[Ileus after the use of loperamide in a child with acute diarrhea]

A 2-year-old girl was diagnosed as having acute gastroenteritis with severe diarrhoea, for which she was prescribed a loperamide solution. Following this she developed paralytic ileus. She was then treated conservatively and was administered fluid and electrolytes parenterally. She started to recover after 48 hours. In young children with acute diarrhoea there usually is no place for medicinal treatment, and certainly not with antimotility drugs such as loperamide.

Intestinal complications after chemotherapy for patients with unresected primary colorectal cancer and synchronous metastases

BACKGROUND

The role of palliative resection of the primary tumour in patients who present with metastatic colorectal cancer is unclear.

AIMS

This study compared the incidence of major intestinal complications in such patients who received chemotherapy treatment with or without prior palliative resection of the primary tumour.

PATIENTS

The incidence of intestinal obstruction, perforation, fistula formation, and gastrointestinal haemorrhage, and the requirement for abdominal radiotherapy in patients with metastatic colorectal cancer treated at a single institution over a 10 year period was determined.

RESULTS

Eighty two patients received initial treatment with chemotherapy without resection of the primary tumour (unresected group) and 280 patients had undergone prior resection (resected group). In the unresected group, the incidence of peritonitis, fistula formation, and intestinal haemorrhage was 2.4% (95% confidence interval (CI) 0.3-8.5%), 3.7% (95% CI 0.8-10.3%), and 3.7% (95% CI 0.8-10.3%), respectively, and was not significantly different from the resected group. Intestinal obstruction affected 13.4% (95% CI 6.9-22.7%) of patients in the unresected group and 13.2% (95% CI 9.2-17.2%) of patients in the resected group. More patients in the unresected group required >/=3 blood transfusions (14.6% v 7.5%; p=0.048) and abdominal radiotherapy (18.3% v 9.6%; p=0.03) than the resected group.

CONCLUSIONS

The incidence of major intestinal complications in patients with unresected colorectal cancer and synchronous metastases who receive initial treatment with chemotherapy is low. Chemotherapy may be successfully used as initial treatment for such patients with no increased risk of most major intestinal complications compared with patients who have undergone initial resection of the primary tumour.

Late colonic obstruction after barium meal examination in a myxoedematous patient

A case in which inspissated barium was retained and produced sigmoid obstruction after one year is described. The patient was elderly and myxoedematous. Prolonged retention of barium producing a bowel obstruction requiring surgery is a rare complication and, to our knowledge, is only the second case described in which the symptoms of obstruction appeared so late after the examination.

[Gastrointestinal toxicity caused by irinotecan in the case of preexistent passage problems]

Two female patients, aged 50 and 62 years respectively, who were treated with irinotecan, fluorouracil and folinic acid (Saltz scheme) due to metastasised colorectal carcinoma, developed progressive abdominal pain, fever and leucopenia. One patient also exhibited intestinal obstruction. The main problem was differentiating between an acute abdomen and irinotecan toxicity. Both patients recovered without the need for an operative intervention. One patient was treated by means of colonic stent placement. The combination of gastrointestinal irinotecan toxicity and pre-existing passage problems is dangerous. However, in such cases restraint should be exercised with respect to operative interventions.

[Colonic stenosis secondary to non-steroid anti-inflammatory agents as a cause of anemia and chronic diarrhea]

Gastroduodenal mucosal injury is a widely recognized side effect of non-steroidal antiinflammatory agents (NSAID). Distal small bowel and colon are additional organs of the gastrointestinal tract exposed to deleterious effects of these drugs. Inflammation and ulceration have been described as pathologic damage associated with NSAID. Strictures of colon induced by NSAID are a new entity characterized by diaphragm-like strictures. Most patients present with anemia, obstructive symptoms, diarrhea, or weight loss. Endoscopic dilation, surgical resection, symptomatic treatment, and interruption of NSAID ingestion are treatment of choice. Only 23 cases of NSAID-related, colonic, diaphragm-like strictures have been reported. Here we describe a case of concentric colonic stricture related to naproxen and clinical features of this entity are discussed.

[Pseudotumoral enterocolic phlebitis of the cecum and rutoside. A case report]

INTRODUCTION

Enterocolic phlebitis is an entity characterized by ischemic injury of the gastrointestinal tract caused by thrombophlebitis of the mesenteric veins without arterial involvement or systemic disease.

EXEGESIS

We report a case of enterocolic phlebitis in a 57-year-old female treated by rutoside, revealed by intestinal obstruction related to a pseudotumoral lesion of the caecum.

CONCLUSION

This case adds to the four cases of enterocolic phlebitis under rutoside already reported in the literature, suggesting a possible involvement of this drug in this rare disease.

Treatment of anticholinergic-induced ileus with neostigmine

A 33-year-old man with a history of recreational benztropine abuse presented to the emergency department with confusion, abdominal pain, and distention. An abdominal radiograph revealed gross fecal loading. He was initially treated with intravenous fluids and opiate analgesia. Subsequently, a diagnosis of anticholinergic poisoning was made, based on tachycardia, delirium, dry mucosa, and reduced bowel sounds. Treatment with tacrine reversed the delirium, and a history of repeated benztropine use was obtained. Persistent ileus was treated with repeated doses of neostigmine, and gastrointestinal motility returned with prompt defecation. Neostigmine appears to be useful in reversing ileus caused by anticholinergic drug overdose. Theoretically, it may be useful in reversing anticholinergic ileus resulting from acute drug overdose, allowing or enhancing decontamination, but the safety and potential efficacy of neostigmine in this scenario have not been established.

Weekly vinorelbine is an effective palliative regimen after failure with anthracyclines and taxanes in metastatic breast carcinoma

BACKGROUND

Currently, there is no gold standard for the treatment of patients with metastatic breast carcinoma who have experienced failure with anthracyclines and taxanes. A biologic rationale suggests that the mechanism of taxane resistance could be because of an excess of depolymerized tubulin that could enhance sensitivity to vinorelbine. The objective of the study was to assess the tolerance and efficiency of weekly vinorelbine in metastatic breast carcinoma after failure with taxanes.

METHODS

Patients with measurable disease, a World Health Organization performance status of less than 3 and a life expectancy longer than 3 months were eligible. Persistent taxane-induced neuropathy higher than Grade 1 was an exclusion criterion. The initial planned dose was 30 mg/m(2)/week on an outpatient basis without granulocyte colony-stimulating factor (G-CSF). Neutrophil and platelet counts of 1.0 and 80 g/L, respectively, were required before each new injection; otherwise vinorelbine was delayed for 7 days with a dose reduction of 5 mg/m(2) at the second episode. The dose also was reduced if Grade 3 or 4 toxicity occurred. If the adverse event persisted or if the delay exceeded 14 days between 2 injections given at a dose of 20 mg/m(2), vinorelbine was definitively discontinued.

RESULTS

Between November 1997 and March 1999, 40 patients with a median age of 49 (range, 39-69) were enrolled. All of them had previously received anthracyclines and taxanes. Because of the delays in neutrophil recovery, the median dose intensity did not exceed 22.5 mg/m(2)/week (range, 11.25-30), and the initial planned dose of 30 mg/m(2)/week appeared unfeasible without G-CSF. The starting dose therefore was 25 mg/m(2)/week after the first 6 patients. Neutropenia led to fever in only three patients. Other severe toxicities were Grade 2-3 neuropathy (n = 5), Grade 2-3 ileus (n = 7), Grade 3 anemia (n = 4), and Grade 3 sepsis (n = 1). Objective responses were observed in 10 of 40 patients (25%), 7 of whom had visceral metastases and 4 who were refractory to taxanes (including 2 patients with liver involvement > 50%). The median time to failure was 6 months (range, 4-12) for responding patients. Disease stabilization was achieved in 9 patients (23%) for a median duration of 5 months (range, 4-6). The median survival duration for the whole population was 6 months (range, 2-18+).

CONCLUSIONS

Weekly vinorelbine is an active salvage therapy for metastatic breast carcinoma after failure with anthracyclines and taxanes, even in patients with taxane-refractory metastatic breast carcinoma. This confirms that vinorelbine and taxanes are not cross-resistant.

NSAID-induced small bowel diaphragms and strictures diagnosed with intraoperative enteroscopy

Nonsteroidal anti-inflammatory drugs are known to cause mucosal damage in the stomach and duodenum, which may lead to hemorrhage and perforation. However, these medications may also cause damage in the more distal small bowel. Due to the location of these lesions, currently available diagnostic testing may yield false negative results. Two cases of nonsteroidal anti-inflammatory drug-induced small bowel diaphragms presenting as obscure gastrointestinal hemorrhage and recurrent small bowel obstruction, respectively, are discussed. Intraoperative enteroscopy was used to confirm this diagnosis after other diagnostic tests failed to identify the etiology. This procedure may increase the accuracy of exploratory laparotomy in these challenging cases.

Gastrointestinal problems in patients with advanced gynaecological malignancy

Gastrointestinal problems are among the most common problems encountered in the management of women with far advanced gynaecological malignancy. They frequently have a multifactorial aetiology and may require a number of different strategies for effective management. Recognition of the central role of alimentary function in human life is essential to effective treatment. Elucidation of the probable cause of each problem is essential. A thorough knowledge of the natural history of the disease and the patient's current status and future prospects is needed to ensure the highest standard of care for the individual suffering from the problem.

Diaphragm disease of the small bowel: a case without apparent nonsteroidal antiinflammatory drug use

BACKGROUND

Diaphragm-like strictures of the small bowel are an infrequent complication of the treatment of patients with nonsteroidal antiinflammatory drugs (NSAIDs).

STUDY

We report a patient with this condition in whom the use of NSAIDs was ruled out by both clinical history and objective blood testing of current aspirin use.

RESULTS

He reported a history of recurrent episodes of colic abdominal pain during the past 25 years; he underwent three surgical operations for this condition. Before these symptoms, he had an undefined abdominal process with diarrhea, weight loss, and diffuse edema, which resolved spontaneously without reaching a diagnosis.

CONCLUSIONS

We suggest that diaphragm-like strictures might be developed as a nonspecific response to different damaging insults to the intestine and are not necessarily associated with NSAID use.

Ileus after administration of cold remedy in an elderly diabetic patient treated with acarbose

A 69-year-old type 2 diabetic man was admitted due to diabetic gangrane. He had a history of subtotal gastrectomy. During hospitalization, he was treated with regular insulin and 300 mg/day of acarbose. He developed a low grade fever, cough and nasal discharge, and was given a compound "cold" remedy with anticholenergic properties. The next day, he suffered from a paralytic ileus. Oral intake and acarbose were withheld and the ileus spontaneously resolved after 2 days. These finding indicate the possibility that the ileus was triggered by drugs with anticholinergic properties in this elderly diabetic patient treated with alpha-glucosidase inhibitors.

Rectal stricture associated with the long-term use of ibuprofen suppositories

Here, we report the case of a 64-year-old woman who suffered from chronic lower backache for which she received ibuprofen suppositories. The patient was admitted to the hospital with a suspected rectal tumor. Clinical examination did not reveal any abnormal finding apart from a mild, bilateral peritibial edema. On rectal examination, an area of stenosis was detected approximately 7 cm above the anal verge. All laboratory parameters, including different tumor markers, were within normal range. Pelvic CT scan and colonoscopy revealed a circular rectal stenosis with severe destruction of the rectal mucosa. The rectal biopsy taken during endoscopy showed severe acute and chronic ulceration, chronic granulation and fibrosis with lymphocytic infiltration. After exclusion of sexually transmitted diseases such as syphilis and lymphogranuloma venerium or exposure to drugs as a possible cause of rectal stenosis, the history in this particular case suggests that the prolonged use of the cyclooxygenase (COX) inhibitor "ibuprofen" as a suppository is the cause of mucosal destruction and rectal stenosis.

[Paralytic ileus during treatment of acute promyelocytic leukemia with all-trans retinoic acid]

A 54-year-old man was referred to our hospital because of petechiae and pancytopenia. Bone marrow aspiration showed a normocellular marrow with 92.4% promyelocytes. PML/RAR alpha mRNA was detected by reverse transcription polymerase chain reaction. On the basis of above data, a diagnosis of acute promyelocytic leukemia (APL) was made, and treatment with all-trans retinoic acid (ATRA) at a dose of 60 mg/day was begun. Fourteen days after the start of treatment, the patient developed paralytic ileus, accompanied by hyperleukocytosis, high fever, renal dysfunction and elevation of the serum FDP level. There was no evidence of infection. At this time, retinoic acid syndrome was suspected, and therefore steroid pulse therapy was started, which led to an improvement of the symptoms within four days. This case suggests that ATRA may have an adverse effect on the small intestine, causing paralytic ileus.

Unusual negative side effects of non-steroidal anti-inflammatory drugs in the proximal colon

Two cases of uncommon side effects of non-steroidal anti-inflammatory drugs (NSAID) are presented which show that in special cases NSAID lesions can be located predominantly in the proximal colon, that NSAID-caused lesions may present themselves as diaphragm-like strictures and that alterations by NSAID in this part of the bowel may bring enormous problems for the differential diagnosis.

Clinical, endoscopic, and histologic spectrum of nonsteroidal anti-inflammatory drug-induced lesions in the colon

PURPOSE

It has become increasingly clear that nonsteroidal anti-inflammatory drugs may cause damage not only to the upper gastrointestinal tract but also to the small and large intestine. Although the colon may be readily investigated by endoscopy, drug-induced lesions are not well known, probably because they are considered to occur only rarely. In the present study we describe endoscopic, histologic, and gross characteristics of nonsteroidal anti-inflammatory drug-induced colonic damage. Furthermore, pathogenetic mechanisms and therapeutic options are discussed.

METHODS

The histories of all patients diagnosed as having nonsteroidal anti-inflammatory drug colitis during the last two years at the department of gastroenterology or the department of pathology at our hospital were reviewed. Endoscopic, histologic, and gross pathologic findings were systematically recorded. In addition, data on duration and type of nonsteroidal anti-inflammatory drug intake and time from onset of symptoms to diagnosis were collected. Therapy and outcome of our patients, if available, are reported.

RESULTS

During the study period 11 patients were diagnosed as having nonsteroidal anti-inflammatory drug colitis. Most patients presented with diarrhea with or without blood loss and complained about diffuse abdominal pain. Endoscopy revealed flat ulcers in the entire colon being more severe in the right colon in the three cases with acute onset of diarrhea. In four cases concentric "diaphragm-like" strictures were seen, all located in the right colon. In the remainder endoscopy showed nonspecific erosions and was normal in one patient. Histology revealed findings similar to ischemic colitis. Additionally, in two cases collagenous colitis was found. Diclofenac slow release was the most commonly involved drug. The median time from onset of symptoms to diagnosis was 1.8 (range, 0-11.5) years.

CONCLUSIONS

Nonsteroidal anti-inflammatory drug colitis is a clinically significant disease, which may present with diarrhea, anemia, and nonspecific abdominal complaints. Careful history taking, together with awareness of endoscopic and histologic findings, allows a timely diagnosis of this disease.

Fedotozine, a kappa-opioid agonist, prevents spinal and supra-spinal Fos expression induced by a noxious visceral stimulus in the rat

Fedotozine, a kappa opioid agonist, reverses digestive ileus caused by acetic acid (AA)-induced visceral pain in rats. The aims of this study were: to map, in conscious rats, central pathways activated by AA using Fos as a marker of neuronal activation; to characterize primary afferent fibres involved in this activation; and to investigate the effect of fedotozine on AA-induced Fos expression. AA (0.6%; 10 mL kg-1) was injected i.p. in conscious rats either untreated; pretreated 14 days before with capsaicin; pretreated 20 min previously with fedotozine; or pretreated 2 h prior to fedotozine with the kappa-antagonist nor-binaltorphimine (nor-BNI). Controls received the vehicle alone. 60 min after injection of AA, rats were processed for Fos immunohistochemistry. Visceral pain was assessed by counting abdominal cramps. AA induced Fos in the thoraco-lumbar spinal cord (laminae I, V, VII and X) and numerous brain structures such as the nucleus tractus solitarius, and paraventricular nucleus (PVN) of the hypothalamus, whereas almost no Fos labelling was observed in controls. Capsaicin pretreatment blocked AA-induced Fos in all structures tested. Fedotozine significantly decreased AA-induced abdominal cramps and Fos immunoreactivity in the spinal cord and PVN, this effect being reversed by nor-BNI pretreatment. AA induces Fos in the spinal cord and numerous brain nucuei, some of which are involved in the control of digestive motility in rats. This effect is mediated through capsaicin-sensitive afferent fibres and prevented by fedotozine most likely through a peripheral action on visceral afferents.