Page 19 - Delaware Medical Journal - May 2016

CASE STUDY
There have been several cases reported in the literature of psychiatric medication-induced acute megacolon that resulted in severe fatal abdominal compartment syndrome.2
al presented a case of a patient with a history of schizophrenia on multiple antipsychotic medications who developed an ileus requiring surgical intervention.4
Our patient was being treated with venlafaxine and temazepam. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor
(SNRI) and is often used to treat depression. Through inhibition
of the reuptake of serotonin and norepinephrine there is increased extracellular concentration of these neurotransmitters. Interestingly, an increase in serotonin has been shown to stimulate intestinal activity 5,6 Conversely, norepinephrine and high adrenergic states will cause decreased gastrointestinal tone and motility.7 Temazepam is a benzodiazepine that increases the effect of GABA neurotransmission and is often prescribed for insomnia as it promotes sedation, anxiolysis, and muscle relaxation.8 One study by Narducci et al, showed a diminished rate of colonic motility in irritable bowel syndrome (IBS) patients undergoing stress who were initially pre- treated with chlordiazepoxide.9
In our patient, several theories could explain his presentation of acute megacolon. Most likely, his intestinal slowing was secondary to
the combined effects of both the SNRI and benzodiazepine. Since serotonin has been shown to increase gastrointestinal motility,
his symptoms were less likely due to the intake of venlafaxine.5,6 However, one explanation could be that the prescribed benzodiazepine caused initial slowing and constipation and the addition of venlafaxine stimulated intestinal promotility leading to colonic dilation, although we cannot verify this proposed timeline of medication administration. With a history of opiate abuse,
one may assume that narcotic medications played a role in his
REFERENCES
1. Palmer SE, McLean RM, Ellis PM, Harrison-Woolrych M. Life-threatening clozapine-induced gastrointestinal hypermotility: an analysis of 102 cases. J Clin Psychiatry. 2008;69:759-768.
2. Jambet S, Guiu B, Olive-Abergel P, Grandvuillemin A, Yeguiayan J, Ortega- Deballon P. Psychiatric drug-induced fatal abdominal compartment syndrome. Amer J of EM. 2012;30:513.e5-513.e7.
3. Elder K, Lashner B, Solaiman F. Clinical approach to colonic ischaemia. Cleve Clin J Med. 2009;76:401-409.
4. Pajouhi P, Bourgeois JA. Clozapine, fluoxetine, and benztropine- associated ileus: case report. Jefferson J Psychiatry. 2007;21.
constipation and acute megacolon; however, we feel this is a less likely hypothesis as the patient had been admitted to an inpatient unit without access to opiates.
This case elucidates the critical importance of considering bowel obstruction and intestinal ischemia in patients being treated with the combination of antipsychotic and benzodiazepine therapy. Often, patients suffering from mental illnesses require multiple medications sometimes life-threatening effect of polypharmacy on the intestinal tract must be considered in patients presenting with complaints of nausea, vomiting, and abdominal pain.
CONTRIBUTING AUTHORS
■ PATRICIA MANGEL, MD is an Emergency Medicine Physician at Virtua Memorial Hospital in Mount Holly, NJ. At the time of this case report she was an Emergency Medicine Resident at Christiana Care Health System in Newark, Del.
■ PATRICK MATTHEWS, MD is an Emergency Medicine Physician at Christiana Care Health System in Newark, Del., and a Clinical Instructor of Emergency Medicine at Sidney Kimmel Jefferson Medical College in Philadelphia, Penn.
■ BRIAN LEVINE, MD is the Program Director for the Emergency Medicine Residency at Christiana Care Health System in Newark, Del. and a Clinical Associate Professor of Emergency Medicine at Sidney Kimmel Jefferson Medical College in Philadelphia, Penn.
■ JAMIE ROSINI, PHARM. D, is a Clinical Pharmacy Specialist and the Pharmacy Emergency Medicine Program Director at Christiana Care Health System in Newark, Del.
5. Salvador MT, Murrilo MD, Rodriquez-Yoldi MC, Alcalde AL, Mesonero JE, Rodriquez-Yoldi MJ. Effects of serotonin on the physiology of the rabbit small intestine. Can J Physiol Pharmacol. 2000;78:359-366.
6. Camilleri M. Serotonin in the gastrointestinal tract. Curr Opin Endocrinol Diabetes Obes. 2009;16:53-59.
7. Mullin G. Integrative Gastroenterology. New York: Oxford University Press; 2011.
8. Oelschlager H. Chemical and pharmacologic aspects of benzodiazepines. Schweiz Rundsch Med Prax. 1989;78:27-28.
9. Narducci F, Snape WJ Jr, Battle WM, London L, Cohen S. Increased colonic motility during exposure to a stressful situation.
Dig Dis Sci. 1985;30:40-44.
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