RESUMEN
While macrocytic anemia is common in vitamin B12 deficiency, rarely, pancytopenia and hemolytic anemia can occur. Homocysteine levels are elevated in severe B12 deficiency, and this is linked to thrombus formation with potentially life-threatening complications. We present a patient with severe vitamin B12 deficiency complicated by hyperhomocysteinemia and obstructive shock from pulmonary embolism. A 56-year-old male with no medical history presented to the hospital with altered mentation. The patient's family stated he was experiencing bilateral paresthesias of his lower extremities, progressive depression, anxiety, and insomnia. Initial vitals were blood pressure of 76/36, heart rate of 70 beats per minute, respiratory rate of 14, and temperature of 36.3 degrees Celsius. He was intubated due to severe encephalopathy. Relevant labs indicated severe macrocytic anemia, thrombocytopenia, decreased B12 levels, elevated methylmalonic acid, and elevated homocysteine. Imaging demonstrated a right common femoral vein thrombosis and subsegmental pulmonary emboli. Peripheral blood smear revealed schistocytes, anisopoikilocytosis, and decreased platelet count. The patient required fluid resuscitation, antibiotics, and multiple blood products. Vitamin B12 was administered intramuscularly, which improved the anemia. Esophagogastroduodenoscopy (EGD) demonstrated gastritis. Gastric and duodenal biopsies were negative for Helicobacter pylori and celiac disease. He was negative for intrinsic factor (IF) antibodies but had elevated gastrin levels. An intravenous unfractionated heparin infusion was started when the platelet count was above 50000. The patient was extubated after seven days. Heparin was transitioned to apixaban and an inferior vena cava (IVC) filter was placed. Hyperhomocysteinemia is a known pro-thrombotic factor that can lead to the development of venous thromboembolism. B12 malabsorption can stem from inflammatory bowel disease, celiac disease, gastritis, pancreatic insufficiency, gastrectomy, gastric bypass surgery, or antibodies to IF. While this case showed gastritis and negative IF antibodies, gastrin levels were elevated, indicating a mixed picture. This highlights the challenge of definitively diagnosing pernicious anemia as the cause of vitamin B12 deficiency. Vitamin B12 deficiency may lead to critical illness in which thromboembolism develops secondary to hyperhomocysteinemia.
RESUMEN
Bouveret syndrome is ectopic gallstone impaction and obstruction of the duodenum or pylorus affecting a small minority of gallstone ileus cases. There have been advances in its endoscopic management, but this remains a challenging condition to treat successfully. We present a patient with Bouveret syndrome who required open surgical extraction and gastrojejunostomy after attempts of endoscopic retrieval and electrohydraulic lithotripsy (EHL). A 79-year-old man with a medical history of gastroesophageal reflux disease, chronic obstructive pulmonary disease on 5 liters of oxygen at baseline, and coronary artery disease with recent stenting presented to the hospital with three days of abdominal pain and vomiting. CT of the abdomen/pelvis demonstrated gastric outlet obstruction, a 4.5 cm gallstone in the proximal duodenum, cholecystoduodenal fistula, gallbladder wall thickening, and pneumobilia. Esophagogastroduodenoscopy (EGD) demonstrated a black pigmented stone impacted in the duodenal bulb with ulceration of the inferior wall. Repeated Roth net retrieval attempts of the stone were unsuccessful even after biopsy forceps were used to trim the stone's margins. The next day, EGD with EHL used 20 shocks of 200 watts, allowing for partial stone removal and fragmentation, but the majority of the stone remained stuck to the wall. Laparoscopic cholecystectomy was attempted but was converted to an open extraction of the gallstone from the duodenum, pyloric exclusion, and gastrojejunostomy. The gallbladder remained in place, and the cholecystoduodenal fistula was not surgically repaired. The patient experienced significant postoperative pulmonary insufficiency and remained on the ventilator with failure of multiple spontaneous breathing trials. Postoperative imaging showed resolution of pneumobilia but a small amount of contrast leaked from the duodenum revealing the fistula's persistence. After 14 days of unsuccessful ventilator weaning, the family opted for palliative extubation. Advanced endoscopic techniques have been regarded as the first-line intervention for Bouveret syndrome as there is low morbidity and mortality associated with them. However, there is a reduced success rate compared to surgical intervention. Open surgical management has high morbidity and mortality in the elderly and comorbid patients commonly affected by this condition. Thus, the risks and benefits must be weighed and individualized for each patient with Bouveret syndrome before therapeutic intervention.
RESUMEN
CONTEXT: Cultural competency is a cornerstone of patient-centered health care. Religious doctrines may define appropriate consumption or use of certain animals and forbid use of others. Many medications contain ingredients that are animal-derived; these medications may be unacceptable to individual patients within the context of their religious beliefs and lifestyle choices. Knowledge of animal-derived medications as a component of cultural competency can facilitate a dialogue that shifts focus from the group to the individual, away from cultural competency toward cultural humility, and away from a paternalistic provider/patient dynamic toward one of partnership. OBJECTIVES: To explore how animal-derived drug components may impact medication selection and acceptability from the perspective of patients, physicians, and religious leaders as evidenced by studies that explore the question via survey or questionnaire. A secondary objective is to use the context of animal-derived drug products as a component of cultural competency to build a framework supporting the development of cultural humility. METHODS: A systematic search was performed in the PubMed, CINAHL, Cochrane, and ProQuest databases using combinations of the following terms: "medication selection," "medication," "adherence," "pharmaceutical preparations," "religion and medicine," "religion," "animal," "dietary," "porcine," and "bovine." Studies that reported using surveys or questionnaires to examine patient, physician, or religious leader perspective on animal-derived medications published in English between 1990 and 2020 were included. Review articles, opinion pieces, case reports, surveys of persons other than patients, religious leaders, or physicians, and studies published in languages other than English were excluded. Three authors independently reviewed articles to extract information pertaining to perspectives on animal-based medication ingredients. RESULTS: Eight studies meeting the described criteria were found that queried beliefs or knowledge of patients, religious leaders, or physicians regarding medications and medical products of biologic origin. Those studies are described in full in this review. CONCLUSIONS: Knowledge of animal-derived ingredients may help open conversations with patients around spiritual history and cultural competency, particularly for those patients belonging to religious sects with doctrines that define appropriate use of human- or animal-derived products. Further formal study is needed to explore more fully the extent to which religious beliefs may impact selection of animal- or human-derived medications. Guidelines developed from this knowledge may aid in identifying individual patients with whom the discussion may be particularly relevant. More studies are needed to quantify and qualify beliefs regarding animal-derived medication constituents.
