A 59-year-old woman presented 5 days after her third instillation of intravesical BTX-A (Botox; Allergan, Irving, California, USA) with a 2-day history of spasmodic right upper quadrant pain and jaundice. She was complaining of nausea, vomiting, pale loose stools and dark urine. Mild icterus was noted on examination. The patient denied taking any regular medications as well as any known drug allergies. She was a non-smoker and had minimal weekly alcohol intake (<5 units per week). Following a diagnosis of urodynamically proven detrusor overactivity, she had undergone two previous intravesical BTX-A instillations. All three procedures were performed under general anaesthetic using a rigid cystoscope. Each treatment consisted of intradetrusor injection of 200 IU of BTX-A (mixed with 20 ml of 0.9% saline) into 20 sites in the bladder sparing the trigone (10 IU per site). On each occasion, fentanyl and propofol were used as the anaesthetic agents and the patient also received 1.2 g of prophylactic co-amoxyclav intravenously at induction. She had previously undergone surgical procedures (appendicectomy, cystocoele repair, hysteroscopy with polypectomy) using identical anaesthetic agents with no subsequent problems.
On direct questioning, the patient admitted to having had similar episodes, though much less severe, after both previous treatments with intravesical BTX-A. Following her first BTX-A treatment, she had experienced abdominal pain and vomiting lasting 1 day, which settled spontaneously without requiring medical attention. Similarly, 2 days following her second dose of BTX-A, she presented to accident and emergency with right upper quadrant pain and vomiting. Routine blood tests, including liver function tests, were normal at that time, as was the abdominal ultrasound. The patient was discharged with a suspected diagnosis of biliary colic despite the lack of biliary calculi on ultrasound. She made a full recovery from this episode over a week.