Page 18 - Delaware Medical Journal - May 2016
P. 18
Colonic Ischemia Leading to Colectomy
in a Young Adult Prescribed Antipsychotic
and Anxiolytic Medications
P atricia Mangel, MD; Patrick Matthews, MD; Brian Levine, MD; Jamie Rosini, Pharm. D
CASE REPORT
A 29-year-old male with a past medical history of opiate abuse presented to the Emergency Department (ED) from an inpatient psychiatric facility complaining of constant diffuse abdominal pain progressively worsening over two days. He was constipated since the onset of his symptoms and recently developed nausea and diaphoresis. He denied recent narcotic use and his only prescribed medications were Restoril (temazepam) and Effexor (venlafaxine) for treatment
of anxiety and depression. He had no prior surgical history.
The physical exam revealed a pale diaphoretic young male who appeared anxious and in mild distress. He was tachypneic to 23 breaths/min and tachycardic to 123 beats/min. Abdominal exam was remarkable for diffuse tenderness and moderate distension with guarding but no rebound tenderness. His bowel sounds were decreased and his rectal exam revealed a fecal impaction.
Initial evaluation with an abdominal obstruction x-ray series showed
levels concerning for small bowel obstruction. He had a normal complete white count, basic metabolic panel, liver enzymes, and lipase. A nasogastric tube (NGT) was placed for decompression and the surgical team was consulted regarding the bowel obstruction. A computed tomography (CT) scan of the abdomen with intravenous a dilated cecum and sigmoid – likely secondary to the large amount of stool present throughout the colon, without concern for free air or free hypotensive with systolic blood pressures in the 80’s mmHg, and
an elevated lactate of 6.5 mmol/L. Given the concern for sepsis and
resuscitated with normal saline, resulting in improvement of the blood pressure. The surgical team emergently evaluated the patient. In light of the clinical presentation, the patient was taken to the operating room. Initial explorative laparotomy revealed severely distended, edematous intestine without evidence of ischemia. The abdomen was left open with a vacuum-assisted device (VAC) in place. However, postoperatively, he remained in septic shock with increasing pressor requirements. Upon bedside VAC change, his bowels were noted
to appear ischemic and he was taken back to the operating room
for additional exploration. At this point, the colon was massively dilated with several areas of necrosis, resulting in a total abdominal colectomy. After a complicated 29-day hospitalization, the patient was discharged, but was re-admitted multiple times for dehydration, bacteremia, and post-ileostomy syndrome.
DISCUSSION
Antipsychotics have many side effects that range in severity from mild constipation to obstipation, such as Ogilvie’s Syndrome (acute megacolon). As a result, abdominal compartment pressures can rise and result in life-threatening complications.1 There have
been several cases reported in the literature of psychiatric medication-induced acute megacolon that resulted in severe fatal abdominal compartment syndrome.2
While it is well known that opiates can lead to dysmotility of
the gastrointestinal tract, it is less known whether antipsychotic medications can have a similar effect.3 The mechanism is theorized as a result of the anticholinergic and anti-serotonergic properties of these medications, which can lead to decreased intestinal motility. Ultimately this causes colonic dilation and can progress to severe complications, as in our patient. In a case series by Jambet et al, two cases of patients receiving chronic benzodiazepine and antipsychotic therapy presented to the ED with unresponsiveness. Both were found to have acute megacolon and abdominal compartment syndrome, ultimately leading to multi-organ failure and death.2 Pajouhi et al
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Del Med J | May 2016 | Vol. 88 | No. 5
