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MONOOCTANOIN

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Monooctanoin is an agent used in dissolving residual cholesterol gallstones after a cholecystectomy. It is a monodiglyceride of medium chain fatty acids.
    B) Capmul 8210 (70% monooctanoin) has been available as a food supplement prepared by Capitol City Products.

Specific Substances

    1) Capmul 8210
    2) Glyceryl-1-mono-octanoate
    3) Alpha-monocaprylin
    4) Glyceryl monocaprylate
    5) CAS 26402-26-6

Available Forms Sources

    A) SOURCES
    1) Capmul 8210 is the name given to monooctanoin by Stokeley-Van Camp, the company that holds the original patent for this agent and its use against gallstones (Anon, 1982).
    B) USES
    1) Monoctanoin is used for cholesterol (radiolucent) gallstones that are retained in the biliary tract when other means of removing stones are ineffective or not possible. It is administered directly into the bile duct via a T-tube or a nasobiliary tube placed through endoscopy (Prod Info Moctanin(R), 1991).

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) WITH THERAPEUTIC USE
    1) Monooctanoin infusions are low in toxicity. Most symptoms occur as a result of an increased perfusion rate and biliary pressure (a pressure of <20 is recommended). Gastrointestinal symptoms are the most common side effects of therapeutic use and include the following: nausea, vomiting, abdominal pain, and diarrhea. Infrequent reports of noncardiogenic pulmonary edema, peritonitis, ascending cholangitis, fever, chills, leukocytosis, and jaundice have occurred with monooctanoin infusions.
    2) Rare reports of death (a total of 5 cases) have been associated with therapeutic use and were attributed to the following: cholangitis, gallbladder perforation and biliary peritonitis, pulmonary embolism, pancreatitis and sepsis.
    0.2.4) HEENT
    A) WITH THERAPEUTIC USE
    1) Facial flushing occurred during one infusion when intrabiliary pressure was 24 to 26 cm of water.
    0.2.5) CARDIOVASCULAR
    A) WITH POISONING/EXPOSURE
    1) Intravenous injection of monooctanoin resulted in respiratory and cardiac arrest and death.
    0.2.6) RESPIRATORY
    A) WITH THERAPEUTIC USE
    1) Dyspnea was seen during an excessive intrabiliary pressure infusion of monooctanoin.
    2) Pulmonary edema has been reported. One report of fatal pulmonary embolism has occurred.
    0.2.8) GASTROINTESTINAL
    A) WITH THERAPEUTIC USE
    1) Therapeutic side effects include nausea, abdominal pain, vomiting, diarrhea, and mild anorexia and are the most frequently reported symptoms.
    2) Duodenitis, which may lead to hemorrhage, has been reported in both animal and human cases.
    0.2.9) HEPATIC
    A) ANIMAL STUDIES - The following adverse effects have been reported in animals after receiving monooctanoin injection: bile duct inflammation, hemorrhagic peritonitis, liver necrosis and abscess.
    B) WITH THERAPEUTIC USE
    1) Cholangitis has been reported in one case. Infrequent reports of jaundice have also occurred.
    0.2.13) HEMATOLOGIC
    A) WITH THERAPEUTIC USE
    1) Leukopenia has been reported with therapy.
    0.2.19) IMMUNOLOGIC
    A) WITH THERAPEUTIC USE
    1) An anaphylactoid reaction has been observed.

Laboratory Monitoring

    A) No toxic levels of monooctanoin have been established. The manufacturer recommends liver function tests for patients undergoing therapy, but liver malfunction has not been a common abnormality during therapeutic treatment.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) DILUTION - This material may be irritating to the gastric mucosa, dilute with 4 to 8 ounces of milk or water (not to exceed 15 mL/kg in a child).
    B) ACTIVATED CHARCOAL: Administer charcoal as a slurry (240 mL water/30 g charcoal). Usual dose: 25 to 100 g in adults/adolescents, 25 to 50 g in children (1 to 12 years), and 1 g/kg in infants less than 1 year old.
    C) Supportive care, as well as discontinuation of the drug or reducing the rate of infusion has been effective therapy for the side effects in minimal toxicity seen with monooctanoin.

Range Of Toxicity

    A) Monooctanoin is perfused via a catheter inserted into the common bile duct via a T-tube or through a nasobiliary tube placed by endoscopy. It is essential to have an overflow manometer, peristaltic pump or similar means to assure pressure does not exceed 15 cm of water. The infusion rate is 3 to 5 mL per hour. Rates higher than these will eventually produce biliary colic.

Clinical Effects

Summary Of Exposure

    A) WITH THERAPEUTIC USE
    1) Monooctanoin infusions are low in toxicity. Most symptoms occur as a result of an increased perfusion rate and biliary pressure (a pressure of <20 is recommended). Gastrointestinal symptoms are the most common side effects of therapeutic use and include the following: nausea, vomiting, abdominal pain, and diarrhea. Infrequent reports of noncardiogenic pulmonary edema, peritonitis, ascending cholangitis, fever, chills, leukocytosis, and jaundice have occurred with monooctanoin infusions.
    2) Rare reports of death (a total of 5 cases) have been associated with therapeutic use and were attributed to the following: cholangitis, gallbladder perforation and biliary peritonitis, pulmonary embolism, pancreatitis and sepsis.

Vital Signs

    3.3.3) TEMPERATURE
    A) WITH THERAPEUTIC USE
    1) FEVER and chills have been reported (Caffrey et al, 1996). In another study, fever was attributed to cholangitis in 5% of patients (JEF Reynolds , 2000).

Heent

    3.4.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) Facial flushing occurred during one infusion when intrabiliary pressure was 24 to 26 cm of water.
    3.4.2) HEAD
    A) WITH THERAPEUTIC USE
    1) FACIAL FLUSHING occurred during one infusion when intrabiliary pressure was 24 to 26 cm of water (Minuk et al, 1982).

Cardiovascular

    3.5.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Intravenous injection of monooctanoin resulted in respiratory and cardiac arrest and death.
    3.5.2) CLINICAL EFFECTS
    A) CARDIAC ARREST
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT - A 57-year-old diabetic male developed respiratory and cardiac arrest and died following intravenous administration of monooctanoin (Hejka et al, 1990).

Respiratory

    3.6.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) Dyspnea was seen during an excessive intrabiliary pressure infusion of monooctanoin.
    2) Pulmonary edema has been reported. One report of fatal pulmonary embolism has occurred.
    3.6.2) CLINICAL EFFECTS
    A) DYSPNEA
    1) WITH THERAPEUTIC USE
    a) Dyspnea was seen during an infusion with monooctanoin. This symptom occurred when intrabiliary pressure was 24 to 26 cm of water (Minuk et al, 1982).
    B) ACUTE LUNG INJURY
    1) WITH THERAPEUTIC USE
    a) Pulmonary edema has been associated with intrabiliary infusion of monooctanoin (Hine et al, 1988; Shustack et al, 1986) and are more likely to occur with infusion pressures greater than 30 cm (Caffrey et al, 1996).
    3.6.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) HYPOXIA
    a) DOGS were given monooctanoin under pressure with an obstructed common bile duct to observe the hepatic effect. Three of 4 died at 40 cm of water pressure and 1 of 3 at 30 cm of water pressure. Deaths were due to hypoxia, acidosis, hemolysis and hemorrhagic pneumonitis. The conclusion of the study was that infusion pressures should be monitored to prevent biliary pressure that might lead to intrahepatic reflux (Sharp & Gadacz, 1984).

Gastrointestinal

    3.8.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) Therapeutic side effects include nausea, abdominal pain, vomiting, diarrhea, and mild anorexia and are the most frequently reported symptoms.
    2) Duodenitis, which may lead to hemorrhage, has been reported in both animal and human cases.
    3.8.2) CLINICAL EFFECTS
    A) NAUSEA, VOMITING AND DIARRHEA
    1) WITH THERAPEUTIC USE
    a) Nausea (11%), abdominal pain (6%), diarrhea (5.5%), vomiting (3%), and mild anorexia have been reported. Side effects may be reduced by decreasing the rate of administration (Anon, 1982; Gadacz, 1981).
    b) In another study of 343 patients treated with monooctanoin, abdominal pain was the most commonly reported symptom which occurred in 40% of patients (JEF Reynolds , 2000). Dose-related symptoms of nausea (25%), vomiting (15%), and diarrhea (16%) were also reported.
    B) ABDOMINAL PAIN
    1) WITH THERAPEUTIC USE
    a) In a study of 42 patients receiving monooctanoin therapy, 16 patients (38%) complained of epigastric or right hypochondriac pain following a 3 milliliter infusion; removal of several milliliters of fluid from the bile duct allowed the infusion to continue (Tritapepe & Piro, 1993).
    C) DUODENITIS
    1) WITH THERAPEUTIC USE
    a) Peripapillary hyperemia and erosions of the duodenal mucosa have been seen with a few patients who received this drug by way of a nasobiliary tube (Anon, 1982; Cohen et al, 1984; Tritapepe et al, 1984). Ulceration leading to life-threatening hemorrhage has been seen as a complication (Train et al, 1983).
    D) PERITONITIS
    1) WITH THERAPEUTIC USE
    a) Peritonitis has been associated with infusions that extravasate into the peritoneal cavity (Caffrey et al, 1996).
    E) PANCREATITIS
    1) ANIMAL STUDIES - Pancreatitis was noted in cats after four days of infusion into the gallbladder (Anon, 1982).
    F) TASTE SENSE ALTERED
    1) WITH THERAPEUTIC USE
    a) CASE REPORT - Metallic taste was reported in one patient who had developed an intrabiliary pressure of 24 to 26 cm of water during an infusion of monooctanoin (Minuk et al, 1982).

Hepatic

    3.9.1) SUMMARY
    A) ANIMAL STUDIES - The following adverse effects have been reported in animals after receiving monooctanoin injection: bile duct inflammation, hemorrhagic peritonitis, liver necrosis and abscess.
    B) WITH THERAPEUTIC USE
    1) Cholangitis has been reported in one case. Infrequent reports of jaundice have also occurred.
    3.9.2) CLINICAL EFFECTS
    A) GALLBLADDER FINDING
    1) WITH THERAPEUTIC USE
    a) Ascending CHOLANGITIS has been reported as a result of obstruction in the common bile duct (Prod Info, 1985; (Palmer & Hofmann, 1986; Caffrey et al, 1996). Infrequent reports of JAUNDICE have also occurred (Caffrey et al, 1996).
    3.9.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) CHOLECYSTITIS
    a) Bile duct inflammation has been seen in several animal studies as has inflammation of the gallbladder mucosa cells (Anon, 1982; Leuschner et al, 1984).
    2) PERITONITIS
    a) RATS - HEMORRHAGIC PERITONITIS was noted after injection of monooctanoin into the hepatic parenchyma of rats. Nine of 10 animals died within one half hour of injection (Anon, 1982).
    3) HEPATIC NECROSIS
    a) DOGS - Liver necrosis and abscesses have been noted in dogs given a 50-hour infusion of Capmul 8210 (Leuschner, 1984). This is yet to be reported in humans.

Hematologic

    3.13.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) Leukopenia has been reported with therapy.
    3.13.2) CLINICAL EFFECTS
    A) LEUKOPENIA
    1) WITH THERAPEUTIC USE
    a) Leukopenia has been observed during therapy (Palmer & Hofmann, 1986; JEF Reynolds , 2000).

Immunologic

    3.19.1) SUMMARY
    A) WITH THERAPEUTIC USE
    1) An anaphylactoid reaction has been observed.
    3.19.2) CLINICAL EFFECTS
    A) ANAPHYLACTOID REACTION
    1) WITH THERAPEUTIC USE
    a) CASE REPORT - An anaphylactoid reaction, characterized by wheezing, rash, and hypotension, was described in one patient during therapeutic use (Palmer & Hofmann, 1986).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) No toxic levels of monooctanoin have been established. The manufacturer recommends liver function tests for patients undergoing therapy, but liver malfunction has not been a common abnormality during therapeutic treatment.
    4.1.2) SERUM/BLOOD
    A) TOXICITY
    1) No toxic levels of monooctanoin have been established.
    B) HEMATOLOGIC
    1) There have been no significant abnormalities in hemoglobin or white cell count (Jarrett er al, 1981; (Teplick & Haskin, 1984).
    C) BLOOD/SERUM CHEMISTRY
    1) There have been no significant abnormalities in liver function tests. One patient reported a slightly increased BUN which resolved (Jarret et al, 1981; (Teplick & Haskin, 1984).
    2) The manufacturer recommends routine liver function tests for patients undergoing therapy (Prod Info, 1985).

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Monitoring

    A) No toxic levels of monooctanoin have been established. The manufacturer recommends liver function tests for patients undergoing therapy, but liver malfunction has not been a common abnormality during therapeutic treatment.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) DILUTION -
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    6.5.2) PREVENTION OF ABSORPTION
    A) DILUTION
    1) This material may be irritating to the gastric mucosa.
    2) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    B) ACTIVATED CHARCOAL
    1) CHARCOAL ADMINISTRATION
    a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    6.5.3) TREATMENT
    A) SUPPORT
    1) Good supportive care, as well as discontinuing the drug or reducing the rate of infusion, has been effective therapy for the side effects and minimal toxicity seen with monooctanoin.

Eye Exposure

    6.8.1) DECONTAMINATION
    A) EYE IRRIGATION, ROUTINE: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, an ophthalmologic examination should be performed (Peate, 2007; Naradzay & Barish, 2006).

Dermal Exposure

    6.9.1) DECONTAMINATION
    A) DERMAL DECONTAMINATION
    1) DECONTAMINATION: Remove contaminated clothing and wash exposed area thoroughly with soap and water for 10 to 15 minutes. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).

Range Of Toxicity

Summary

    A) Monooctanoin is perfused via a catheter inserted into the common bile duct via a T-tube or through a nasobiliary tube placed by endoscopy. It is essential to have an overflow manometer, peristaltic pump or similar means to assure pressure does not exceed 15 cm of water. The infusion rate is 3 to 5 mL per hour. Rates higher than these will eventually produce biliary colic.

Therapeutic Dose

    7.2.1) ADULT
    A) GENERAL
    1) Monooctanoin is perfused by way of a catheter inserted into the common bile duct via a T-tube or through a nasobiliary tube placed by endoscopy. It is essential to have an overflow manometer, peristaltic pump or similar means to assure pressure does not exceed 15 centimeters of water (USPDI, 2002).
    2) The infusion rate is 3 to 5 milliliters per hour at a pressure of 10 cm of water (JEF Reynolds , 2000). The solution should be warmed prior to perfusion, and maintained at 37 degrees Celsius during administration. The duration of therapy is generally 2 to 10 days, if no reduction is observed within 7 to 10 days further treatment is unlikely to be beneficial.
    3) Rates higher than 5 milliliters per hour eventually produce biliary colic (Prod Info, 1985; (Teplick & Haskin, 1984). A pressure of at least 2 cm but less than 20 cm is recommended to avoid drug overflow (Caffrey et al, 1996).

Minimum Lethal Exposure

    A) CASE REPORTS
    1) A 57-year-old diabetic male died of respiratory and cardiac arrest following intravenous administration of monooctanoin (Hejka et al, 1990). Postmortem findings included pulmonary lipid embolization, detection of monooctanoin in the lung parenchyma, and histopathological evidence of multifocal pulmonary hemorrhagic infarcts.

Maximum Tolerated Exposure

    A) GENERAL/SUMMARY
    1) Infusion pressures greater than 30 cm may result in noncardiogenic pulmonary edema and respiratory distress (Caffrey et al, 1996). In addition acidosis may occur in patients with hepatic dysfunction (JEF Reynolds , 2000).

Pharmacology Toxicology

Pharmacologic Mechanism

    A) Monooctanoin is a cholesterol solvent used to dissolve bile duct stones retained after cholecystectomy (JEF Reynolds , 2000).

Toxicologic Mechanism

    A) Upper right quadrant pain is most likely due to distention of the bile ducts during an infusion (Sharp & Gadacz, 1984; Tritapepe & Piro, 1993; Caffrey et al, 1996). Symptoms of nausea and vomiting are likely due to drug absorption through the gastrointestinal lumen or catheter displacement (Caffrey et al, 1996).
    B) The cramps, diarrhea and inflammation are most likely due to the effects of the solution into the duodenum (Sharp & Gadacz, 1984; Caffrey et al, 1996).

Physicochemical

Physical Characteristics

    A) Monooctanoin is a liquid at temperatures greater than 18.5 degrees C (Abate & Moore, 1985). Sterile water for injection 10% by volume must be added to monooctanoin. This dilution reduces the viscosity of the solution by nearly 50%, enhancing bathing of the stones. Keeping the solution at 37 degrees C further reduces viscosity and maintains optimal cholesterol solubility (Palmer & Hofmann, 1986).

Molecular Weight

    A) 218.29

References

General Bibliography

    1) Abate MA & Moore TL: Monooctanoin use for gallstone dissolution. Drug Intell Clin Pharm 1985; 19:708-712.
    2) Anon: Monooctanoin for dissolution of cholesterol gallstones retained after cholecystectomy. Fed Reg 1982; 47:55520-55522.
    3) Burgess JL, Kirk M, Borron SW, et al: Emergency department hazardous materials protocol for contaminated patients. Ann Emerg Med 1999; 34(2):205-212.
    4) Caffrey LK, Coughlin P, & Lyons K: Moctanin. Gastroenterol Nurs 1996; 19:183-185.
    5) Caravati EM: Alkali. In: Dart RC, ed. Medical Toxicology, Lippincott Williams & Wilkins, Philadelphia, PA, 2004.
    6) Chyka PA, Seger D, Krenzelok EP, et al: Position paper: Single-dose activated charcoal. Clin Toxicol (Phila) 2005; 43(2):61-87.
    7) Cohen LB, Rubin KP, & Waye JD: Duodenal ulcerations after monooctanoin therapy. Gastrointest Endosc 1984; 30:49-50.
    8) Elliot CG, Colby TV, & Kelly TM: Charcoal lung. Bronchiolitis obliterans after aspiration of activated charcoal. Chest 1989; 96:672-674.
    9) FDA: Poison treatment drug product for over-the-counter human use; tentative final monograph. FDA: Fed Register 1985; 50:2244-2262.
    10) Gadacz TR: The effect of monooctanoin on retained common duct stones. Surgery 1981; 89:527-531.
    11) Golej J, Boigner H, Burda G, et al: Severe respiratory failure following charcoal application in a toddler. Resuscitation 2001; 49:315-318.
    12) Graff GR, Stark J, & Berkenbosch JW: Chronic lung disease after activated charcoal aspiration. Pediatrics 2002; 109:959-961.
    13) Harris CR & Filandrinos D: Accidental administration of activated charcoal into the lung: aspiration by proxy. Ann Emerg Med 1993; 22:1470-1473.
    14) Hejka AG, Poquette M, & Wiebe DA: Fatal intravenous injection of monooctanoin. Am J Forensic Pathol 1990; 11:165-170.
    15) Hine LK, Arrowsmith JB, & Gallo-Torres HE: Monootanoin-associated pulmonary edema. Am J Gastroenterol 1988; 83:1128-1131.
    16) JEF Reynolds : Martindale, The Complete Pharmacopoeia. The Pharmaceutical Press. London, UK (Internet Version). Edition expires 2000; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    17) Kastrup EK: Facts and Comparisons, JB Lippincott Co, St Louis, MO, 1988.
    18) Leuschner U, Sieratzki J, & Klempa I: Investigations on the toxicity of bile salt solutions. Capmul 8210 and a bile salt-EDTA solution for common bile duct perfusion in dogs. Digestion 1984; 30:23-32.
    19) Minuk GY, Hoofnagle JH, & Jones EA: Systemic side effects from the intrabiliary infusion of monooctanoin for the dissolution of gallstones. J Clin Gastroenterol 1982; 4:133-135.
    20) Naradzay J & Barish RA: Approach to ophthalmologic emergencies. Med Clin North Am 2006; 90(2):305-328.
    21) None Listed: Position paper: cathartics. J Toxicol Clin Toxicol 2004; 42(3):243-253.
    22) Palmer KR & Hofmann AF: Intraductal mono-octanoin for the direct dissolution of bile duct stones: experience in 343 patients. Gut 1986; 27:196-202.
    23) Peate WF: Work-related eye injuries and illnesses. Am Fam Physician 2007; 75(7):1017-1022.
    24) Pollack MM, Dunbar BS, & Holbrook PR: Aspiration of activated charcoal and gastric contents. Ann Emerg Med 1981; 10:528-529.
    25) Product Information: Moctanin(R), monooctanoin. Ethitek Pharmaceuticals, Skokie, IL, 1991.
    26) Rau NR, Nagaraj MV, Prakash PS, et al: Fatal pulmonary aspiration of oral activated charcoal. Br Med J 1988; 297:918-919.
    27) Sharp KW & Gadacz TR: Toxic effects of intrahepatic reflux of monooctanoin in a canine model. J Surg Res 1984; 36:475-479.
    28) Shustack A, Noseworthy TW, & Johnston RG: Noncardiogenic pulmonary edema during intrabiliary infusion of mono-octanoin. Crit Care Med 1986; 14:659-660.
    29) Technical Information: Information for the physician on Capmul (IND 3615)/ Moctanin(R) (Summary of Scientific Data). Ascot Pharmaceuticals, 1985.
    30) Teplick SK & Haskin PH: Monooctanoin perfusion for in vivo dissolution of biliary stones. Radiology 1984; 153:379-383.
    31) Train JS, Dan SJ, & Cohen LB: Duodenal ulceration associated with monooctanoin infusion. AJR 1983; 141:557-558.
    32) Tritapepe R & Piro D: Mono-octanoin and methyl tert-butyl ether mixture for bile duct stones. Panminerva Med 1993; 35:22-27.
    33) Tritapepe R, Di Padova C, & Pozzoli M: The treatment of retained biliary stones with monooctanoin: report of 16 patients. Am J Gastroenterol 1984; 79:710-714.