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Zhang W, Zhang X, Han J, Zhang W, Xu J, Zhang X, Bian H, Meng C, Shang D, Zhou Y, Wang D, Feng B. Case report: Paralytic ileus resulted from nirmatrelvir/ritonavir-tacrolimus drug-drug interaction in a systemic lupus erythematosus patient with COVID-19. Front Pharmacol 2024; 15:1389187. [PMID: 38601471 PMCID: PMC11004316 DOI: 10.3389/fphar.2024.1389187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 03/18/2024] [Indexed: 04/12/2024] Open
Abstract
Patients with systemic autoimmune rheumatic diseases are at a high risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and effective antiviral treatments including nirmatrelvir/ritonavir can improve their outcomes. However, there might be potential drug-drug interactions when these patients take nirmatrelvir/ritonavir together with immunosuppressants with a narrow therapeutic window, such as tacrolimus and cyclosporine. We present a case of paralytic ileus resulting from tacrolimus toxicity mediated by the use of nirmatrelvir/ritonavir in a patient with systemic lupus erythematosus (SLE). A 37-year-old female SLE patient was prescribed nirmatrelvir/ritonavir without discontinuing tacrolimus. She presented to the emergency room with symptoms of paralytic ileus including persistent abdominal pain, nausea, and vomiting, which were verified to be associated with tacrolimus toxicity. The blood concentration of tacrolimus was measured >30 ng/mL. Urgent medical intervention was initiated, while tacrolimus was withheld. The residual concentration was brought within the appropriate range and tacrolimus was resumed 8 days later. Physicians must be aware of the potential DDIs when prescribing nirmatrelvir/ritonavir, especially to those taking immunosuppresants like tacrolimus.
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Affiliation(s)
- Wei Zhang
- Department of Poisoning and Occupational Diseases, Shandong Provincial Hospital, Shandong University, Jinan, China
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xingguo Zhang
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Poisoning and Occupational Diseases, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Jinming Han
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Wen Zhang
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Jiarui Xu
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Poisoning and Occupational Diseases, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xin Zhang
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Hongjun Bian
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Chong Meng
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Deya Shang
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yi Zhou
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Dawei Wang
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Baobao Feng
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Poisoning and Occupational Diseases, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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Hashiba T, Sugahara M, Ota Y, Kaseda K, Kashiwagi Y, Nakamura M, Shinohara T, Ikeda M, Okugawa S, Sugimoto K, Sasaki K, Hamasaki Y, Yamada D, Kume H, Moriya K, Nangaku M. Paralytic Ileus during Treatment of Pulmonary and Renal Tuberculosis in a Non-Human Immunodeficiency Virus Patient: An Unusual Presentation of Tuberculosis-immune Reconstitution Inflammatory Syndrome. Intern Med 2023; 62:2559-2564. [PMID: 36642517 PMCID: PMC10518560 DOI: 10.2169/internalmedicine.0898-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/29/2022] [Indexed: 01/15/2023] Open
Abstract
Paralytic ileus as tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS) is extremely rare. We herein report a 44-year-old man with pulmonary and renal tuberculosis who developed paralytic ileus 14 days after starting antituberculosis therapy (ATT) despite an initial favorable response to ATT. Paralytic ileus was successfully managed with conservative care. He initially required hemodialysis because of obstructive uropathy due to renal tuberculosis, but he was able to withdraw from dialysis after placement of ureteral stents. TB-IRIS can affect organs other than the original sites of tuberculosis, and the combined use of steroids may be effective for its prevention and treatment.
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Affiliation(s)
- Toyohiro Hashiba
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Mai Sugahara
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Yui Ota
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Ken Kaseda
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Yusuke Kashiwagi
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Motonobu Nakamura
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
| | - Takayuki Shinohara
- Department of Infectious Diseases, the University of Tokyo Hospital, Japan
| | - Mahoko Ikeda
- Department of Infectious Diseases, the University of Tokyo Hospital, Japan
| | - Shu Okugawa
- Department of Infectious Diseases, the University of Tokyo Hospital, Japan
| | - Kazuma Sugimoto
- Department of Urology, the University of Tokyo Hospital, Japan
| | - Kenichi Sasaki
- Department of Urology, the University of Tokyo Hospital, Japan
| | - Yoshifumi Hamasaki
- Department of Hemodialysis & Apheresis, the University of Tokyo Hospital, Japan
| | - Daisuke Yamada
- Department of Urology, the University of Tokyo Hospital, Japan
- Department of Hemodialysis & Apheresis, the University of Tokyo Hospital, Japan
| | - Haruki Kume
- Department of Urology, the University of Tokyo Hospital, Japan
| | - Kyoji Moriya
- Department of Infectious Diseases, the University of Tokyo Hospital, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, the University of Tokyo Hospital, Japan
- Department of Hemodialysis & Apheresis, the University of Tokyo Hospital, Japan
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Meisenheimer Vii J, Dattadeen J, Thomley M, Aslam S. Strongyloides Hyperinfection Syndrome Triggered by a Single Dose of Dexamethasone Administered for Fetal Lung Development. Cureus 2023; 15:e46067. [PMID: 37900370 PMCID: PMC10607639 DOI: 10.7759/cureus.46067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/31/2023] Open
Abstract
Strongyloides hyperinfection syndrome is a rare manifestation caused by the Strongyloides stercoralis parasite and has mortality rates close to 90% if left untreated. Corticosteroids are commonly implicated as a trigger for hyperinfection syndrome in patients with Strongyloides autoinfection, and it has been suggested that even a single dose of corticosteroids can trigger hyperinfection syndrome. Here, we report a case of hyperinfection syndrome eight days after administering a single 8 mg dose of dexamethasone for fetal lung development before a late preterm, emergency cesarean section (C-section) delivery secondary to placental abruption. Prior to the C-section, the patient had been exhibiting signs of autoinfection syndrome, cough, and abdominal pain, for several months. Following corticosteroid administration, she had sequelae of Strongyloides hyperinfection syndrome, including gram-negative bacteremia, undulating fevers, protein wasting enteropathy, and hypersensitivity pneumonitis. Sputum cultures were positive for Strongyloides, and after treatment with ivermectin and albendazole, the patient fully recovered. Strongyloides hyperinfection syndrome is a documented consequence of short courses of corticosteroids. Still, this case is unique because the patient only received a single dose of corticosteroids before developing hyperinfection syndrome. Clinicians must recognize patients at risk for Strongyloides hyperinfection syndrome and understand the risks of administering corticosteroids to patients harboring the parasite.
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Affiliation(s)
| | | | | | - Sadaf Aslam
- Internal Medicine, University of South Florida, Tampa, USA
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Miyahara M, Osaki K, Hasegawa Y. Non-thyroidal Illness Syndrome in an Infant With Acute Anorexia and Psychological Stress. Cureus 2023; 15:e39803. [PMID: 37398767 PMCID: PMC10313497 DOI: 10.7759/cureus.39803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 07/04/2023] Open
Abstract
Non-thyroidal illness syndrome (NTIS), a remarkable ensemble of changes in serum thyroid hormone concentration during acute illness, was first reported in the 1970s. While NTIS is not a form of hypothyroidism, it is characterized by a decrease in serum triiodothyronine (T3) or thyroxine (T4) or both with normal or decreased thyroid-stimulating hormone (TSH). Notably, it typically resolves without thyroid hormone replacement therapy. We report a case of paralytic ileus caused by NTIS in an infant with psychological stress. This case illustrates the development of NTIS during psychological stress, which can lead to severe symptoms such as those seen in pathological hypothyroidism.
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Affiliation(s)
| | - Kyoko Osaki
- Department of Pediatrics, Okanami General Hospital, Iga, JPN
| | - Yukihiro Hasegawa
- Division of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo, JPN
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Ammendola M, Ammerata G, Filice F, Filippo R, Ruggiero M, Romano R, Memeo R, Pessaux P, Navarra G, Montemurro S, Currò G. Anastomotic Leak Rate and Prolonged Postoperative Paralytic Ileus in Patients Undergoing Laparoscopic Surgery for Colo-Rectal Cancer After Placement of No-Coil Endoanal Tube. Surg Innov 2023; 30:20-27. [PMID: 35582732 DOI: 10.1177/15533506221090995] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Colorectal cancer (CRC) is the second most common gastrointestinal tumor in men and the third in women. Left-hemicolectomy (LC) and low anterior resection (LAR) are considered the gold standard curative treatment. In this retrospective study, we evaluated the presence or absence of post-operative complications, in all patients who underwent Video-laparoscopic (VLS) LAR/LC with No Coil trans-anal tube positioning, and compared the data with the current literature on the topic. METHODS Thirty-nine patients diagnosed with CRC of the descending colon, splenic flexure, sigma, and rectum were recruited. LC was performed for sigmoid and descending colon cancers, while LAR was applied for tumors of the upper two-thirds of the rectum. The No Coil trans-anal tube (SapiMed Spa, Alessandria, Italy) was placed in all patients of the study at the end of surgical treatment. RESULTS Eighteen patients received a LAR-VLS (46%) and 21 patients received a LC-VLS (54%). The average length of hospital stay after surgery was 7 days. PPOI occurred in only one in 39 patients (2.6%) who had undergone LAR-VLS. As for complications, in no patient of the study did AL (0%) occur. CONCLUSION In patients undergoing LAR-VLS and LC-VLS, we performed colorectal anastomosis and in the same surgical operation we introduced the No-Coil device. Although this is a preliminary study and subject to further investigation, we believe that the No Coil tube positioning may reduce the time of presence of first flatus and feces and the risk of AL.
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Affiliation(s)
- Michele Ammendola
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Giorgio Ammerata
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Francesco Filice
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Rosalinda Filippo
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Michele Ruggiero
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Roberto Romano
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Riccardo Memeo
- Hepato-Biliary and Pancreatic Surgical Unit, "F. Miulli" Hospital, Bari, Italy
| | - Patrick Pessaux
- Department of General, Digestive and Endocrine Surgery,IHU-Strasbourg, Institute of Image-Guided Surgery, IRCAD, Research Institute Against Cancer of the Digestive System, University Hospital of Strasbourg, Strasbourg, France
| | - Giuseppe Navarra
- Department of Human Pathology of Adult and Evolutive Age, Surgical Oncology Division, "G. Martino" Hospital, University of Messina, Messina, Italy
| | - Severino Montemurro
- Science of Health Department, Digestive Surgery Unit, RinggoldID:9325University "Magna Graecia" Medical School, Catanzaro, Italy
| | - Giuseppe Currò
- Science of Health Department, General Surgery Unit, University "Magna Graecia" Medical School, Catanzaro, Italy
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Muacevic A, Adler JR, Zamora N, Aaron Lee HT, Balassiano N, Abdelmoteleb S, Khan MG, Abosheaishaa H, Ahmed K. Silent Bowels From a Silent Bite: A Rare Case of Paralytic Ileus Complicating Plasmodium falciparum Infection. Cureus 2023; 15:e34061. [PMID: 36824555 PMCID: PMC9943535 DOI: 10.7759/cureus.34061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 01/23/2023] Open
Abstract
Malaria is a life-threatening, parasitic disease that continues to infect millions of people, especially in endemic regions. Despite advancements in malaria treatment, treating the disease remains challenging. One major challenge is identifying the disease from its unconventional manifestations. Therefore, recognizing its unusual clinical presentations is imperative in early detection and management with a better prognosis. This case report highlights the unique finding of paralytic ileus from a patient with confirmed malaria. Further investigation on the concurrence between paralytic ileus and malaria may aid in identifying the disease and subsequent improvement in treatment.
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Doukas P, Hellfritsch G, Krabbe H, Frankort J, Jacobs MJ, Gombert A, Simon F. Onset of Adverse Abdominal Events Due to Intestinal Ischemia-Reperfusion Injury after Aortic Cross-Clamping Is Associated with Elevated HSP70 Serum Levels in the Early Postoperative Phase. Int J Mol Sci 2022; 23. [PMID: 36499389 DOI: 10.3390/ijms232315063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/18/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022] Open
Abstract
Tissue injury of the viscera during open thoracoabdominal aortic (TAA) reconstructions has been reported as the aftermath of the ischemia-reperfusion mechanism following supracoeliac aortic cross-clamping. Abdominal complications after open aortic reconstructions, although rare through the intraoperative implementation of selective visceral artery blood perfusion, are associated with high rates of reinterventions and a poor prognosis. Recent animal experiments demonstrated that provoking mesenteric ischemia in rats induces the leukocyte-mediated transcription of heat-shock protein 70 (HSP70), a chaperone belonging to the danger-associated molecular pattern proteins (DAMPs). Translating these findings clinically, we investigated the serum levels of HSP70 in patients undergoing open aortic reconstructions with supracoeliac clamping. We postoperatively observed a relevant induction of HSP70, which remained significantly elevated in cases of postoperative abdominal complications (paralytic ileus, abdominal compartment syndrome, and visceral malperfusion). The receiver-operator curve analysis revealed the reliable prognostic accuracy of HSP70 as a biomarker for these complications as soon as 12 h post-operation (AUC 0.908, sensitivity 88.9%, specificity 83.3%). In conclusion, measuring HSP70 serum levels in the early postoperative phase may serve as a further adjutant in the diagnostic decision making for both the vascular surgeon and intensivist for the timely detection and management of abdominal complications following open TAA surgery.
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Muacevic A, Adler JR. Exploring the Association Between Paralytic Ileus and Endoscopic Retrograde Cholangiopancreatography Complications Using the National Inpatient Sample Database. Cureus 2022; 14:e30319. [PMID: 36407216 PMCID: PMC9661870 DOI: 10.7759/cureus.30319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2022] [Indexed: 01/25/2023] Open
Abstract
Introduction Paralytic ileus (PI) is often seen in critically ill hospitalized patients. Those with pancreaticobiliary diseases will require endoscopic retrograde cholangiopancreatography (ERCP) for management. Here, we will explore the association between patients with paralytic ileus who underwent ERCP and post-procedural complications, which has not been done before. Methods Patients who underwent ERCP between 2007 and 2017 in the National Inpatient Sample database were selected. Cases were matched 1:1 by age, gender, race, and the Elixhauser comorbidity index for patients with and without pre-procedural paralytic ileus. Primary outcomes were associations between paralytic ileus and length of stay, payor status, and average total charges. Secondary outcomes were associations between paralytic ileus and post-ERCP complications (infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage), and overall mortality. The Chi-squared analysis was used to compare categorical data, and the independent t-test was used for continuous data. Regression analysis was used to assess primary and secondary outcomes. Results Of 2,008,217 hospitalized patients from 2007 to 2017, 43,643 patients had paralytic ileus and 43,859 patients did not, before undergoing ERCP. There were no differences in age, gender, race, or the Elixhauser comorbidity index. The differences in the length of stay, payor status, and total charges were significant (p<0.001). Patients with paralytic ileus had increased risks of post-ERCP infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage, and overall mortality (p<0.001). Conclusions Patients hospitalized with paralytic ileus who underwent ERCP had a longer length of stay, higher total charges, and were less compensable. They also had increased risks for post-ERCP infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage, and overall mortality, which can be from critical illness and the systemic inflammatory response.
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Liu X, Chen X, Zhou Y, Zhang X. Paralytic ileus as first symptom of Miller Fisher syndrome: A case report. Medicine (Baltimore) 2022; 101:e30434. [PMID: 36086690 PMCID: PMC10980455 DOI: 10.1097/md.0000000000030434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 07/28/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Miller Fisher syndrome (MFS), regarded by many scholars as a variant of Guillain Barre syndrome (GBS), accounts for approximately 5% to 10% of GBS cases. The typical clinical manifestations of MFS are extraocular muscle paralysis, ataxia, and tendon reflex loss or disappearance. To date, intestinal obstruction has rarely been reported as the initial symptom. PATIENT CONCERNS A 48-year-old woman presenting with abdominal pain and distention was diagnosed with paralytic ileus. There was no significant improvement in symptoms after symptomatic treatment. After that, the patient developed visual rotation, with limited binocular abduction and adduction, and ataxia. Anti-ganglioside testing revealed positive anti-ganglioside antibodies. DIAGNOSIS The patient was diagnosed as MFS. INTERVENTIONS The early stage is mainly symptomatic treatment of paralytic ileus. After MFS was diagnosed, the patient was given large amounts of immunoglobulin and hormone shock therapy. OUTCOMES After 1 week, the symptoms of intestinal obstruction and MFS gradually improved. The patient was later discharged automatically for financial reasons. Six months after discharge, the patient was interviewed by telephone, and she had recovered. CONCLUSION To date, intestinal obstruction has rarely been reported as the initial symptom. In case of inconsistencies between the imaging examinations and clinical symptoms, neuroelectrophysiology and cerebrospinal fluid puncture should be performed, striving for timely detection and treatment.
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Affiliation(s)
- Xiubin Liu
- Shandong Institute of Literature and Culture, Shandong University of Traditional Chinese Medicine, Jinan City, Shandong Province, People’s Republic of China
| | - Xiqi Chen
- The First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan City, Shandong Province, People’s Republic of China
| | - Yongkun Zhou
- Department of General Surgery, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan City, Shandong Province, People’s Republic of China
| | - Xiaoxia Zhang
- Shandong Institute of Literature and Culture, Shandong University of Traditional Chinese Medicine, Jinan City, Shandong Province, People’s Republic of China
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Elgar G, Smiley P, Smiley A, Feingold C, Latifi R. Age Increases the Risk of Mortality by Four-Fold in Patients with Emergent Paralytic Ileus: Hospital Length of Stay, Sex, Frailty, and Time to Operation as Other Risk Factors. Int J Environ Res Public Health 2022; 19:ijerph19169905. [PMID: 36011537 PMCID: PMC9408669 DOI: 10.3390/ijerph19169905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/26/2022] [Accepted: 08/03/2022] [Indexed: 05/20/2023]
Abstract
Background: In the United States, ileus accounts for USD 750 million of healthcare expenditures annually and significantly contributes to morbidity and mortality. Despite its significance, the complete picture of mortality risk factors for these patients have yet to be fully elucidated; therefore, the aim of this study is to identify mortality risk factors in patients emergently admitted with paralytic ileus. Methods: Adult and elderly patients emergently admitted with paralytic ileus between 2005−2014 were investigated using the National Inpatient Sample Database. Clinical outcomes, therapeutic management, demographics and comorbidities were collected. Associations between mortality and all other variables were established via univariable and multivariable logistic regression models. Results: A total of 81,674 patients were included, of which 45.2% were adults, 54.8% elderly patients, 45.8% male and 54.2% female. The average adult and elderly ages were 48.3 and 78.8 years, respectively. Elderly patients displayed a significantly (p < 0.01) higher mortality rate (3.0%) than adults (0.7%). The final multivariable logistic regression model showed that for every one-day delay in operation, the odds of mortality for adult and elderly patients increased by 4.1% (p = 0.002) and 3.2% (p = 0.014), respectively. Every additional year of age corresponded to 3.8% and 2.6% increases in mortality for operatively managed adult (p = 0.026) and elderly (p = 0.015) patients. Similarly, non-operatively treated adult and elderly patients displayed associations between mortality and advanced age (p = 0.001). The modified frailty index exhibited associations with mortality in operatively treated adults, conservatively managed adults and conservatively managed elderly patients (p = 0.001). Every additional day of hospitalization increased the odds of mortality in non-operative adult and elderly patients by 7.6% and 5.8%, respectively. Female sex correlated to lower mortality rates in non-operatively managed adult patients (odds ratio = 0.71, p = 0.028). Undergoing invasive diagnostic procedures in non-operatively managed elderly patients related to reduced mortality (odds ratio = 0.78, p = 0.026). Conclusions: Patients emergently admitted for paralytic ileus with increased hospital length of stay, longer time to operation, advanced age or higher modified frailty index displayed higher mortality rates. Female sex and invasive diagnostic procedures were negatively correlated with death in nonoperatively managed patients with paralytic ileus.
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Affiliation(s)
- Guy Elgar
- Westchester Medical Center, School of Medicine, New York Medical College, Valhalla, NY 10595, USA
| | - Parsa Smiley
- School of Engineering, University of Massachusetts at Amherst, Amherst, MA 01003, USA
| | - Abbas Smiley
- Westchester Medical Center, School of Medicine, New York Medical College, Valhalla, NY 10595, USA
- Correspondence: (A.S.); (R.L.)
| | - Cailan Feingold
- Westchester Medical Center, School of Medicine, New York Medical College, Valhalla, NY 10595, USA
| | - Rifat Latifi
- Minister of Health, 10000 Pristina, Kosovo
- School of Medicine, University of Arizona, Tucson, AZ 85721, USA
- Correspondence: (A.S.); (R.L.)
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Kadirogullari P, Seckin KD, Yalcin Bahat P, Aytufan Z. The effect of chewing gum on bowel function postoperatively in patients with total laparoscopic hysterectomy: a randomised controlled trial. J OBSTET GYNAECOL 2021; 42:1192-1197. [PMID: 34379539 DOI: 10.1080/01443615.2021.1941821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We aimed to investigate the efficacy of chewing gum on bowel movements after minimally invasive gynaecologic surgery, total laparoscopic hysterectomy (TLH). The study was designed as a prospective randomised controlled study. We divided the patients into two groups regarding postoperative chewing gum after elective TLH operation. The demographic status and characteristics of the patients as well as, anaesthesia and operation records were obtained. The study group was asked to chew gum for 15 min in an hour starting from post-operative 4th hour until the patient passed flatus. In each patient, first auscultation of bowel sounds, first flatus and first defaecation time, as well as first mobilisation time and discharge time, were recorded. We compared the difference in abdominal distension, nausea and vomiting and post-operative ileus (POI) rates. Eight patients were excluded from the study due to matching with exclusion criteria. The remaining 126 patients were divided into two groups. First bowel sounds, first bowel movements, the timing of first gas discharge and the timing of the first defaecation was found significantly earlier in the given-chewing gum group (p < .001). The timing of patient discharge and POI were found to be similar in each group (p > .05). Mild symptoms of ileus were observed in two patients (3.2%) in the not given-chewing gum group and three patients (5.5%) in the given-chewing gum group. The symptoms were better tolerated by the patients who chew gums and no side effects regarding the treatment were observed. In post-operative patient care after minimally invasive surgery, chewing gum has a beneficial effect on bowel movements. This inexpensive and well-tolerated procedure ameliorates gastrointestinal (GI) functions, whereas it has little benefit on early mobilisation and timing of the patient discharge after patients undergoing TLH.Impact StatementWhat is already known on this subject? There are many studies in the literature on the effect of gum on postoperative bowel movements, early mobilisation and short-term hospitalisation. However, there are still doubts about its use after minimally invasive surgery, especially in gynaecology practice.What do the results of this study add? Chewing gum after surgery is a well-tolerated, effective, safe, easy and convenient method and is easily accepted by patients. Its use by gynaecologists after TLH is still not clear. Our aim is to show the relationship between chewing gum and TLH with this study; We believe that early mobilisation after laparoscopic hysterectomy will not be of significant benefit after minimally invasive gynaecological surgeries as it is not significantly effective in early nutrition and early patient discharge.What are the implications of these findings for clinical practice and/or further research? Our statistically not significant results obtained in this study may change after conducting randomised prospective studies involving more patients. However, we believe that giving chewing-gum after laparoscopic hysterectomy will not have a significant benefit.
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Affiliation(s)
- Pinar Kadirogullari
- Department of Obstetrics and Gynecology, Acıbadem University Atakent Hospital, Istanbul, Turkey
| | - Kerem Doga Seckin
- Department of Obstetrics and Gynecology, Health Sciences University, Istanbul Kanuni Sultan Suleyman Research and Training Hospital, Istanbul, Turkey
| | - Pinar Yalcin Bahat
- Department of Obstetrics and Gynecology, Health Sciences University, Istanbul Kanuni Sultan Suleyman Research and Training Hospital, Istanbul, Turkey
| | - Zubeyde Aytufan
- Department of Obstetrics and Gynecology, Health Sciences University, Istanbul Kanuni Sultan Suleyman Research and Training Hospital, Istanbul, Turkey
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12
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Emery JD, Samedi VM, Bingham WT. Paralytic ileus in the neonate as a rare complication of maternal methadone treatment-a case report. Oxf Med Case Reports 2021; 2021:omab004. [PMID: 33732483 PMCID: PMC7947274 DOI: 10.1093/omcr/omab004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/29/2020] [Accepted: 12/18/2020] [Indexed: 12/02/2022] Open
Abstract
Narcotic bowel syndrome is defined as worsening abdominal bloating and cramping with chronic opiate use, leading to paralytic ileus. This syndrome is common yet underreported in adults. However, there is no current evidence of such conditions in the newborn after exposure in utero to high doses of opiates. Our patient was a female indigenous preterm infant born to a mother on a high dose of methadone. On admission at the age of 12 h, she was found to have significant gastric distension. Initial abdominal X-ray showed a large gastric bubble with little evidence of rectal gas. Malrotation was suspected and surgical intervention was discussed. However, repeat abdominal X-ray, ultrasound and upper Gastrointestinal series were found to be normal and without acute findings. Thus, surgery was avoided. The gastric distension resolved spontaneously. She never required opiate therapy for neonatal abstinence syndrome. Given the pattern of gas seen on the initial abdominal X-ray and its spontaneous resolution after removal of maternal methadone, we suspect this baby had neonatal narcotic bowel syndrome. This has never been reported in the literature and is a unique finding. Given the lack of current reports, further observations for this syndrome should be conducted.
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Affiliation(s)
- Joshua D Emery
- Department of Pediatrics, Neonatal Intensive Care Unit, Royal University Hospital, University of Saskatchewan, 103 Hospital Dr, Saskatoon, Saskatchewan, Canada
| | - Veronica M Samedi
- Department of Pediatrics, Neonatal Intensive Care Unit, Royal University Hospital, University of Saskatchewan, 103 Hospital Dr, Saskatoon, Saskatchewan, Canada
| | - William T Bingham
- Department of Pediatrics, Neonatal Intensive Care Unit, Royal University Hospital, University of Saskatchewan, 103 Hospital Dr, Saskatoon, Saskatchewan, Canada
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13
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Jandee S, Wetwittayakhlang P, Boonsri P. Efficacy of prucalopride in critically ill patients with paralytic ileus: A pilot randomized double-blind placebo-controlled trial. J Gastroenterol Hepatol 2021; 36:362-366. [PMID: 32483847 DOI: 10.1111/jgh.15127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/19/2020] [Accepted: 05/28/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIM Paralytic ileus is a common intestinal dysfunction in critically ill patients, which results in complications and poor hospital outcomes. There are still no established effective medications, except correcting the primary causes and prokinetics trial, which have limited efficacy and potential adverse events. This study aims to evaluate the efficacy of prucalopride on paralytic ileus in critically ill patients. METHODS A randomized, double-blind, placebo-controlled trial of five consecutive days treatment periods was conducted. Critically ill patients with paralytic ileus were included. The primary endpoint was the improvement of bowel dilatation on plain abdominal radiography. The secondary endpoint was the change of abdominal circumference. RESULTS Twenty patients were consecutively enrolled in the study. There was no significant difference in baseline characteristics of patients. The common causes of hospitalization were infection and respiratory problems. The maximum large bowel diameters dramatically decreased in prucalopride group and reached maximum point on the third day after intervention when compared with placebo (-2.1 [± 1.8] vs 0.3 [± 1.5] cm, P = 0.01). The maximum small bowel diameters were noticeably less decreased and were not significantly different when compared with placebo. The abdominal circumferences notably decreased and significantly diverged from placebo on the third day. CONCLUSIONS Prucalopride was an effective enterokinetic agent to improve non-severe inflammatory/ischemic bowel conditions related paralytic ileus in critically ill patients. Its effect was predominant on large intestine but could not be well demonstrated on small bowel in this study. Future study or concomitant other prokinetics for upper gut motility should be further evaluated.
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Affiliation(s)
- Sawangpong Jandee
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Panu Wetwittayakhlang
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Pattira Boonsri
- Diagnostic Radiology Unit, Division of Radiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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14
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Kitamura A, So C, Jinta T. Improvement of COVID-19 with renal failure and paralytic ileus by using steroids. Respirol Case Rep 2021; 9:e00689. [PMID: 33282314 PMCID: PMC7700917 DOI: 10.1002/rcr2.689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/25/2020] [Accepted: 10/28/2020] [Indexed: 11/06/2022] Open
Abstract
A 51-year-old man attended our hospital with chief complaints of fever and diarrhoea for the past eight days. Chest computed tomography showed peripherally dominant ground-glass opacity. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA was detected by real-time polymerase chain reaction, and the patient was diagnosed with coronavirus disease (COVID-19). His clinical course included respiratory failure, acute kidney injury, and paralytic ileus. Systemic management was difficult, but he recovered with high-dose steroids, temporary haemodialysis therapy, and a nasointestinal tube, without antiviral drugs. COVID-19 can be associated with multiple organ failure due to vascular endothelial injury.
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Affiliation(s)
- Atsushi Kitamura
- Department of Pulmonary MedicineThoracic Center, St. Luke's International HospitalTokyoJapan
| | - Clara So
- Department of Pulmonary MedicineThoracic Center, St. Luke's International HospitalTokyoJapan
| | - Torahiko Jinta
- Department of Pulmonary MedicineThoracic Center, St. Luke's International HospitalTokyoJapan
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15
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Cazzaniga M, Baselli LA, Cimaz R, Guez SS, Pinzani R, Dellepiane RM. SARS-COV-2 Infection and Kawasaki Disease: Case Report of a Hitherto Unrecognized Association. Front Pediatr 2020; 8:398. [PMID: 32719757 PMCID: PMC7347899 DOI: 10.3389/fped.2020.00398] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/10/2020] [Indexed: 12/25/2022] Open
Abstract
Coronavirus-associated disease (COVID-19) was firstly reported at the end of 2019. Generally, COVID-19 seems to be a less severe disease in children than in adults. According to the current literature, children account approximately for 2% of diagnosed COVID-19 cases. Northern Italy is one of the geographical areas mainly affected by the ongoing COVID-19 pandemic. We describe a pediatric patient diagnosed and treated for atypical/incomplete Kawasaki Disease (KD) complicated with paralytic ileus, who also resulted positive for SARS-COV-2.
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Affiliation(s)
- Marco Cazzaniga
- Pediatric Intermediate Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Lucia Augusta Baselli
- Pediatric Intermediate Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Rolando Cimaz
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, University of Milan, Milan, Italy
| | - Sophie Suzanne Guez
- Pediatric Highly Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Raffaella Pinzani
- Pediatric Highly Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Rosa Maria Dellepiane
- Pediatric Intermediate Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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16
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Kozawa K, Miura H, Kawamura Y, Tanaka M, Kudo K, Higashimoto Y, Ihira M, Yoshikawa T. Frequency of subclinical herpes zoster in pediatric hematology-oncology patients receiving chemotherapy: A retrospective cohort analysis. J Med Virol 2019; 92:1260-1265. [PMID: 31821586 DOI: 10.1002/jmv.25650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/04/2019] [Indexed: 12/16/2022]
Abstract
Varicella-zoster virus (VZV) reactivation from the enteric nervous system can cause ileus (Ogilvie's syndrome) in adult patients. Since no pediatric cases have been described, we sought to retrospectively analyze VZV reactivation in pediatric hematology-oncology patients to determine whether VZV infection including subclinical VZV reactivation can induce gastrointestinal complications such as Ogilvie's syndrome. Thirty-five patients who received chemotherapy at our institution between September 2013 and June 2018 were included. Serum samples were collected weekly during hospitalization and every 3 months during outpatient maintenance chemotherapy. A real-time polymerase chain reaction assay was used to measure VZV DNA load in serum. The clinical features of patients with VZV infection were retrospectively analyzed. Of 1165 serum samples, 7 (0.6%) were positive for VZV DNA. VZV DNA was detected in 3 of 35 patients. In patient A, VZV DNA was detected during two episodes. The first episode involved varicella-like eruptions caused by the Oka VZV vaccine strain. The second episode involved herpes zoster (HZ) caused by the same strain. Patients B and C had a clinical course that was typical for HZ caused by wild-type VZV. No gastrointestinal symptoms were observed at the time of VZV infection in these three patients. VZV DNA was not detected in any other samples. No pediatric cases with Ogilvie's syndrome caused by VZV reactivation were demonstrated in this cohort. Additionally, no subclinical VZV reactivation was found in this cohort. Further study is needed to elucidate the precise incidence of pediatric Ogilvie's syndrome caused by VZV reactivation.
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Affiliation(s)
- Kei Kozawa
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Hiroki Miura
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Yoshiki Kawamura
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Makito Tanaka
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Kazuko Kudo
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Yuki Higashimoto
- Faculty of Medical Technology, Fujita Health University School of Medical Sciences, Toyoake, Aichi, Japan
| | - Masaru Ihira
- Faculty of Clinical Engineering, Fujita Health University School of Medical Sciences, Toyoake, Aichi, Japan
| | - Tetsushi Yoshikawa
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
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17
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Liang W, Li J, Zhang W, Liu J, Li M, Gao Y, Wang N, Cui J, Zhang K, Xi H, Wei B, Chen L. Prolonged postoperative ileus in gastric surgery: Is there any difference between laparoscopic and open surgery? Cancer Med 2019; 8:5515-5523. [PMID: 31385451 PMCID: PMC6745839 DOI: 10.1002/cam4.2459] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 06/28/2019] [Accepted: 07/18/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Prolonged postoperative ileus (PPOI) is a common complication after abdominal surgery, but data about risk factors of PPOI for patients with gastric cancer are rare. We sought to investigate the impact of laparoscopic versus open surgery for PPOI after gastric cancer surgery. METHODS A retrospective cohort study was conducted using a registry database consecutively collected from June 2016 to March 2017. PPOI was defined as no bowel function persisting for more than 4 days. Univariate analysis and multiple logistic regression models were performed to investigate risk factors, and stratified analysis was carried out to examine the primary association at different levels of a potential confounding factor. RESULTS A total of 162 patients composed of 63 patients undergoing laparotomy and 99 patients undergoing laparoscopy were enrolled and PPOI was observed in 32 (19.75%) patients. Risk factors significantly correlated with PPOI were as follows: open surgery, older age, late surgical pathologic staging, postoperative use of opioid analgesic, low level of postoperative albumin and serum potassium. Compared to open surgery, the laparoscopic surgery was a strong protective factor for PPOI after adjusting related variables (OR = 0.17, CI: 0.05-0.52, P = .002). There was an interaction between surgical methods and the postoperative WBC level (P for interaction = .007). In the two group stratified analysis of WBC, laparoscopic surgery had a significant lower risk of PPOI than open group for the patients with WBC counts above the middle level in crude or adjusted models. This result remained significantly in the three group stratified analysis for the patients with WBC counts in the middle and or high tertile groups. CONCLUSIONS PPOI is a common postoperative complication of patients after gastrectomy. Laparoscopic surgery is associated with decreased risk of PPOI in gastric surgery. Patients who underwent open surgery and presented with high level of WBC should be cautious with PPOI.
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Affiliation(s)
- Wenquan Liang
- Department of General Surgery, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China.,General Surgery Institute, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Jiyang Li
- Department of General Surgery, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China.,General Surgery Institute, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Wang Zhang
- Department of General Surgery, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China.,General Surgery Institute, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Jie Liu
- Department of Vascular and Endovascular Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Mingsen Li
- Anorectal Desease Diagnosis and Treatment Center, Tianjin Union Medical Center Nankai University Affiliated Hospital, Tianjin, China
| | - Yunhe Gao
- Department of General Surgery, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China.,General Surgery Institute, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Ning Wang
- Department of General Surgery, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Jianxin Cui
- Department of General Surgery, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China.,General Surgery Institute, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Kecheng Zhang
- Department of General Surgery, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China.,General Surgery Institute, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Hongqing Xi
- Department of General Surgery, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China.,General Surgery Institute, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Bo Wei
- Department of General Surgery, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China.,General Surgery Institute, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Lin Chen
- Department of General Surgery, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China.,General Surgery Institute, The First Medical Center of Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
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18
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Abstract
Postoperative ileus (POI) is a common complication following colon and rectal surgery, with reported incidence ranging from 10 to 30%. It can lead to increased morbidity, cost, and length of stay. Although definitions vary considerably in the literature, in its pathologic form, it can be characterized by a temporary inhibition of gastrointestinal motility after surgical intervention due to nonmechanical causes that prevents sufficient oral intake. Various risk factors for development of POI have been identified including increasing age, American Society of Anesthesiologists scores 3 to 4, open approach, operative difficulty, operative duration more than 3 hours, bowel handling, drop in hematocrit or need for a transfusion, increasing crystalloid administration, and delayed mobilization. While treatment is expectant and supportive, significant investigations into strategies to mitigate development of POI or shorten its duration have been undertaken with mixed results. There is significant evidence to suggest that a minimally invasive approach and multimodal pain regimens reduce the development of POI. The beneficial effect of chewing gum, alvimopan, and enhanced recovery after surgery protocols may decrease development of POI in selected groups of patients who undergo elective colorectal surgery, and shorten time to return of bowel function, but overall, the data remain inconclusive.
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Affiliation(s)
- Cristina R Harnsberger
- Division of Colon and Rectal Surgery, University of Massachusetts, Boston, Massachusetts
| | - Justin A Maykel
- Division of Colon and Rectal Surgery, University of Massachusetts, Boston, Massachusetts
| | - Karim Alavi
- Division of Colon and Rectal Surgery, University of Massachusetts, Boston, Massachusetts
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19
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Tahara S, Sakai Y, Katsuno H, Urano M, Kuroda M, Tsukamoto T. Pneumatosis intestinalis and hepatic portal venous gas associated with gas-forming bacterial translocation due to postoperative paralytic ileus: A case report. Medicine (Baltimore) 2019; 98:e14079. [PMID: 30633214 PMCID: PMC6336625 DOI: 10.1097/md.0000000000014079] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
RATIONALE Pneumatosis intestinalis (PI) and hepatic portal venous gas (HPVG) are rare but potentially lethal conditions in which gas pathologically accumulates in the portal vein and intestinal wall, respectively. Proposed mechanisms include flatus escaping through an injured intestinal mucosa into the submucosa and thence into the portal venous system, or bacterial translocation (BT) of gas-forming enteric microorganisms from the gut into and through the intestinal wall to other organs. However, there has been no clear histopathological evidence to support these hypotheses. PATIENT CONCERNS A 61-year-old man underwent sigmoidectomy for colonic adenocarcinoma. Postoperatively, he developed paralytic ileus and then had a sudden cardiopulmonary arrest. DIAGNOSES PI and HPVG were found at autopsy, presumably caused by the postoperative paralytic ileus and associated with BT of gas-forming organisms. INTERVENTIONS Cardiopulmonary resuscitation was unsuccessful. OUTCOMES Postmortem imaging indicated the presence of massive PI and HPVG. At autopsy, there was marked intestinal emphysema with diffuse ischemic mucosal necrosis and severe pneumatosis in the stomach and intestine and marked gaseous dilation of the intrahepatic portal veins. Postmortem bacterial cultures revealed enteric bacteria in the peripheral blood and liver tissue. LESSONS Postoperative ileus leading to intestinal mucosal damage may be associated with BT of gas-forming enteric bacteria and the rapid onset of PI and HPVG with a lethal outcome.
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Affiliation(s)
| | | | - Hidetoshi Katsuno
- Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
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20
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Ahmed MR, Sayed Ahmed WA, Khamess RE, Youwakim MS, El-Nahas KM. Efficacy of three different regimens in recovery of bowel function following elective cesarean section: a randomized trial. J Perinat Med 2018; 46:786-790. [PMID: 29451863 DOI: 10.1515/jpm-2017-0389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/18/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Aim:
To compare the efficacy of three postoperative feeding regimens on bowel function recovery after term elective cesarean section (CS).
Methods:
Women recruited for this randomized trial were allocated into three groups. Women in group (A) were instructed to chew sugarless gum for 10 min every 2 h after surgery. Group (B) mothers received IV fluids for 6 h followed by sipping fruit juices sweetened with honey. Group (C) had oral intake of clear fluids after passage of flatus and regular diet with the passage of bowel movement. The main outcome measures were the timing of first return to bowel movement and initiation of regular diet.
Results:
The mean times to first hearing of bowel sounds, to first flatus passage and to first defecation were significantly lower in group A (10, 17.5 and 28.1 h, respectively) compared to groups B and C [15.1, 24.9 and 36 h (B) and 21.6, 38.8 and 49.4 h (C)]. Initiation of regular diet was significantly earlier in group A compared to groups B and C (21 vs. 27.5 and 40.3 h, respectively).
Conclusion:
Chewing gum appears to be more advantageous than early or traditional feeding regimens after term elective CS resulting in rapid recovery of bowel function.
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Affiliation(s)
- Magdy Refaat Ahmed
- Obstetrics and Gynecology Department, Suez Canal University, Ismailia, Egypt
| | | | | | - Manar S Youwakim
- Obstetrics and Gynecology Department, Suez Canal University, Ismailia, Egypt
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21
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Abstract
Background Qat-induced intestinal obstruction is an acute manifestation of qat chewing which was not described previously in the literature. The aim of this case series is to describe the clinical presentation, the diagnostic and therapeutic measures, and the course of the disease. Methods This retrospective case series included all patients who presented with qat-induced intestinal obstruction between July 1, 2013, and December 31, 2015. Results The study included seven patients (five males and two females). The mean age was 41.4 years (22-60 years). All patients presented after 8-12 h of prolonged qat chewing with abdominal pain, severe abdominal distension, and inability to pass stool. Laboratory results were normal apart from slight leukocytosis (<15 × 109/L) in three patients. All patients showed air-fluid levels on the erect abdominal X-ray. The management included intravenous fluids and symptomatic therapy. The symptoms resolved in 1-2 days and the follow-up after 1 week showed no residual complaints. Conclusions Qat-induced intestinal obstruction is associated with the heavy and prolonged consumption of qat. The presentation mimics acute intestinal obstruction, but the course is benign. Spontaneous resolution with supportive inpatient treatment is the rule.
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Affiliation(s)
- Mhd Firas Safadi
- Department of Surgery, Yemeni-Egyptian Hospital, Sanaa, Yemen, Darmstadt, Germany.,Department of General, Visceral, and Thoracic Surgery, Klinikum Darmstadt, Darmstadt, Germany
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22
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Li J, Zhao Y, Wen Q, Xue Q, Lv J, Li N. [Electroacupuncture for severe acute pancreatitis accompanied with paralytic ileus:a randomized controlled trial]. Zhongguo Zhen Jiu 2018; 36:1126-1130. [PMID: 29231293 DOI: 10.13703/j.0255-2930.2016.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To observe the clinical efficacy differences between electroacupuncture (EA) and regular treatment for severe acute pancreatitis accompanied with paralytic ileus. METHODS This was a prospective pragmatic randomized controlled trial. A total of 140 cases of severe acute pancreatitis accompanied with paralytic ileus were randomly assigned into an EA group and a regular treatment group, 70 cases in each one. The patients in the regular treatment group were treated with regular treatment, including intensive care, gastrointestinal decompression, fasting, blood capacity supplement, acid suppression treatment, internal environment maintenance, infection prevention, inhibition of pancreatic exocrine secretion, etc. Based on the regular treatment, patients in the EA group were treated with EA at Zusanli (ST 36) and Zhigou (TE 6), 30 min for each treatment, once a day for totally 5 days. The VAS-based abdominal distension severity scale and abdominal pain severity scale were compared before and during treatment in the two groups, moreover, the number of patients who transferred to surgery or ICU was compared. RESULTS (1) After the 1st EA, the abdominal pain and distension severity scales were both improved in the EA group, which were superior to those of the regular treatment group (all P<0.05); afterwards, the abdominal distension and pain severity scales of each day in the EA group were all significantly superior to those of the regular treatment group (all P<0.05). (2) The number of patients who transferred to surgery or ICU was not significantly different between the two groups (P>0.05). CONCLUSIONS EA at Zusanli (ST 36) and Zhigou (TE 6) can significantly reduce the abdominal distension and pain severity scales in patients of severe acute pancreatitis accompanied with paralytic ileus, indicating positive clinical significance; in addition, EA is safe and can be recommended to the treatment of severe acute pancreatitis in combination with treatment plan of integrated Chinese and western medicine.
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Affiliation(s)
- Jia Li
- Department of Integrated Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Yu Zhao
- Department of Integrated Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Qian Wen
- Department of Integrated Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Qiming Xue
- Department of Integrated Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Jianqin Lv
- Department of Integrated Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Ning Li
- Department of Integrated Chinese and Western Medicine, West China Hospital of Sichuan University, Chengdu 610041, China
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23
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Abstract
RATIONALE Paralytic ileus is characterized by the signs and symptoms of intestinal obstruction but without any mechanical lesions in the intestinal lumen. Several medical and surgical conditions can lead to this ailment, such as electrolyte disturbances that impair intestinal motility. However, hypercalcemia secondary to multiple myeloma as a major cause of paralytic ileus has rarely been reported. PATIENT CONCERNS The patient got severe constipation with difficulty in the passage of both gas and feces for 7 days. DIAGNOSES The patient was diagnosed with a small intestinal obstruction initially and then developed type II respiratory failure. Investigations revealed hypercalcemic crisis, and examination of a bone marrow aspirate was consistent with multiple myeloma. INTERVENTIONS Conservative treatment was administered for the intestinal obstruction, consisting of food and water deprivation, gastrointestinal decompression, colonic irrigation, intravenous fluid transfusion, anti-inflammatory therapy. Invasive respiratory support was provided after type II respiratory failure occurred and salmon calcitonin was used to reduce the blood calcium level. Further therapy was given by the Department of Hematology and Oncology in our hospital after the diagnosis of multiple myeloma. OUTCOMES Spontaneous respiration and gastrointestinal function were restored after the correction of hypercalcemia. LESSONS An appropriate diagnostic approach is needed in emergency practice to identify the paralytic ileus and type II respiratory failure caused by hypercalcemia secondary to multiple myeloma.
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Affiliation(s)
- Yuchen Guo
- Department of Gastrointestinal Surgery, First Hospital of Jilin University
| | - Liang He
- Department of Gastrointestinal Surgery, First Hospital of Jilin University
| | - Yiming Liu
- Department of Pharmacy, Second Hospital of Jilin University, Changchun, China
| | - Xueyuan Cao
- Department of Gastrointestinal Surgery, First Hospital of Jilin University
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24
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Abstract
A 78-year-old female was referred to our hospital with a diagnosis of type A acute aortic dissection. There was a history of thrombosed aortic dissection six months prior and conservative management has been performed. Enhanced computed tomography showed type A acute aortic dissection with patent false lumen limited to the ascending aorta and ileus of the small intestine. Emergency hemiarch replacement was performed under mild hypothermic circulatory arrest and selective antegrade cerebral perfusion. Due to preoperative paralytic ileus, oral intake was initiated postoperative day four. Postoperative computed tomography revealed improvement of paralytic ileus. J. Med. Invest. 64: 286-287, August, 2017.
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Affiliation(s)
- Naoto Fukunaga
- Department of Cardiovascular surgery, Kobe City Medical Center General Hospital
| | - Yasunobu Konishi
- Department of Cardiovascular surgery, Kobe City Medical Center General Hospital
| | - Takehiko Matsuo
- Department of Cardiovascular surgery, Kobe City Medical Center General Hospital
| | - Yoshiaki Saji
- Department of Cardiovascular surgery, Kobe City Medical Center General Hospital
| | - Tadaaki Koyama
- Department of Cardiovascular surgery, Kobe City Medical Center General Hospital
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25
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Kobayashi H, Wakuda K, Takahashi T. Effectiveness of afatinib in lung cancer with paralytic ileus due to peritoneal carcinomatosis. Respirol Case Rep 2016; 4:e00197. [PMID: 28031832 PMCID: PMC5167315 DOI: 10.1002/rcr2.197] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/28/2016] [Accepted: 09/30/2016] [Indexed: 11/22/2022] Open
Abstract
A 61‐year‐old never‐smoking woman with stage IV lung adenocarcinoma with initially unknown epidermal growth factor receptor (EGFR) status, lung metastasis, pleural dissemination, and malignant pleural effusion in 2007 received 10 prior anti‐cancer regimens including gefitinib as second‐ and ninth‐line treatments, with minimal efficacy with gefitinib. EGFR mutation analysis performed in pleural effusion specimens during ninth‐line gefitinib was negative. In 2015, she developed progressive disease with peritoneal dissemination. Few/absent bowel sounds and no gross features of mechanical obstruction on the imaging led to the diagnosis of paralytic ileus. Blood test revealed elevated C‐reactive protein (CRP). EGFR mutation analysis revealed S768I point mutation in EGFR exon 20 without the T790M resistance mutation in pleural and peritoneal effusion cytology specimens. She received afatinib (20 mg once daily) as 11th‐line treatment, with resolution of peritoneal carcinomatosis and CRP normalization, confirmed by follow‐up computed tomography. At 12 months after afatinib initiation, there was no symptomatic recurrence or disease exacerbation.
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Affiliation(s)
- Haruki Kobayashi
- Division of Thoracic Oncology Shizuoka Cancer Center Shizuoka Japan
| | - Kazushige Wakuda
- Division of Thoracic Oncology Shizuoka Cancer Center Shizuoka Japan
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Oh CH, Ji GY, Yoon SH, Hyun D, Park HC, Kim YJ. Paralytic Ileus and Prophylactic Gastrointestinal Motility Medication after Spinal Operation. Yonsei Med J 2015; 56:1627-31. [PMID: 26446646 PMCID: PMC4630052 DOI: 10.3349/ymj.2015.56.6.1627] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 12/16/2014] [Accepted: 01/03/2015] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To investigate the prevalence of paralytic ileus after spinal operation in the supine or prone operative position and to determine the efficacy of prophylactic gastrointestinal motility medications in preventing symptomatic paralytic ileus after a spinal operation. MATERIALS AND METHODS All patients received spinal surgery in the supine or prone operative position. The study period was divided into two phases: first, to analyze the prevalence of radiographic and symptomatic paralytic ileus after a spinal operation, and second, to determine the therapeutic effects of prophylactic gastrointestinal motility medications (postoperative intravenous injection of scopolamine butylbromide and metoclopramide hydrochloride) on symptomatic paralytic ileus after a spinal operation. RESULTS Basic demographic data were not different. In the first phase of this study, 27 patients (32.9%) with radiographic paralytic ileus and 11 patients (13.4%) with symptomatic paralytic ileus were observed. Radiographic paralytic ileus was more often noted in patients who underwent an operation in the prone position (p=0.044); whereas the occurrence of symptomatic paralytic ileus was not different between the supine and prone positioned patients (p=0.385). In the second phase, prophylactic medications were shown to be ineffective in preventing symptomatic paralytic ileus after spinal surgery [symptomatic paralytic ileus was observed in 11.1% (4/36) with prophylactic medication and 16.7% (5/30) with a placebo, p=0.513]. CONCLUSION Spinal surgery in the prone position was shown to increase the likelihood of radiographic paralytic ileus occurrence, but not symptomatic paralytic ileus. Unfortunately, the prophylactic medications to prevent symptomatic paralytic ileus after spine surgery were shown to be ineffective.
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Affiliation(s)
- Chang Hyun Oh
- Department of Neurosurgery, Guro Teun Teun Hospital, Seoul, Korea
| | - Gyu Yeul Ji
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hwan Yoon
- Department of Neurosurgery, Inha University College of Medicine, Incheon, Korea.
| | - Dongkeun Hyun
- Department of Neurosurgery, Inha University College of Medicine, Incheon, Korea
| | - Hyeong-chun Park
- Department of Neurosurgery, Inha University College of Medicine, Incheon, Korea
| | - Yeo Ju Kim
- Department of Radiology, Inha University College of Medicine, Incheon, Korea
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Nakae H, Kusanagi M, Okuyama M, Igarashi T. Paralytic ileus induced by glyphosate intoxication successfully treated using Kampo medicine. Acute Med Surg 2014; 2:214-218. [PMID: 29123725 DOI: 10.1002/ams2.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 10/24/2014] [Indexed: 12/24/2022] Open
Abstract
Case A 65-year-old woman ingested glyphosate-surfactant herbicide in an attempt to commit suicide. She experienced glyphosate intoxication associated with multiple organ failure and developed a paralytic ileus. Daijokito, a traditional Japanese Kampo medicine was given to the patient to improve constipation and psychological symptoms. Next, rikkunshito was given to increase her gastric motility. Finally, daikenchuto was given to improve overall digestive peristalsis. Outcome All abdominal symptoms ultimately improved after treatment with daikenchuto. Conclusion Kampo medicines may help improve abdominal symptoms associated with glyphosate intoxication in cases where modern medical treatment alone proves inadequate.
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Affiliation(s)
- Hajime Nakae
- Department of Emergency and Critical Care Medicine Akita University Graduate School of Medicine Akita Japan
| | - Misato Kusanagi
- Department of Emergency and Critical Care Medicine Akita University Graduate School of Medicine Akita Japan
| | - Manabu Okuyama
- Department of Emergency and Critical Care Medicine Akita University Graduate School of Medicine Akita Japan
| | - Toshiko Igarashi
- Department of Emergency and Critical Care Medicine Akita University Graduate School of Medicine Akita Japan
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Mukhopadhyay S, Jana S, Roy MK, Chatterjee A, Sarkar A, Mazumdar S, Mukherjee P, Mukhopadhyay J. Lupus cystitis: An unusual presentation of systemic lupus erythematosus. Indian J Nephrol 2014; 24:308-11. [PMID: 25249721 PMCID: PMC4165056 DOI: 10.4103/0971-4065.133010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Lupus cystitis is a rare complication of systemic lupus erythematosus (SLE) and occurs in association with gastrointestinal symptoms. This rare disorder has been reported mainly from Japan. We report a 20 year old female who diagnosed as having SLE associated with paralytic ileus and chronic interstitial cystitis. Treatment with intravenous methylprednisolone, cyclophosphamide pulse therapy followed by oral prednisolone and azathioprine led to amelioration of manifestations. Later she developed lupus nephritis which was treated with mycophenolate mofetil.
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Affiliation(s)
- S Mukhopadhyay
- Department of Internal Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - S Jana
- Department of Internal Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - M K Roy
- Department of Internal Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - A Chatterjee
- Department of Internal Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - A Sarkar
- Department of Internal Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - S Mazumdar
- Department of Internal Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - P Mukherjee
- Department of Internal Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - J Mukhopadhyay
- Department of Internal Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
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Abstract
We report a case of a chronic hemodialysis patient who developed hypermagnesemia due to an overdose of magnesium-containing laxative and paralytic ileus resulting in colonic perforation. Despite intravenous calcium infusion and daily hemodialysis, the patient developed ischemic colitis and intestinal perforation. Colonic perforation accompanied with hypermagnesemia in hemodialysis patients has rarely been reported. This case suggests that hypermagnesemia should be considered in renal failure patients as this can result in life-threatening events despite prompt treatment.
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Affiliation(s)
- Hye Eun Yoon
- Division of Nephrology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Wook Kim
- Division of Nephrology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyung Sun Ha
- Division of Nephrology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eun Hui Sim
- Division of Nephrology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seong Woo Go
- Division of Nephrology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok Joon Shin
- Division of Nephrology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Kunnathuparambil SG, Payangappadom PK, Yerol PK, Madhavan M, Sreesh S, Narayanan P, Devdas K, Ramakrishanan Kattoor V. Hypercalcemic crisis due to adult T cell leukemia: a rare cause of paralytic ileus. Ann Gastroenterol 2012; 25:170-172. [PMID: 24714244 PMCID: PMC3959384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Accepted: 01/11/2012] [Indexed: 11/18/2022] Open
Abstract
Adult T cell leukemia- lymphoma is a rare aggressive malignancy of the peripheral T lymphocytes, caused by human T cell lymphotropic virus -1 (HTLV-1) infection. Hypercalcemia occurs in about 70% of patients with acute adult T cell leukemia. However, there are very few case reports of adult T cell leukemia presenting as a hypercalcemic crisis. We report a case of a 54-year-old male who presented with abdominal pain, constipation and altered sensorium. On examination he had generalized lymphadenopathy, hepatosplenomegaly and paralytic ileus. Investigation revealed hypercalcemic crisis with low parathormone (PTH) levels. Peripheral smear and bone marrow aspirate were consistent with adult T cell leukemia. HTLV-1 serology was positive. Despite the corrective measures for hypercalcemia and chemotherapy, he succumbed to the illness in a week.
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Affiliation(s)
- Sojan George Kunnathuparambil
- Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala, India,
Correspondence to: Dr Sojan George Kunnathuparambil, Senior Resident, Department of Medical Gastroenterology, SSB – 3, super specialty block 3rd floor, Govt. Medical College, Thiruvananthapuram 695 011, India, Tel: +01 94000 73067, e-mail:
| | | | - Praveen Kumar Yerol
- Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Mukunda Madhavan
- Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Sreejaya Sreesh
- Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Premaletha Narayanan
- Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Krishnadas Devdas
- Department of Medical Gastroenterology, Government Medical College, Thiruvananthapuram, Kerala, India
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