Ischemic or toxic injury: A challenging diagnosis and treatment of drug-induced stenosis of the sigmoid colon.

A 48-year-old woman was admitted with 15-mo history of abdominal pain, diarrhea and hematochezia, and 5-mo history of defecation difficulty. She had been successively admitted to nine hospitals, with an initial diagnosis of inflammatory bowel disease with stenotic sigmoid colon. Findings from computed tomography virtual colonoscopy, radiography with meglumine diatrizoate, endoscopic balloon dilatation, metallic stent implantation and later overall colonoscopy, coupled with the newfound knowledge of compound Qingdai pill-taking, led to a subsequent diagnosis of ischemic or toxic bowel disease with sigmoid colon stenosis. The patient was successfully treated by laparoscopic sigmoid colectomy, and postoperative pathological examination revealed ischemic or toxic injury of the sigmoid colon, providing a final diagnosis of drug-induced sigmoid colon stenosis. This case highlights that adequate awareness of drug-induced colon stenosis has a decisive role in avoiding misdiagnosis and mistreatment. The diagnostic and therapeutic experiences learnt from this case suggest that endoscopic balloon expansion and colonic metallic stent implantation as bridge treatments were demonstrated as crucial for the differential diagnosis of benign colonic stenosis. Skillful surgical technique and appropriate perioperative management helped to ensure the safety of our patient in subsequent surgery after long-term use of glucocorticoids.

Ileus and Intra-Abdominal Hypertension due to Phosphate- Containing Enema.

The most well known complications of fleet enema solution are cardiac insufficiency, renal failure, water-electrolyte imbalance, and ileus. A 7-y-old girl with phenylketonuria and long-term constipation was admitted to the emergency department with symptoms of seizure, vomiting and abdominal distention. Laboratory results revealed hypocalcemia and hyperphosphatemia. ECG findings showed normal sinus rhythm and prolonged QT interval. At the follow-up, the patient's abdominal distention was markedly increased. She was evaluated for a surgical pathology and, this was considered unlikely. Intra-abdominal pressure (IAP) was 19.5 mmHg. Gastric and colonic decompression, intravenous 10 % calcium gluconate were applied. After 2 d of treatment, the patient's condition became stable, and serum calcium and phosporus normalized to 8.8 mg/dl and 4.0 mg/dl, respectively. Abdominal distention regressed and the last IAP measurement was 3.5 mmHg. Thus, IAP measurements are a useful adjunct in clinical follow-up of patients with progressive abdominal distention due to phosphate enema use.

Proton-Pump Inhibitors Reduce Gastrointestinal Events Regardless of Aspirin Dose in Patients Requiring Dual Antiplatelet Therapy.

BACKGROUND: The COGENT (Clopidogrel and the Optimization of Gastrointestinal Events Trial) showed that proton-pump inhibitors (PPIs) safely reduced rates of gastrointestinal (GI) events in patients requiring dual antiplatelet therapy (DAPT). However, utilization of appropriate prophylactic PPI therapy remains suboptimal, especially with low-dose aspirin. OBJECTIVES: The authors investigated the safety and efficacy of PPI therapy in patients receiving DAPT in low- and high-dose aspirin subsets. METHODS: Randomized patients with available aspirin dosing information in COGENT (N = 3,752) were divided into "low-dose" (≤ 100 mg) and "high-dose" (>100 mg) aspirin groups. The primary GI and cardiovascular endpoints were composite upper GI events and major adverse cardiac events, respectively. All events were adjudicated by independent, blinded gastroenterologists and cardiologists. RESULTS: Median duration of follow-up was 110 days. Low-dose aspirin users (n = 2,480; 66.1%) were more likely to be older, female, and have higher rates of peripheral artery disease, prior stroke, and hypertension, whereas high-dose aspirin users (n = 1,272; 33.9%) had higher rates of hyperlipidemia, smoking, a history of percutaneous coronary intervention, and were more than twice as likely to be enrolled from sites within the United States (80.4% vs. 39.8%). High-dose aspirin was associated with similar 180-day Kaplan-Meier estimates of adjudicated composite GI events (1.7% vs. 2.1%; adjusted hazard ratio: 0.88; 95% confidence interval: 0.46 to 1.66) and major adverse cardiac events (4.8% vs. 5.5%; adjusted hazard ratio: 0.73; 95% confidence interval: 0.48 to 1.11) compared with low-dose aspirin. Randomization to PPI therapy reduced 180-day Kaplan-Meier estimates of the primary GI endpoint in low-dose (1.2% vs. 3.1%) and high-dose aspirin subsets (0.9% vs. 2.6%; p for interaction = 0.80), and did not adversely affect the primary cardiovascular endpoint in either group. CONCLUSIONS: Gastroprotection with PPI therapy should be utilized in appropriately selected patients with coronary artery disease requiring DAPT, even if the patients are on low-dose aspirin. (Clopidogrel and the Optimization of Gastrointestinal Events Trial [COGENT]; NCT00557921).

Lead poisoning associated with Ayurvedic drug presenting as intestinal obstruction: a case report.

INTRODUCTION: Lead poisoning is most commonly caused by occupational exposure. It presents with a myriad of signs and symptoms ranging from mild anemia to frank encephalopathy, depending on the blood lead levels as well as the duration of exposure. Intake of herbal/Ayurvedic medicine may also lead to plumbism as heavy metals are often incorporated in such medications with the belief that such metals have medicinal properties. METHODS: We report a case of lead poisoning caused by Ayurvedic medication. The patient presented with symptoms of intestinal obstruction to the surgical casualty. RESULTS: The patient presented with symptoms that mimicked intestinal obstruction. No specific etiology could be determined. Serum lead levels were determined and diagnosis of lead poisoning ascertained. The lead content of the medicine was analyzed and it contained 30% w/w lead. CONCLUSIONS: The diagnosis of heavy metal poisoning consequent to intake of alternative medicine must be kept in mind when a patient presents with vague complaints.

Superwarfarin poisoning as a cause of intestinal obstruction.

A 17-year-old boy was brought to our department with nausea, vomiting, absence of flatus or bowel movements, abdominal distension, and pain for about 5 days. Emergency abdominal CT scan showed extensive gas-fluid levels in the intestinal tract and intestinal wall swelling that indicated acute intestinal obstruction. Routine coagulation tests revealed abnormality and further provided evidence of superwarfarin poisoning. With high dosage of vitamin K1 and fresh frozen plasma therapy, surgery was avoided.

Synchronous postoperative adjuvant chemoradiation therapy for locally advanced carcinoma of the rectum.

BACKGROUND AND AIMS: The adjuvant management of locally advanced rectal cancer has been the subject of much debate over the past 10 years. Whilst it is now widely accepted that combined chemoradiation therapy is the treatment of choice for adjuvant therapy following resection of high-risk tumours, there is still no clear answer on the sequencing of the two modalities in the postoperative setting. PATIENTS AND METHODS: Soon after the NCI in the United States issued its recommendations on the management of resected rectal cancer, we decided to commence a phase 2 study to collect data prospectively on the toxicity of postoperative combined chemoradiation therapy. Radiation therapy was given early in combination with bolus chemotherapy using 5-fluorouracil ( n=80). The prescribed radiation dose was 50.4 Gy in 28 fractions, and the chemotherapy was 450 mg/m(2) given with fractions 1 - 3 and 26 - 28. On completion of the radiation therapy the patient was given a further four cycles of bolus 5-fluorouracil at monthly intervals. The patients were then closely monitored for side effects from the therapy and for signs of local and distant relapse. RESULTS: Acute toxicity of the therapy was significant, with 16% of patients experiencing severe bowel morbidity. The other major side effects of the therapy were skin reactions, neutropenia and bladder problems. Late bowel toxicity was also severe. The local in field relapse rate was 10%. The majority of relapses were at distant sites, mostly in the liver and lungs. The actuarial survival at 5 years was 55%. CONCLUSION: We conclude that the combined adjuvant postoperative chemoradiation therapy using this protocol is effective but has significant acute and late morbidity. The optimum regimen for those patients requiring postoperative adjuvant therapy is yet to be determined.

Colon ischaemia secondary to barolith obstruction.

A case is described of an elderly woman who developed an obstructing barolith in the sigmoid colon following a barium enema. Colonic ischaemia developed in the proximal colon. Predispositions and prevention of baroliths are discussed.

[Occurrence of ileus after voglibose treatment in an elderly diabetic patient with gait disturbance caused by cerebral hemorrhage].

Alpha-glucosidase inhibitor can suppress postprandial hyperglycemia by delaying the absorption of carbohydrates in the intestine, and may be useful in obese patients with non-insulin-dependent diabetes mellitus (NIDDM) and preserved insulin secretion. We encountered an obese elderly patient with NIDDM in whom gait disturbance had developed after cerebral hemorrhage and who suffered from ileus after treatment with voglibose. The patient had received voglibose which is reported to cause fewer abdominal symptoms than acarbose, for 15 days. The patient, a 63-year-old woman, was given a diagnosis of NIDDM in February 1995, and was treated with a sulfonylurea agent. However, her glycemic control remained poor and she was admitted to our hospital in April 1995. Her body mass index was 30.5 kg/m2 and laboratory investigation revealed a fasting plasma glucose level of 211 mg/dl, a postprandial (2 h) plasma glucose level of 288 mg/dl, HbAlc of 9.9%, a fasting insulin level of 9 microU/ml, urinary C-peptide excretion of 95.7 micrograms/ day, and an coefficient of variation of R-R value of 2.1%. Fifteen days after glibenclamide was replaced by to voglibose, abdominal pain, nausea, constipation, and ausculatory sounds of gurgling developed, and niveau were noted on an abdominal roentgenogram which indicated that simple ileus had developed. Voglibose was discontinued and the patient was treated with an enema and hot air. She recovered from simple ileus on the next day. This patient had had two abdominal surgeries and a cerebral hemorrhage, and her daily physical activities were limited, which might have contributed to ileus. In elderly patients with NIDDM, a history of abdominal surgery and the amount of daily exercise must be considered when deciding whether or not to give alpha-glucosidase inhibitors.

Gut inflammation in children with cystic fibrosis on high-dose enzyme supplements.

We used a whole-gut perfusion technique to study subclinical gut inflammation in children with cystic fibrosis (18 elective tests, three lavages to treat distal intestinal obstruction syndrome); and in 12 control children with constipation or pre-colonoscopy. We assayed for haemoglobin, IgG, albumin, alpha-1-antitrypsin, granulocyte elastase, interleukin-1 beta (IL-1 beta) and IL-8 concentrations in whole-gut lavage fluid. Results for two children with distal intestinal obstruction syndrome, the only children in the series taking Nutrizym 22, were strikingly abnormal. This new test has revealed subclinical gut mucosal inflammation in a minority of CF children, for which distal intestinal obstruction syndrome, Nutrizym 22 treatment, or both, may be risk factors.

Fedotozine reversal of peritoneal-irritation-induced ileus in rats: possible peripheral action on sensory afferents.

Two kappa agonists, fedotozine and trans-(+/-)-3,4-dichloro-N-methyl-N-[2-(1-pyrrolydinyl)-cyclohexyl ]- benzeneacetamide methanesulfonate [(+/-)U-50,488H] were used to reverse the gastrointestinal transit inhibition induced by either peritoneal irritation (PI) or intracisternal (i.c.) administration of corticotropin releasing factor (CRF). PI was induced by acetic acid given i.p. Gastric emptying and intestinal transit were estimated with a 51Cr-labeled test meal. PI inhibited both gastric emptying (-50.9%) and intestinal transit (-48.8%). These inhibitions were prevented in a dose-dependent manner by the CRF antagonist, alpha-helical-CRF9-41 at doses (1-10 nmol/rat i.c.) that had no effect in control animals. CRF (300 pmol/rat i.c.) reproduced the gastrointestinal transit inhibitions seen under PI. The CRF effects were blocked by alpha-helical-CRF9-41 (10 nmol/rat) given i.c. but not i.v. Fedotozine (1-10 mg/kg s.c. but not 300 micrograms/rat i.c.v. or intrathecally) and (+/-)U-50,488H (0.3-3 mg/kg s.c. but not 100 micrograms/kg i.c.v.) reversed PI- but not CRF-induced ileus. Neither PI-induced ileus nor the fedotozine response was affected by perivagal capsaicin treatment. It was concluded that the PI-induced ileus depends on central CRF receptors. This result is consistent with the activation of an extrinsic inhibitory reflex. The reversal by kappa agonists of PI- but not CRF-induced ileus suggests that kappa agonists do not act after but before the CRF receptors. A possible peripheral action on nonvagal sensory afferents is suggested.

Acute ileus from steroid withdrawal simulating intestinal obstruction after surgery for ulcerative colitis.

Sixty of 127 prednisone-dependent patients with ulcerative colitis who underwent colectomy and endorectal ileal pull-through with ileal reservoir and subsequent laparotomy with ileostomy closure (254 operations) during a 4-year period developed 95 episodes of intestinal obstruction during the early post-operative period. Acute ileus due to steroid withdrawal caused symptoms of intestinal obstruction in 43 patients (76 episodes), whereas true mechanical small-bowel obstruction occurred in only 17 patients (19 episodes). Symptoms of both conditions were similar; however, hypoactive bowel sounds, acute onset of emotional depression, no evidence of obstruction on radiologic contrast stomatogram or enema, and prompt relief of symptoms within 4 hours after intravenous administration of hydrocortisone acetate distinguished acute steroid withdrawal. Since ileus from acute steroid withdrawal occurred four times as frequently as mechanical small-bowel obstruction, prompt recognition and treatment should appreciably reduce postoperative morbidity and hospital costs.

Toxicity studies of adjuvant intravenous versus intraperitoneal 5-FU in patients with advanced primary colon or rectal cancer.

Clinical studies were prospectively conducted to quantitate the toxic side-effects of 5-FU administered by either the intravenous (i.v.) or intraperitoneal (i.p.) route. Sixty-six patients were treated following resection of a primary large bowel cancer after randomization to receive 5-FU by i.p. or i.v. routes. In both groups of patients, the dose of drug was increased a fixed amount until a toxic response occurred. At this point, the dose of drug was maintained or reduced in an attempt to complete 12 monthly treatment cycles of chemotherapy. The overall mean dose of drug administered by the i.p. route (1,479 mg) was significantly greater than given i.v. (1,019 mg), as it was for each treatment cycle. The primary adverse side-effect, resulting in drug dose stabilization or reduction, was leukocyte suppression of i.v. 5-FU or physical symptoms (abdominal pain or discomfort) for i.p. 5-FU (p2 = 0.0006 and p2 = 0.0318, respectively). The most frequent symptom reported by all patients was fatigue. Even though i.v. 5-FU dose was titrated to reduce toxicity, the nadir leukocyte count was suppressed over all cycles. The total numbers of immediate and delayed serious complications that resulted from i.v. or i.p. 5-FU were similar, although the nature of these complications differed markedly between the two routes of drug administration. Failure to complete 5-FU chemotherapy was significantly more common if patients received i.v. 5-FU plus pelvic irradiation. These studies indicate that intraperitoneal 5-FU administration decreases systemic drug effects even when the i.p. drug dose is increased to cause local toxicity.

Vincristine in the etiology of toxicity of high-dose methotrexate therapy.

A 14-year-old received a six-hour infusion of methotrexate (71/2 g/M2) with vincristine (2 mg) and citrovorum rescue according to a standard protocol for adjunctive chemotherapy of osteogenic sarcoma. Signs of mild vincristine toxicity occurred from 2-5 days following the infusion; these including jaw pain, decreases in deep tendon reflexes, and a transient ileus. Clearance of serum methotrexate was delayed during the period of ileus and severe methotrexate toxicity was observed.

Bulk laxative ileus.

In an elderly nursing home resident who had taken excessive dosages of bulk laxative for many years, small-bowel obstruction developed, requiring surgical intervention. A carcinoma of the ascending colon probably was the immediate cause of the obstruction, which resulted in the accumulation and inspissation of the bulk laxative throughout the small bowel. Great care should be exercised in the long-term use of these laxatives.