Paralytic ileus induced by the combined use of nifedipine and diltiazem in the treatment of vasospastic angina

Extensive Bowel Ischaemia after Nifedipine Overdose

A 57-year-old woman presented with abdominal distension and vomiting two days after overdosing an unknown amount of sustained-release nifedipine tablets. She had refractory shock requiring calcium chloride, glucagon, insulin-glucose and multiple high-dose inotropic agent infusions in the intensive care unit. Her abdominal computed tomography showed features of bowel ischaemia and exploratory laporotomy reviewed non-salvageable massive bowel ischaemia. She finally succumbed after 22 days of hospital treatment. This case illustrates the importance of awareness of this potentially fatal complication of calcium channel blocker overdose, requiring early recognition and intervention.

Paralytic ileus associated with use of diltiazem

PURPOSE

A case of paralytic ileus in a patient receiving oral diltiazem therapy for atrial fibrillation is reported.

SUMMARY

A 64-year-old man with a history of multiple serious comorbidities, poly-pharmacy, and a recent hospital stay for acute cardiac problems was readmitted to the hospital for gastrointestinal (GI) bleeding. On day 2 of the readmission, he suffered a myocardial infarction complicated by atrial fibrillation with a rapid ventricular response. After initial treatment with oral metoprolol for ventricular rate control was discontinued (due to ineffective rate control and patient complaints of respiratory symptoms), oral diltiazem hydrochloride therapy (30 mg every six hours) was initiated on day 7; the dose was adjusted to a maximum of 120 mg every six hours on day 10. On day 12, the patient complained of nausea, abdominal pain and tenderness, and infrequent bowel movements; imaging studies on day 13 indicated paralytic ileus. Pursuant to a surgical consultation, a nasogastric tube was inserted and nothing was given by mouth except medications. After initial improvement of the GI symptoms, the feeding tube was removed; however, the symptoms worsened over the next two to three days, requiring reinsertion of the tube on day 16. On day 18, after other potential causes of ileus were ruled out, diltiazem therapy was withdrawn. The man experienced rapid symptomatic improvement, with no further GI symptoms, and was discharged four days later.

CONCLUSION

A 64-year-old man receiving high-dose diltiazem to treat atrial fibrillation developed paralytic ileus, which quickly resolved after the medication was discontinued.

Paralytic Ileus Possibly Associated with Nebulized Ipratropium Bromide

Objective:

To report a case of paralytic ileus possibly associated with nebulized ipratropium bromide.

Case Summary:

A 43-year-old man fell from a wall and was admitted to the intensive care unit (ICU) for the resulting thoracic trauma. An epidural thoracic catheter was placed for pain control using bupivacaine 0.25% and methadone 0.2 mg/mL. On hospital day 4, he developed purulent bronchiole constriction, and treatment with nebulized mesna and ipratropium bromide was started. Six hours after the first nebulization, the patient developed abdominal pain and bowel distension. An abdominal X-ray showed intestinal gas retention and dilated loops of large bowel. Paralytic ileus was diagnosed. Nebulized ipratropium bromide treatment was stopped and, during the following 24 hours, the patient gradually improved.

Discussion:

Nebulized ipratropium bromide–induced paralytic ileus is an uncommon adverse event that may be of considerable clinical relevance. Nebulized ipratropium bromide is predominantly deposited in the oropharynx, but some amount of the drug may be swallowed with resultant systemic adverse effects. Ipratropium bromide is a nonselective muscarinic antagonist and may inhibit contraction of the gastrointestinal tract. Paralytic ileus could not be attributed to an electrolyte disturbance or abdominal injury. The patient's paralytic ileus resolved when nebulized ipratropium bromide was stopped. An objective causality assessment showed that the paralytic ileus was possibly associated with this drug.

Conclusions:

This case report indicates that ipratropium bromide should be considered capable of inducing paralytic ileus.