Case 31-2009: A 26-year-old man with abdominal distention and shock

Indications:1 patient with paranoid schizophrenia.

Patients:One 26-year-old male patient (dropped out due to side effects).

TypeofStudy:A case report describing Leponex-induced gastrointestinal motility resulting to acute megacolon (Ogilvie's syndrome), septic shock, and multiple organ failure in a patient with paranoid schizophrenia.

DosageDuration:550 mg daily. Duration: at least several months to more than a year.

AuthorsConclusions:This case highlights the morbidity and mortality associated with clozapine-induced gastrointestinal hypomotility and the importance of screening.

Results:The patient developed abdominal pain and distension, nausea, hypotension, and unresponsiveness to painful stimuli. He was obtunded with agonal respirations, and the pupils reacted sluggishly to light with an absence of corneal reflexes. There was presence of coffee-grounds material emanating from his mouth. HR was 127 bpm, and the respiratory rate was 24 bpm. A nasogastric tube was inserted, and brown material (200 to 300 ml) was aspirated. CT of the abdomen and pelvis showed markedly dilated loops of bowel. The abdomen was rigid and distended, with tympany. The legs were cold and pale. The radial pulse was weakly palpable, and pedal or femoral pulses were absent. An ECG showed tachycardia of sinus origin, right-axis deviation, and an intraventricular conduction defect. There was fecal material throughout the colon and in the distal small bowel. Levofloxacin, metronidazole, vancomycin, intravenous fluids, norepinephrine, and phenylephrine were administered. The patient underwent laparotomy. Terminal ileum and the entire colon were removed. On histological examination, the colonic mucosa showed coagulative necrosis with hemorrhage, loss of crypts, and basal regeneration of the remaining crypts indicating ischemic damage. The necrosis and hemorrhage were confined to the mucosa. The segment of ileum showed similar mucosal changes. Additional operations, including resection of ischemic ileum, creation of an ileostomy, delayed abdominal closure, drainage of an intraabdominal hematoma, and placement of a tracheostomy tube were made. Parenteral nutrition, 55 units of packed red cells, 70 units of platelets, and 134 units of fresh-frozen plasma were also given. After surgery, the patient refused further treatment with Leponex. Risperidone and oxcarbazepine were given to control his psychiatric symptoms.

AdverseEffects:1 patient developed gastrointestinal hypomotility resulting to acute megacolon (Ogilvie's syndrome) characterized by abdominal distention, colonic distention, hypotension, nausea, abdominal pain, sinus tachycardia, intraventricular conduction defect, severe coagulopathy, bleeding, acidosis, hypothermia, septic shock, and multiple organ failure (renal, liver, respiratory) leading to withdrawal.

FreeText:Tests: heart rate (HR) in beats per minute (bpm), computed tomography (CT), electrocardiography (ECG), blood pressure (BP), respiratory rate, terminal ileum and colon biopsy, lactate level, liver function (total bilirubin), renal function. Concomitant drugs: valproic acid 2250 mg, and glycopyrrolate 4 mg orally at night.