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Kumar M, Dixit R, Kapoor R, Singh S. From neglect to peril: diabetic ketoacidosis unleashing colonic necrosis and perforation in an adolescent girl with type 1 diabetes mellitus. J Pediatr Endocrinol Metab 2024; 37:170-173. [PMID: 38167416 DOI: 10.1515/jpem-2023-0412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES Abdominal pain is a common presentation in patients of diabetic ketoacidosis (DKA). However, this pain generally resolves with resolution of dehydration and acidosis. Persistence of abdominal pain even after resolution of ketosis and acidosis should warrant careful reassessment to find evidence of sepsis and concomitant abdominal pathology. CASE PRESENTATION We report a rare case of type 1 diabetes mellitus in a 15 year old girl diagnosed 6 months ago who presented with mild DKA (pH 7.24, HCO3 - 13.5 mmol/L). Her hospital course was extremely stormy and despite best of our efforts she succumbed due to colonic ischemia and perforation peritonitis. CONCLUSIONS A high index of suspicion for gut ischemia or perforation should be kept if DKA is associated with septic shock and there is suboptimal response to standard treatment. Mesenteric ischemia can occur in pediatric patients even with mild DKA having very poor diabetes control.
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Affiliation(s)
- Mritunjay Kumar
- Department of Pediatrics, All India Institute of Medical Sciences - Raebareli, Raebareli, Uttar Pradesh, India
| | - Rini Dixit
- Department of Pediatrics, All India Institute of Medical Sciences - Raebareli, Raebareli, Uttar Pradesh, India
| | - Rohit Kapoor
- Department of Paediatric Surgery, All India Institute of Medical Sciences - Raebareli, Raebareli, Uttar Pradesh, India
| | - Sunita Singh
- Department of Paediatric Surgery, All India Institute of Medical Sciences - Raebareli, Raebareli, Uttar Pradesh, India
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Park JH, Muncie C, Sawaya DE. Intestinal ischemia resulting in enterectomy in poorly controlled type 1 diabetes mellitus with diabetic ketoacidosis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Frontino G, Di Tonno R, Castorani V, Rigamonti A, Morotti E, Sandullo F, Scialabba F, Arrigoni F, Foglino R, Dionisi B, Ferri CIC, Zirpoli S, Barera G, Meschi F, Bonfanti R. Non-Occlusive Mesenteric Ischemia in Children With Diabetic Ketoacidosis: Case Report and Review of Literature. Front Endocrinol (Lausanne) 2022; 13:900325. [PMID: 35928892 PMCID: PMC9345499 DOI: 10.3389/fendo.2022.900325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Despite the use of technology, recurrent diabetic ketoacidosis (DKA) prevention remains an unmet need in children and adolescents with T1D and may be accompanied by life-threatening acute complications. We present a rare case of non-occlusive mesenteric ischemia (NOMI) with overt manifestation after DKA resolution and a discussion of recent literature addressing DKA-associated NOMI epidemiology and pathogenesis in children and adolescents. CASE PRESENTATION A 13-year-old female with previously diagnosed T1D, was admitted at our emergency department with hypovolemic shock, DKA, hyperosmolar state and acute kidney injury (AKI). Mildly progressive abdominal pain persisted after DKA correction and after repeated ultrasound evaluations ultimately suspect for intestinal perforation, an intraoperative diagnosis of NOMI was made. CONCLUSION The diagnosis of DKA-associated NOMI must be suspected in pediatric patients with DKA, persistent abdominal pain, and severe dehydration even after DKA resolution.
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Affiliation(s)
- Giulio Frontino
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Raffaella Di Tonno
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Valeria Castorani
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
- *Correspondence: Valeria Castorani,
| | - Andrea Rigamonti
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Elisa Morotti
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Federica Sandullo
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Francesco Scialabba
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Francesca Arrigoni
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Riccardo Foglino
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Benedetta Dionisi
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Salvatore Zirpoli
- Pediatric Radiology and Neuroradiology, Children’s Hospital “V. Buzzi”, Milan, Italy
| | - Graziano Barera
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
| | - Franco Meschi
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Riccardo Bonfanti
- Department of Pediatrics, IRCCS San Raffaele Hospital, Milan, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Tsai A, Teichman A, Butts CA, Cai JY, Peck GL, Adams CD, Hanna JS. Mesenteric venous thrombosis: A lethal complication of hyperglycemic crises. Am J Health Syst Pharm 2021; 78:105-107. [PMID: 33119766 DOI: 10.1093/ajhp/zxaa353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
PURPOSE Although hyperglycemic crises can lead to a hypercoagulable state, few instances of associated mesenteric venous thrombosis (MVT) have been reported. Worsening abdominal pain in the context of shock requiring vasopressor support should prompt urgent further investigation. SUMMARY A 44-year-old Hispanic male arrived at an emergency department with chief complaints of lethargy, polydipsia, and polyuria. His past medical history included type 2 diabetes, epilepsy, obesity, tobacco smoking, and noncompliance with his medications. On arrival the patient had a serum glucose concentration of >1,600 mg/dL, and hyperosmolar hyperglycemic syndrome (HHS) was diagnosed. The patient was admitted to the intensive care unit with respiratory failure and subsequently developed shock refractory to fluid resuscitation, necessitating vasopressor support. On hospital day 4, a computerized tomogram obtained for investigation of increasing abdominal tenderness revealed superior MVT and pneumatosis intestinalis. Despite an emergency laparotomy and enterectomy, the patient ultimately succumbed on hospital day 41 due to recurrent pneumonia complicated by acute respiratory distress syndrome and septic shock. CONCLUSION Shock that is refractory to aggressive fluid resuscitation, necessitating pressor support, in the setting of HHS or diabetic ketoacidosis should prompt investigation for the underlying source of shock. Other etiologies, including hypovolemic, cardiogenic, and obstructive shock, should be considered; however, infection is the leading trigger of hyperglycemic crises. Although rarely reported, MVT should be considered in the diagnostic algorithm in the absence of an identified infectious source. Prompt investigation should include use of diagnostic modalities such as computed tomography to assess for MVT.
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Affiliation(s)
- Andrew Tsai
- Robert Wood Johnson University Hospital Somerset, Somerville, NJ
| | - Amanda Teichman
- Robert Wood Johnson University Hospital Somerset, Somerville, NJ.,Division of Acute Care Surgery, Rutgers-Robert Wood Johnson School of Medicine, New Brunswick, NJ
| | | | - Jenny Y Cai
- Robert Wood Johnson University Hospital Somerset, Somerville, NJ
| | - Gregory L Peck
- Division of Acute Care Surgery, Rutgers-Robert Wood Johnson School of Medicine, New Brunswick, NJ.,Rutgers School of Public Health, Piscataway, NJ
| | - Christopher D Adams
- Robert Wood Johnson University Hospital Somerset, Somerville, NJ.,Rutgers School of Public Health, Piscataway, NJ
| | - Joseph S Hanna
- Robert Wood Johnson University Hospital Somerset, Somerville, NJ.,Division of Acute Care Surgery, Rutgers-Robert Wood Johnson School of Medicine, New Brunswick, NJ
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Al Hazmi A, Manning S. Limb Ischemia in a Patient with Hyperosmolar Hyperglycemic State. Clin Pract Cases Emerg Med 2018; 2:348-352. [PMID: 30443624 PMCID: PMC6230346 DOI: 10.5811/cpcem.2018.9.39920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 09/04/2018] [Accepted: 09/07/2018] [Indexed: 12/02/2022] Open
Abstract
A 61-year-old male with a recent diagnosis of pemphigus vulgaris was brought to the emergency department for altered mental status. He had recently started taking prednisone to manage his autoimmune disease and had a progressive decline in his mental status along with decreased oral intake. Evaluation revealed hyperosmolar hyperglycemic state (HHS) and occlusive arterial thrombosis, a rare but known complication of HHS. He was resuscitated aggressively with intravenous fluids, insulin, and heparin and admitted to the intensive care unit. Emergency physicians should remain vigilant for ischemic complications in patients with HHS. Early recognition and treatment can reduce the morbidity and mortality associated with this endocrine emergency.
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Affiliation(s)
- Ahmed Al Hazmi
- University of Maryland Medical Center, Department of Emergency Medicine, Baltimore, Maryland
| | - Sara Manning
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
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Karayiannakis AJ, Bolanaki H, Kouklakis G, Dimakis K, Memet I, Simopoulos C. Ischemic colitis of the left colon in a diabetic patient. Case Rep Gastroenterol 2011; 5:239-45. [PMID: 21552382 PMCID: PMC3088756 DOI: 10.1159/000327981] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Diabetes mellitus may affect the gastrointestinal tract possibly as a result of autonomic neuropathy. Here we present a 68-year-old male with non-insulin-dependent diabetes mellitus who presented with prolonged watery diarrhea and in whom imaging studies demonstrated ischemic colitis of the left colon. Resection of the affected colon resulted in sustained disappearance of symptoms.
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Ortega Carnicer J. [Acute hyperlipidemic pancreatitis and diabetic ketoacidosis associated with intestinal necrosis]. Med Clin (Barc) 2005; 125:199. [PMID: 16153366 DOI: 10.1157/13077145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Huang HH, Chang YC, Yen DHT, Kao WF, Chen JD, Wang LM, Huang CI, Lee CH. Clinical factors and outcomes in patients with acute mesenteric ischemia in the emergency department. J Chin Med Assoc 2005; 68:299-306. [PMID: 16038369 DOI: 10.1016/s1726-4901(09)70165-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The purpose of this study was to determine the initial clinical characteristics of acute mesenteric ischemia and identify variables associated with adverse outcomes in the emergency department (ED). METHODS The charts of 124 consecutive patients with surgically and pathologically identified acute mesenteric ischemia from September 1990 to September 2000 were reviewed retrospectively to obtain data about demographics, initial clinical presentations, predisposing diseases, previous medications, laboratory tests, and common findings on computed tomography scans with contrast. Only patients admitted through the ED and treated on medical or surgical wards were enrolled. RESULTS Mean patient age was 71.1 years (range, 25-100 years). The overall mortality rate was 50%. There were no significant differences in gender, underlying disease, previous medication, initial signs and symptoms, and causes of mesenteric infarction, between survivors and non-survivors. Univariate analysis demonstrated that older age, bandemia, hepatic and renal impairment, hyperamylasemia, metabolic acidosis, hypoxia, intramural pneumatosis, and septic syndrome, were more frequent in patients who died than in those who survived (p < 0.05). Logistic regression identified the following variables as independent predictors of death: old age (odds ratio, OR, 1.077; 95% confidence interval, Cl, 1.013, 1.146; p = 0.02); bandemia (OR, 3.894; 95% Cl, 1.160, 13.074; p = 0.03); elevated serum aspartate aminotransferase (AST; OR, 4.532; 95% Cl, 1.274, 16.122; p = 0.02); increased blood urea nitrogen (BUN; OR, 7.219; 95% Cl, 1.166, 44.696; p = 0.03); and metabolic acidosis (OR, 6.604; 95% Cl, 1.804, 24.171; p < 0.01). CONCLUSION A high index of suspicion and aggressive diagnostic imaging can facilitate early diagnosis and improve outcomes for patients with acute mesenteric ischemia. Risk stratification showed that elderly patients with metabolic acidosis, bandemia, or elevated AST and BUN had a poor prognosis. Greater therapeutic intervention is advocated to reduce mortality in high-risk patients with acute mesenteric ischemia.
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Affiliation(s)
- Hsien-Hao Huang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, R.O.C
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DiMeglio LA, Chaet MS, Quigley CA, Grosfeld JL. Massive ischemic intestinal necrosis at the onset of diabetes mellitus with ketoacidosis in a three-year-old girl. J Pediatr Surg 2003; 38:1537-9. [PMID: 14577083 DOI: 10.1016/s0022-3468(03)00510-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A previously healthy 3-year-old girl had severe diabetic ketoacidosis complicated by hypovolemic shock. When her abdominal pain and acidosis failed to improve despite vigorous fluid resuscitation and insulin therapy, further investigation found an intestinal perforation. At laparotomy, gangrenous bowel was found, requiring an extensive enterectomy from the distal jejunum to the transverse colon; less than 90 cm of viable small intestine remained. The child survived a complicated postoperative course and currently is thriving on a normal diet.
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Affiliation(s)
- Linda A DiMeglio
- Section of Pediatric Endocrinology and Diabetology, Department of Pediatrics, Indiana University School of Medicine and J.W. Riley Hospital for Children, Indianapolis, IN 46202, USA
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