments and subsequently suffered gastrointestinal hemorrh age requiring transfusion. All patients were discharged recovered from the hospital, Discussion: Clomipramine, a potent tricyclic antidepressant, has been previously reported to be nonradiopaque, and has not been reported to induce formation of concretions. These cases suggest that massive ingestion s of clomipramine may form bezoars which are radiopaque and may be associat ed with. serious toxicity. Careful consideration should be given prior to t he use of gastric endoscopy for the retrieval of tablet fragments since sig nificant hemorrhage, attributed to the procedure itself rather than to clom ipramine toxicity, may ensue.