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QJM: An International Journal of Medicine, 2017, 43
doi: 10.1093/qjmed/hcw172
Advance Access Publication Date: 18 October 2016
Clinical picture
Proton pump inhibitors, purple gastric juice and peptic
ulcer disease
An 87-year-old woman has a 6-year history of chronic kidney
disease with medical control and valvular heart disease status
post metal valve repair in 2011. She had underwent warfarin
therapy for 5 years. Passage of melena developed 6 days prior to
admission and normocytic anemia (hemoglobin: 4.0 mg/dl) was
observed. Pale conjunctiva and epigastric tenderness were
found during physical examination. Esophagogastroduodenoscopy revealed gastric ulcer (Forrest IIa), duodenal ulcer scars
with luminal deformity and delayed gastric emptying. Although
endoscopic hemostasis was underwent, passage of tarry stool
presented. Therefore, proton pump inhibitor injection (esomeprazole 40 mg/d) was continued. Although gastrointestinal
bleeding improved gradually, intravenous esomeprazole was
shifted to the enteral form (Nexium 40 mg/d). And she was
allowed to take clear liquid diet (Resource Fruit Beverage) since
there was no evidence of concurrent gastrointestinal tract
bleeding. However, she was plagued with poor digestion and
purple fluid regurgitated from nasogastric tube was observed.
No occult blood in the purple fluid was found by guaiac test and
this phenomenon was resolved rapidly after adding prokinetics
(Figure 1).
Esomeprazole and omeprazole rapidly degrade to dark purple-coloured ‘poppy seed’—like compound below pH 4.1,2 Once
the tablets was dispersed in the water, it will loss the protection
of enteric coating. Drug is released before it reaches the intestine, and delayed gastric emptying might increase contact between gastric acid and the drug. Purple discoloration of the
feces and sputum were reported to the Netherlans
Pharmacovigilance Centre Lareb, almost all of these cases
occurred accompanied with delayed gastric emptying.2 Some
cases of gastric content discoloration associated with oral esomeprazole/omeprazole in liquid dispersion form were reported
more in infants.1,2 This phenomenon is usually benign and resolves spontaneously.
Photographs and text from: Y.-C. Chang, Department of Internal
Medicine, Taoyuan Armed Forces General Hospital, Taiwan,
Republic of China, P.-J. Hsiao, K.-L. Wu, C.-J. Hsiao, Division of
Nephrology, Department of Internal Medicine, Tri-Service
General Hospital, National Defense Medical Center, Taipei,
Taiwan, Republic of China. email: [email protected]
Conflict of interest: None declared.
1. Tuleu C, Arenas-Lopez S, Robinson C, McCarthy D, Paget RI,
Tibby S, et al. 0 Poppy seeds0 in stomach aspirates: is oral omeprazole extemporaneous dispersion bioavailable?. Eur J
Pediatric 2008; 167:823–5.
2. van Hunsel F, de Jong L, de Vries T. (Es)omeprazole and discoloration of regurgitated gastric contents in infants: worrying
for care-takers and a sign of a reduced bioavailability. J Pediatr
Pharmacol Ther 2016; 21:260–2.
Figure 1. (A) Purple gastric juice filled in nasogastric tube and (B) enlarged view of the purple gastric juice.
C The Author 2016. Published by Oxford University Press on behalf of the Association of Physicians.
All rights reserved. For Permissions, please email: [email protected]